‘New’ Spine Surgery: Looking Beyond Decompression

Atul Goel

July 11, 2022


- Colleagues and friends, thank you for joining us for another session of "The Virtual Operating Room." My name is Aaron Cohen. Our guest today is Dr. Atul Goel, who's very well known for his really innovative spirit and provocative lectures. He had a lecture with us just recently, so he needs no introduction. He really is one of the most, I would say, innovative spirits in neurosurgery who really brings up a new perspective to surgical management of craniovertebral junction, as we had during the last lecture, and today he's going to talk to us about how we can look at spinal surgery differently, and way beyond decompression. Atul, I've really been following your philosophy and your thought process for a long time. Sincerely appreciate your contributions to neurosurgery, and very much looking forward to learning from you more today. Please go ahead.

- Thank you, Aaron. Needless to say that it is my great honor and absolute pleasure to be a part of this very important show in neurosurgery, and I hope I can change some thought process of the neurosurgeons who are going to watch me. And I am going to actually, I don't want to bring out terms like revolution and things like that, but I want to give a message to neurosurgeons and spine surgeons who in general think about compression as a problem and decompression as the treatment. So the title is "Looking Beyond Decompression." My firm belief is majority of issues that are confronted with a spine surgeon are related to instability, and stabilization is the treatment. Decompression is not the treatment. Compression is not the issue. Compression is always secondary. Compression is not primary. Compression is protective and compression is reversible. I also wish to again emphasize the issue of central or axial atlantoaxial instability, and then I want to take this further to rest of the spine. Movement is the music, and movement is life. In human body, the entire movement of muscle, entire bulk of muscle is related to standing human position. The bulk located on the back or at the extensor compartment. There is nothing actually in the front of the body. There is nothing much in relation to the disc in relationship to the multiple bodies. Everything is behind. Unlike four-legged animals where the legs are strong, and the problems can be in the legs, in the bird, the problem it can be in the hands. If these muscles become weak, they can be problem in the spine. That is the concept. Atlantoaxial joint is the most mobile joint of the body. It is circumferential movements are there, and because there are circumferential movements, there is a possibility of circumferential dislocation. Atlantoaxial joint is the most mobile joint, and atlantoaxial joint is potentially the most unstable joint of the body. On the other hand, subaxial facets are almost vertically poised, and if the muscles become weak, there can be only one type of dislocation on the facets that is vertical dislocation, a fact that has never been talked about in the literature. Facets, all the muscles, all the muscles of the back, of the spine attached to the spinous process, transverse process are focused on the facets. And if these muscles become weak, there can be facetal weakness or listhesis. The facets are the issue. So vertical facetal instability and telescoping the segments of the spine telescopes subaxial spine, and that telescoping is vertical facetal instability. This instability will not be seen on dynamic radiographs. Now I am talking about chronic situation. You see, when you talk of acute dislocation, the things are different. When you talk of chronic dislocation like chronic atlantoaxial dislocation, the dislocation in such situations is subtle. It's very minor, very small, and dislocation is chronic for years and several decades, means it goes on for years. And what happens in a chronic situation is nature comes into play. Nature protects the human spinal cord and body from potential and manifest instability by doing various maneuvers as I had talked in my last lecture, and this is the slide showing chronic atlantoaxial instability can be a cause of chiari, syringomyelia, syringobulbia, short head, basilar invagination, and thing like that. So chronic instability is the cause of these problems. And the chiari may be with syrinx, chiari may be without syrinx. It may be with Klippel-Feil. It may be with platybasia, or may be present discreetly. So whenever you have chiari, it is chronic atlantoaxial instability. Whenever you have short head, short neck, Klippel-Feil abnormality, platybasia, are all secondary protective maneuvers by the nature. This fact has, the understanding of this issue has a potential of complete revolution, complete change in the understanding of these issues, and I have no hesitation to say a revolution is here. I said last time basilar invagination was considered to be a fixed anomaly as I had myself classified, but