About

Welcome to my blog, Spinal(con)Fusion.  My name is J. Alex Thomas, M.D.  I am a practicing neurosurgeon in Wilmington, North Carolina at Atlantic Neurosurgical and Spine SpecialistsI perform the typical mix of cranial and spinal neurosurgery although I specialize in advanced minimally-invasive techniques in spinal surgery.  My goal with this blog is to provide patients with a clear, concise description of neurosurgical and spinal conditions and procedures.  The information found here should not be viewed as a neurosurgical reference like a textbook or a medical journal.  Rather, I hope to be able to explain various aspects of neurosurgery to you in a way that is easy for the non-medical person to understand. In some cases I may interject my opinion on certain aspects of neurosurgical care (and perhaps life in general).  Be aware that these interjections reflect my opinion and may not reflect the opinion of other neurosurgical practitioners.  My opinions should not be interpreted as medical recommendations.  For more information please read my legal disclaimer.

At the very least I hope this blog will be educational and maybe even entertaining.  It may also allow you to make more informed decisions about neurosurgical care for you or your loved one. Please check the blog frequently for the latest installment of Spinal(con)Fusion.

6 thoughts on “About

  1. Hello! I am a pain management physician and I LOVE your blog!!! I just started reading – so you may have touched upon this at some point – but can you discuss why central decompression seems to be the main goal in most spine surgeries even when the root of the problem (saw what I did there? lol) appears to be foraminal with nerve root compression? I have SEVERAL patients who have undergone surgery for radiculopathy – but only the central canal was decompressed. The unilateral radicular complaints persist after surgery! Are there procedures tailored to shaving the foramen, maybe? These are the patients who do pretty well with transforaminal epidurals when the nerve root is medicated. Please help shed some light on the surgeon’s perspective on this. Thanks so much

    • Hi There,

      Thanks for message! I think it’s helpful to breakdown stenosis into three categories.

      1) First, there’s central stenosis (https://spinalconfusion.wordpress.com/2015/07/26/what-is-lumbar-stenosis/). This is the patient you see with circumferential stenosis usually caused by ligamentous buckling and facet hypertrophy who is claudicating. Classic clinical presentation. Central decompression works well here.

      2) The second type of stenosis is lateral recess stenosis. The lateral recess is that region just medial to the pedicle, underneath the facet complex. Here, the traversing nerve is compressed on its way to the foramen (thus lateral recess stenosis at L4/5 will cause an L5 radic.) You can usually decompress this with a “central” decompression but you’d better be sure you undercut the facet and see that nerve root. I’ve had patients in the past where I thought I was out lateral enough but in follow up, after the patient was still in pain, I’d realize that indeed there was persistent lateral recess stenosis. It’s always a fine line with how much of the facet you can undercut and remove without causing iatrogenic instability.

      3) Lastly, there’s foraminal stenosis (https://spinalconfusion.wordpress.com/2015/10/19/what-is-lumbar-foraminal-stenosis/) which I feel is often overlooked when planning surgical intervention. Maybe it’s not that it’s overlooked but rather it’s just hard to get a good decompression there. This is what the patient you mentioned, who responded well to TFESI after a failed decompression, likely had. First, as mentioned above, it’s hard to get a complete foraminal decompression because most of the roof of the foramen is the facet joint. If I completely unroof the nerve I’ve basically removed most of the facet joint and have really done the patient a disservice. The other reason it’s hard to get a good decompression there is that the real reason for the stenosis is overlooked. As you probably know, the main cause of foraminal stenosis is disc space height loss, particularly at L5/S1. Me removing bone off the nerve isn’t going to fix the real problem. In the past I’d try a foraminotomy (which is basically a laminectomy where you work more lateral along the exiting nerve root) here. The patients would do well for a while but their symptoms would eventually return (because the disc space height loss would progress.) These days, I now believe that in these cases the best fix is an interbody fusion with large spacers (https://spinalconfusion.wordpress.com/2017/06/12/implants-in-spinal-surgery-part-iii-intervertebral-spacers/). You get a patient with radiculopathy from foraminal stenosis at L5/S1 and they do GREAT with a standalone lateral ALIF, the main purpose of which is to reestablish the disc/foraminal height. This is called indirect decompression (https://spinalconfusion.wordpress.com/2017/08/26/believe-in-indirect-decompression/). Lastly, in working up radiculopathy you really have to think about the root that it’s involved. If it’s an L4 radic and you see central or lateral recess stenosis at L4/5 then obviously decompressing there (without a foraminotomy at L4) isn’t gonna help.

      I hope that answers your question!

      AT

      P.S. do me a favor and tell your patients and colleagues about the blog!

      • THANK YOU THANK YOU THANK YOU!!!
        That was exactly what I was looking for. I appreciate the time you took to give me such a detailed response.

  2. Thank you for pointing me to your blog. I think reading your posts is helping me better understand the issues and how they can be addressed. I also like the bit of yourself that you interject.

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