An evolution in back surgery
Joel Bornstein was a prisoner to back pain so severe that he rarely left his home in Mashpee, where he was forced to get around using a walker and wheelchair.
“The pain was excruciating. I was seeing stars,” said Bornstein, 78, who had a bone spur and a herniated disc in his spine. After cortisone injections failed to ease the pain, Bornstein’s doctor referred him to Paul Houle, MD, FAANS, a neurological surgeon at Cape Cod Hospital.
Dr. Houle, who is one of five neurosurgeons at Cape Cod Healthcare Neurosurgeons in Hyannis, treated Bornstein’s bone spur first, then turned his attention to the herniated disc, which he repaired with an innovative new approach known formally as the Transforaminal Endoscopic Surgical System (TESSYS), but which is also called the Joimax procedure, in a nod to the name of the German company that developed and manufactures the equipment.
“The Joimax procedure represents an evolution in the techniques we use to treat herniated discs,” said Dr. Houle.
As an analogy, he noted that knee surgery, such as repair of damaged ligaments, used to require large incisions, but is now usually performed with arthroscopy, which uses small instruments and illuminated lenses that are inserted through small puncture holes in the skin. Likewise, the way doctors treat herniated discs is evolving, with Joimax and other related techniques recently emerging as the latest step toward making the surgery less taxing for patients.
Dr. Houle is one of just two doctors in all of New England who performs the Joimax procedure. He regularly travels across the United States to lead seminars for other surgeons interested in learning the technique. He has taught the finer points of Joimax to physicians at major medical centers such as Boston’s Brigham and Women’s Hospital, the University of Southern California, and the University of California San Francisco among others, as well as doctors at hospitals in Europe and Asia. He even self-produces instructional videos about Joimax for interested clinicians (shot with his own video equipment, against a green screen set up in his bedroom).
Herniated discs are one of the most common causes of back pain, especially in the lower (or lumbar) region of the back. Discs are rubbery pads that sit between each vertebra (or spinal bone), where they act as cushions or shock absorbers, and make the spine flexible. A disc has a hard shell and is filled with a jelly-like substance. A herniated disc occurs when the shell breaks open, allowing the substance to leak out and irritate nerves.
As Bornstein discovered, herniated discs can cause significant back pain. Often, the pain can be managed with conservative treatments, such as pain relievers, ice packs, massage and physical therapy. However, when these therapies don’t bring relief after an extended period, surgery is an option.
For many years, the standard technique for treating a herniated disc has been microdiscectomy. In this traditional approach, the patient is put to sleep under general anesthesia and positioned face down on an operating table. The surgeon makes an incision of about one inch in the back, then cuts through muscle to expose the spine. To reach the nerve root that’s irritated by the herniated disc, the surgeon uses surgical tools to remove a portion of the facet joint and cut away a ligament that stands in the way. Now that a path to the problem has been cleared, the surgeon trims away the disc fragment that’s compressing nerves, or in other cases, may remove the entire disc.
Microdiscectomy is an effective surgery, according to Dr. Houle, but patients who undergo the procedure face a lengthy recovery and must cope with significant post-operative pain—the more muscle a surgeon must cut, the longer the discomfort lingers. He pointed out that many patients who undergo microdiscectomies have already been through several months of physical therapy to strengthen the muscles around their spine in a failed bid to ease back pain, before they were referred for surgery. But a microdiscectomy, Dr. Houle noted with irony, “destroys those muscles that you spent months trying to make strong. This doesn’t make sense, right?” What’s more, injury to the muscles and facet joint can make the spine less stable, leaving the patient at risk for future back problems.
In the early 2000s, Dr. Houle and other neurosurgeons at the hospital began using a less-traumatic approach to treating herniated discs that does not involve cutting muscle. The minimally invasive procedure, known as tubular microdiscectomy, requires only a small incision in the back, through which the surgeon slips a thin, cylindrical device known as a tubular retractor, which is guided between muscle fibers to the area of the spine to be treated. The tube is then dilated, or widened, giving the surgeon enough room to insert instruments used to performs the surgery. The surgeon views the spine with a microscope or other magnification device. When the disc fragment causing back pain has been excised, the tubular retractor is removed and the muscle resumes its shape.
Studies have found this less-invasive procedure to be just as effective as traditional microdiscectomy. However, while this procedure doesn’t destroy muscle, it nonetheless still requires cutting the facet joint and ligament.
A Leap Forward
The Joimax procedure takes the treatment of herniated discs a leap forward by largely eliminating the need to cut or damage any healthy tissue in order to access the compressed nerve. Instead, explained Dr. Houle, “We exploit a natural opening in the spine.” That opening is the neuroforamen, a kind of doorway on either side of a vertebra where nerves pass through as they connect the brain to your muscles, organs and other tissues. That’s also where a bulging disc crimps nerves, causing pain.
With that in mind, the developers of Joimax had an idea: Why not enter the spine through this passageway?
In a Joimax procedure, Dr. Houle makes an incision the width of a number two pencil in the patient’s side. Through this portal he inserts a tube that’s just eight millimeters in width, which is passed through muscle and enters the spine by way of the neuroforamen. The instruments used to perform the surgery are inserted through this tube, much as in tubular microdiscectomy, but they also include an endoscope, or illuminated camera, which projects images of the herniated disk and surrounding tissues onto a TV monitor.
While watching his work on the monitor, Dr. Houle uses forceps (a tweezer-like tool) and other instruments to remove the disc portion that’s pinching the nerve root.
A Rapid Recovery
Importantly, patients do not receive general anesthesia during the Joimax procedure. Instead, they are given a medication that relaxes them during the operation, similar to the sedation used in a colonoscopy, for example. Dr. Houle favors this approach because accessing the spine carries a small risk of damaging nerves.
“When the patient is awake, if you irritate a nerve, they’ll tell you,” said Dr. Houle, since he or she will feel a twinge. That allows Dr. Houle to reposition his instruments to avoid harming the nerve.
Since Joimax doesn’t require general anesthesia, patients can leave the hospital soon after the procedure, which is performed on an outpatient basis. That’s also a plus for elderly patients, who have an increased risk for complications after receiving general anesthesia. And because no muscle or other tissue is damaged, pain is minimal.
“A lot of patients don’t take pain medicine after the surgery—none,” said Dr. Houle. Most others need very little pain relief and end up taking just a pill or two.
Studies indicate that the Joimax procedure and other endoscope-based microdiscectomies are just as effective as traditional surgery. Yet another key benefit for patients who have herniated discs repaired with the endoscopic approach is a rapid recovery. The typical employed patient who has a microdiscectomy returns to work in about seven weeks. By comparison, patients who undergo discectomy with the Joimax procedure and other endoscope-based techniques are back to work in about half that time.
Bornstein underwent the Joimax procedure in June of 2018.
“I had very little pain during recovery,” he recalled.
More importantly, he was soon able to drive and now regularly walks laps at the Hyannis Community Center’s indoor track.
“I couldn’t walk the length of a room before the surgery,” said Bornstein. “It’s been a miracle that Dr. Houle could get me out of that pain.”