in 2004 I changed my classification, and for group A I said that this is an unstable situation and decompression is not the treatment. Earlier decompression by mount, by transoral root, and by foramen magnum, posterior foramen magnum decompression, for group B, these were the norms, and these are still existing quite a bit. So in 2004 we said that group A does not need decompression, it needs stabilization, and wherever possible, craniovertebral junction realignment can be done. So this is the realignment can be a possibility. So these are basilar invagination and realignment. So we have done over the years as I mentioned last time, more than 3,200 cases of C one C two fixation, and several of these cases involved reduction of basilar invagination. Open the joint, distract the facet, introduce bone graft in the facetal articulation, put bone graft behind, and then do direct C one C two fixation. So basilar invagination is a consequence of chronic atlantoaxial instability. And you know, this fact was not at all there about 20 years ago, and decompression was the treatment. So instability due to muscle weakness, muscle injury, muscle disuse, abuse is the cause of basilar invagination. Instability, atlantoaxial instability is the cause, and stabilization is the treatment. So transoral decompression has been completely gone into historical perspective because in this situation, decompression is not the treatment. Stabilization is the treatment. So this kind of listhesis, C one or C two listhesis as a cause of basilar invagination, like lumbosacral listhesis we talked about in 1999, and as we treat listhesis like open the joint, distract the facet, reduce the dislocation, there is no scope for any decompression. So this compression is not primary. Compression is secondary, compression is protective, and compression is reversible. About 15 years ago, we introduced this brand new concept of central or axial atlantoaxial instability, and this has wide ramifications. Central instability is associated with chiari malformation, syringomyelia, cervical degeneration, deformities, OPLL, Hirayama disease, and things like that like I taught in my last lecture. So we have three types of dislocation. Type one is when the facet of atlas is dislocated and tiered to the facet of axis. Listhesis, anterior listhesis, there is compression of the dural structures and neural structures. Listhesis is the problem. This is an unstable situation. Stabilization is the treatment. This is we described in 1999. Now we introduce another kind of dislocation or instability where there is no atlantodental interval disturbance. There is neural compression or dural compression, but there is retro listhesis of facets. This is unstable situation, you have to stabilize. There is no need for decompression. Now the other more beautiful thing is in chronic situations, chronic when there is platybasia, syringomyelia, chiari malformation, these are all chronic musculoskeletal and neural alterations, not anomalies, and these are indicators of atlantoaxial instability. Stabilization is the treatment, and once you stabilize, there is a magical clinical outcome. Decompression in this situation is a negative phenomenon. So basilar invagination instability is the cause, and for both group A and group B, atlantoaxial fixation is the treatment. There is no role for any kind of decompression. So chiari is the neural or . Syringomyelia, chiari, and all these things, syringobulbia, externals syringobulbia, external syringomyelia are all secondary. They are all protective to chronic atlantoaxial instability, so there is a complete revolution. So foramen magnum decompression for chiari, in my estimation, which I was myself doing for a long time, is a negative operation. In an unstable situation you are doing bone decompression, you can only harm the person. You do atlantoaxial fixation even when there is facetal , or no atlantoaxial facetal instability, you so atlantoaxial stabilization, and without any question, there is a magical clinical outcome. And also syringomyelia will reduce in 100% of cases when you do scan after one year, and in about 50% of cases if you do the scan in about two or three or four months. So even when there is no atlantodental interval disturbance, no facetal malalignment, presence of transalar herniation is an indicator of atlantoaxial instability. Stabilization is the treatment. We had said in 1998 that there is tight posterior fossa, but there is no question of tight posterior fossa being being a cause of chiari malformation. So these are, we have got several hundred cases now where we have treated chiari with only atlantoaxial instability. Chiari is a chronic phenomena. Syringomyelia is a chronic and disabling phenomena. It is absolutely progressive, and it can completely demolish the person. You do stabilization, you completely reverse the clinical situation. So atlantoaxial instability, chronic instability is the cause of chiari. Atlantoaxial fixation