About 25% of Dr. Jenkins cases are revisions of other surgeon’s prior procedures. As one of the leaders of a major medical school spinal surgery practices, he sees and treats these more complex cases regularly and with skill and compassion that sets him apart from his peers. Some of Dr. Jenkins biggest success stories were previously other surgeons’ failures. Other successful revision procedures were in people who had one successful operation, but have developed additional problems at other spinal levels, and wanted Dr. Jenkins’ expertise.
Revision surgery, when indicated, is more complicated than “virgin” or first-time around spinal surgery. The anatomy is distorted, and some of the regional landmarks are often missing or altered. There is often extensive scarring of bone to nerve, and even within the nerves themselves. Prior placement of hardware (screws, rods, cages, or in other words, anything artificial) makes the re-operation even more complicated, as there are many different and often incompatible systems, various types of screws and locking mechanisms. Sometimes the hardware has broken or caused complications, and removal may be more difficult. In some cases, the actual removal may be more risky than leaving it in place; other times, removal is a primary goal, either to make room to get to the primary target of the surgery, or to fix what is not right about the hardware.
Revisions require significant specialized skills, whether it’s going back in for a “simple” repeat diskectomy (with about 5-10 times the incidence of injury to the covering of the nerves, or the dura) or a more complicated spinal fusion revision or extension, or other forms of revision surgery. Dr. Jenkins has pioneered and improved various techniques for managing these and other complications based on his training and experience.
Dr. Jenkins works collaboratively with many different specialists to ensure that he has assembled the best and most skilled team to tackle any challenge. Dr. Jenkins uses a team of neuroanesthesiologists and neurological critical care specialists who are experienced in the medical management of complicated spinal procedures and are skilled in managing complex airways that often accompany spinal deformities and prior surgeries. These specialists have in many cases are experts of have developed new techniques and protocols widely in use today. He also often, as the case dictates, collaborates surgically with various surgical specialists to optimize the patient’s experience and outcome, including operating with:
- Orthopedic Spine Surgeons – Complementary and similar skill sets to add spinal surgical expertise and make the case go faster and smoother
- Plastic Surgeons – Help close complex wounds (such as long incisions in re-operation cases, patients with impaired healing such as diabetics, morbidly obese, cancer, other skin disorders)
- Otolaryngologists (ENT)– help with exposure on anterior cervical re-operations to facilitate exposure of delicate structures in the neck such as the esophagus and major nerves and arteries, all of which can be extensively scarred down from prior surgeries, radiation, or cancer.
- Vascular surgeons – help with exposure on anterior lumbar re-operations and many primary anterior spinal procedures due to their experience operating in the area of the abdomen and major blood vessels, many of which are extensively scarred to the spine from prior surgery
- Urologists – they may facilitate placement of a foley catheter in patients who have prior history of bladder, prostate, or urethral infections, trauma, or radiation
Indications for revision spinal surgery:
2-10% of all single level fusion procedures do not successfully “fuse” or heal the bones together – this number goes up significantly more for multiple level procedures, depending on the region of the spine and the type of procedure done in the first procedure. This failure of fusion (also known as a pseudoarthrosis) is a fact of life, although not all surgeons discuss this risk with patients in advance. Typically this shows up later, on average 6 to 9 months after the original operation, often after a period of improving symptoms that then come back. Dr. Jenkins lets patients know this up front and believes that patients have a right and a need to understand the risks of a procedure, including the possibility that a second procedure may need to be done to ensure the final good result. Dr. Jenkins is vigilant about watching for these signs and intervening early rather than let the patient suffer needlessly.
5-10% of all lumbar disk operations result in a re-herniation at the same level and site 2 days to 20+ years later. This number may be even higher in those patients who are overweight, out of shape, or work in jobs that result in significant trauma to the back. This number holds up across most surgeons, although there are certain factors that may predispose to higher rates of disk re-herniation. Dr. Jenkins does his best to minimize those factors.
The degenerative processes continue on at unoperated levels, sometimes accelerated by the original operation. Having one herniated lumbar disk correlates with a greater risk of herniations at other levels. Spinal stenosis can continue to develop over time at adjacent levels, even when it does not come back in the operated area. Spinal fusion (which eliminates movement at one or more levels) may concentrate the body’s movement in the remaining spinal levels, which tends to wear those “adjacent segments” down faster. Certain factors can predispose to these problems, such as “flat back syndrome”, where the surgeon may have fused the patient in a position that is too straight and does not follow the ideal spinal curvature. Dr. Jenkins has experience treating these situations, and pays exquisite attention to these types of details to prevent these types of problems in his own cases.
The first operation may not have achieved the goals the original surgeon set for the patient. Not all patients improve with surgery, as some nerves are so compressed that permanent changes have occurred in the nerves. In addition, not all back and neck pain is improved with spinal fusion or disk replacement procedures. Spinal fusion for back pain for degenerative disk disease (as opposed to other diagnoses which may respond better to surgery, like a lytic spondylolisthesis) has success rates in the 70-80% range, and sometimes even lower.
Things may not have gone well in the first operation – Poor planning, poor positioning, poor execution, improper equipment, inadequate decompression, all of these and more can contribute to the need for a revision to “set things right”.