is the treatment, whether there are bone abnormalities or not, whether basilar invagination is with chiari, whether chiari is with syrinx, or whether chiari is with Klippel-Feil, whether it is without all these things. So all these are discreet, are in cohort, are indicators of atlantoaxial instability, and stabilization is the treatment. About two years ago I published my series with 388 cases. Now we are having about 450 cases where all patients have been treated by only fixation without any decompression. So chiari is a protective nature's airbag. Syringomyelia is a protective airbag. They are secondary. You don't have to treat them. This is nature's treatment, respect it. You find the cause and treat the cause. The atlantoaxial instability can cause remote kyphoscoliosis You identify the cause in kyphoscoliosis, and all related symptoms like breathing issues, hands problem, legs problem can all disappear if you identify the cause. In this age group, I will say more than 80% of children have atlantoaxial instability which is the cause. There's no need to introduce several long rods. So central or atlantoaxial instability is a real phenomena. Even when there is no compression of the neural structure, it means nothing. When there is a syrinx, atlantoaxial instability is the cause. When there is bifurc, atlantoaxial instability. These are central instability. It may not be decipherable on dynamic images. Atlantoaxial stabilization is the treatment. So foramen magnum decompression, transoral decompression, these are all negative kind of treatment. They should not be done for atlantoaxial instability. Now I go to another chapter, chapter of spine. Vertical instability is a chronic phenomena. Instability is mild due to muscle weakness, muscle age related or injury related, disuse related. So anterior approaches to spine I was myself doing. I wrote this chapter in , which is a respected book in spine and neurosurgery. So anterior approaches I was doing myself with multi-level corpectomies, diskectomy, stabilization. These were common in my surgical list, and this kind of exposure, removing osteophyte, removing this. These were common surgical procedures in my operation theater. In 1993, about 20 years ago we talked about tricortical screws, this screw going from one cortex, two cortex, three cortex, one cortex, two cortex, three cortex can be put without any plate, standalone screws. So these I introduced. So I was quite familiar, and we used to do anterior surgery. Now I am going to another thing. All the muscles are located at the back, all the muscles are focused at the facet. My answer to the question is disc is divine. Disc cannot be the cause of spinal degeneration. Disc space reduction, disc reduction, if you read any textbook for last one century, you will find disc as the issue of spinal degeneration. My answer is muscle weakness is the issue. The fulcrum of movements is at the facet. Facetal listhesis is the first or the primary or the nodal point of pathogenesis or spinal degeneration. So this is degeneration of craniovertebral junction. Nobody really talks about it. And I have to say that atlantoaxial joint is the most mobile joint. Atlantoaxial joint is potentially the most unstable joint. Atlantoaxial degeneration is the number one spinal degeneration much more than C 5-6, C 6-7, or any other level. So we wrote this article several years ago about craniovertebral junction instability due to degenerative osteoarthritis. Now I will like to change this that instability is the cause of degenerative osteoarthritis of the atlantoaxial joint. Now I want you, my dear friends, look very carefully at this slide, reduction in the joint space. You see there is reduction in the joint space. There's reduction in the joint space, buckling of the posterior longitudinal ligament, osteophyte formation. These are not primary processes. These are due to vertical, vertical instability due to the muscle weakness or injury. Vertical instability leads to buckling of the ligament, leads to reduction in the joint space, and osteophyte formation. There is no need to remove this ligament. There is no need to touch the joint. There is no need to touch the osteophyte. These are secondary, these are protective, and these are reversible. Ossification in the apical ligament, this is not a primary process. This is secondary to chronic atlantoaxial instability, vertical spinal instability. Atlantoaxial instability is the cause, and stabilization is the treatment. Any form of anterior or posterior decompression is a negative operation. Retro-odontoid pseudo tumor, this was a very common entity which was discussed earlier where the people used to talk about transoral decompression and things like that. So we talked about that this is not a primary process. This is secondary to atlantoaxial instability like osteophytes, and atlantoaxial stabilization is the treatment. So retro-odontoid mass is an evidence of atlantoaxial instability. It should not be touched. It should not be by transoral route. There is no need for foramen magnum decompression. There is no need for anterior decompression. The problem is atlantoaxial instability, and the treatment is atlantoaxial stabilization. And we have published several articles on this subject, and this concept is quite recognized in the field of craniovertebral junction. Now very few people will like to decompress this situation. Retro-odontoid cyst, you see this retro-odontoid cyst? Retro-odontoid cyst is not a primary process. It is secondary to atlantoaxial instability. You stabilize, and this disc will disappear. So this is a very important concept that you don't have to transoral to decompress. You don't have to to decompress. What is required is the primary, the atlantoaxial instability is the issue. and stabilization is the treatment. So you see this cyst, there is a clear evidence of instability at the atlantoaxial joint. Atlantoaxial stabilization, you see the cyst spontaneously disappear. So it is very important to know what is primary and where to attack. You see this cyst, and this cyst has disappeared, and this is a very important different kind of understanding. Retro-odontoid, this kind of pseudo tumor, you see this here? In case of OS odontoideum, it is a very common kind of phenomena, this kind of cyst, and if you realize, this cyst, there is a buffer in the bone. So when you do flexion, there is, this cyst kind of thing goes inside and outside. And this buffer is such an important nature's protection in the presence of chronic instability due to OS odontoideum, as I mentioned last time that OS odontoideum is a natural protective phenomena. It indicates the presence of atlantoaxial instability, and atlantoaxial stabilization is the treatment. There is no other treatment. So we have got several cases where we have retro-odontoid pseudo tumor, and you see the bone. There is a destruction in the bone where there is a possibility of movement of the pseudo tumor. These are indicators of atlantoaxial instability that would not be primarily attacked. There's no need for. These are like osteophytes, they are protected. These are secondary, and these are reversible. I wrote this article, and I wish that you please read this article. Another thing that many of you might know that about 20 years ago, retro-odontoid pannus, this pannus was the main indicator for transoral decompression in rheumatoid arthritis. So we said about 20 years ago that this pannus is secondary to vertical instability, and this is due to buckling of the posterior longitudinal ligament. You have to stabilize, and this pannus will disappear, so there is no need to do transoral surgery or posterior decompression. What is required is stabilization, and I have no hesitation to say that this concept has completely revolutionized treatment of rheumatoid craniovertebral junction. We introduced these intraarticular implants for the first first time in the literature about 20 years ago, and these can be standalone stabilizers and distractors. My indicators of use of this intraarticular spacers has over the period reduced. So these were the implants or spacers that are described and I used, and quite elaborately, these are very popular in the world of craniovertebral junction. Now you carefully see this slide. You see the strongest part of the bone is the facet. This facet are the strongest. Vertical body is not the strongest part. Trans spinous process is not the strongest part. These facets are the strongest part of the bone, and any kind of, you know, these facets are completely not exploited in the stabilization procedure. They are, of course, it is done, but not to that level which I think they should have could have been exploited. On the other hand, this pedicle, pedicle is also a strong bone, but not as strong as the facets. The problem in pedicle screw insertion is the multiple artery which is in close proximity, and you can have issues, and you have to have very lateral oblique angle, which is not a good angle to do fixation during surgery. So all the muscles are focused at the facets, and facetal listhesis is the issue. You see like basilar invagination, there is C one over C two listhesis? Similarly, there is listhesis due to muscle weakness in the subaxial spine which is not recognized on dynamic imaging, and this is the cause of spinal degeneration, not disc space reduction. Disc space reduction, in my estimation, is secondary. I want you to very carefully see this slide, very carefully. You see the disc space reduction? This disc space reduction is due to vertical instability. Multiple level bulges of the disc are not due to any problem in the disc, but they are due to vertical instability, listhesis of the facets due to muscle weakness. Osteophyte formation, this osteophyte formation is not a primary phenomena, it is secondary. It is seen in compression, but it is a secondary event. Compression is never primary. Compression is always protective, and compression is always reversible. Similarly, you see multi-level disc bulges are here? These disc bulges are due to vertical collapse or vertical instability. That instability is not recognized on dynamic imaging, and that is why we tend to ignore. So vertical instability is without any question, the point of genesis of spinal spondylotic disease. Disc is not the issue. Disc is not the problem. Disc can never be a problem. Now in about 15 years ago, I introduced the technique of facetal distraction. Like listhesis is the problem, you introduce these kind of intraarticular spaces, which we described for the first time in the literature. There is a buckling of the posterior longitudinal ligament due to vertical instability. You distract the facet, and this ligament will open up. There will be the new disc formation can be seen. So this theory, this concept introduced a new hypothesis of spinal degeneration that facetal listhesis is the problem. Disc is not the issue, and you can treat by just distraction without any kind of decompression. This procedure I described about 15 years ago. You see multi-level ligamentum flavum buckling, multi-level disc bulges, and this is immediate postoperative. I have introduced several spacers on multiple levels. The entire thing has now straightened, and most importantly, the patient dramatically improves in the immediate postoperative period, and there is no decompression. So what my concept is that instability is the issue. Decompression is not the treatment. Similarly, you see here, there is an osteophyte kind of thing here. There is buckling ligamentum flavum. I have introduced two spacers, and there is a new disc formation. The ligamentum flavum has gone, the osteophyte has gone in the immediate postoperative period, and this is the image. And we can introduce this at multiple levels, and basically, the thing is for spinal degeneration or spondylosis, myelopathy or radiculopathy, instability is the issue, and stabilization and arthrodesis is the treatment. Decompression is not a treatment. Instability is the issue. Decompression can have negative consequences. You see this is multi-level issue, and I have done multi-level introduction of the spacers. So we have got at that time about 15 years ago, multiple places where you see here there is compression, and here that is gone, and there is a new disc and ligamentum flavum buckling has gone in the immediate postoperative period. Ultimate aim is to achieve arthrodesis. There is no decompression, no laminectomy, no foraminotomy, and nothing is there. So compression is not the issue. Decompression is not the treatment. So this was facetal distraction as the treatment for spinal spondylotic radiculopathy and myelopathy. And this was published as a cover page of "Journal of Neurosurgery." So this introduced a new hypothesis of spinal degeneration, and this was a concept, and there is no question that this has quite a implication in the understanding of spinal degeneration. These are the spacers that we designed and introduced, and we have done several anatomical studies. I will quickly show you this video. Now you see here the how much unstable it is? Can you see I'm introducing a small osteotome in the articulation? I must say that this is the technique that I used to do about 15 years ago. I will show you what I use now. So these are the spacers which I introduced in the articulation. You can jam it inside, and then of course, you can introduce some bone graft by the side of these spacers, and these they introduce a very strong kind of, you know, this stabilization and distraction arthrodesis, and the technique is so very, very simple, absolutely safe. There is no screw beyond the articulation. There is no possibility of danger to any neural structures or vascular structures, and absolutely safe. And you can see that you can open the joint, introduce the spacers, you can ram the spacers. There are multiple sizes, multiple thickness of the spacers that can be used. And I have got, you know, a whole set in my tray, and I introduce these spacers in this facet distraction technique. I don't like percutaneous. There are some people who have now started doing percutaneous these things, but I like to open, then I like to drill, then I like to use bone graft by the side of the spacer, and on the posterior elements. So this is the technique, and you can use multi. And you see in this is unedited kind of tape, and you can do multiple levels in very quick time. Okay, can I go to the next slide? And you see the postoperative result. The compression is gone, and there is no kind of decompression. So this I called it secondary decompression. And even for disc in herniated disc where the posterior longitudinal ligament was intact, in the immediate postoperative period, there can be reversal of the disc. You just see this slide. The whole world will come and do this anterior surgery. You introduce spacers, and this disc can go in the immediate postoperative period by the distraction. And the same concept I use for lumbar canal stenosis. Multi-level buckling of the ligament, multi-level bulging of the disc, spinal canal is called stenosed. So I introduced intraarticular spacers, and several cases I did at that time, and this was published in "Journal of Neurosurgery" in 2013 where I submitted my series of 21 cases, and after elaborate study of anatomy of the subject. So essentially, for spinal degeneration, decompression of the compressed and deformed neural system has been the basis of treatment. So if you talk to any spine surgeon, they talk of compression, and they talk of decompression. So I am saying compression is not the issue, and decompression is not the treatment. So as we went further in our understanding, we introduced the concept that you don't even need to distract. You have to only fixation. There is no need for distraction reduction. So more recently, I published my series with 218 cases where there was no decompression, no foraminotomy, no anterior surgery, no discectomy, no osteophyte resection, and for several cases, and only stabilization using Camille's technique, Camille's, transarticular Camille's technique. And once you see these are multi-segmental stable, multi-segmental osteophytes and compression. This compression, as I have said, is not an issue. These are secondary. Only stabilization, only stabilization, and you see after one and a half year, the whole system has changed and there is no compression, no osteophyte remaining, and more important than anything, the patient will recover in the immediate post-operative period in a fashion that you have never seen by decompressive surgery. So we have got now several hundred cases where we have not done any kind of decompression, only trans articular Camille's technique of fixation, which is absolutely simple and straightforward technique. Facets are the strongest part of the bone. You introduce transarticular, it is safe, it is absolutely strong, and it is absolutely result-oriented. And you see the entire spinal cord is now free of compression after a period of time. But these osteophytes are reversible, this compression is reversible, and more important than that, you don't have to wait. And I have to tell you we have done various kinds of fixation from front, from pedicles, and all, but this Camille's technique has some kind of magic. This magic, it just has to be believed. You see, it is such a straightforward, simple technique, and a strong technique, and a magical technique, so the degenerative spinal cervical myelopathy has to be viewed in a different perspective, not compression and decompression, but instability. So we have written several articles on this subject on radiculopathy. If there is lumbar pain, it indicates spinal instability. If there is radicular pain, it indicates. If there is cord atrophy, it indicates chronic, you see this word chronic has come. Chronic instability introduces several issues in the spine, in the boney neuromuscular structures, and neural structures. So instability is the cause of symptoms. You see, there may be no compression, no osteophyte. Instability by itself is a cause of symptom, and stabilization is the treatment, so that is the concept. Another beautiful sentence I want to put before you is it's not neural deformation or compression, but instability is the cause of symptoms in degenerative spinal disease, absolutely a magical statement, and there is no question about this. So Camille's technique is, without any doubt, is a very underused technique. It is a very strong technique, and I was not using this technique till about 10 years ago. But after that, I have just loved this technique of fixation, and I want to quickly show you you this video. And you see this is almost, you know, this is quite an unstable situation. You can know when you go for to do degeneration surgery, you see how unstable the whole thing is. If you do laminectomy in this situation, you are only going to harm the person. And you see, I was doing laminectomy, I was doing anterior surgery and all those things, but there is without any doubt, without any question, instability is the issue in degenerative spine, and stabilization is the treatment. And you see this is the facetal articulation, and I'm doing transarticular fixation. My screw goes from one facet in an oblique fashion to the other. It is not very clearly seen in this video, but this screw has gone from one direction to the other facet, and then I introduced this guide hole, and then I do this transarticular fixation, which in a quick time, you see, and I sometimes, you know, my associates open the thing, and I do five level fixation in 10 minutes, and that is the beauty of this. You do five level fixation from anterior, you will take five hours, and spines should use this technique. You see the whole facet articulation is oblique. You introduce in an oblique fashion laterally, and once you have done this, you know it is absolutely safe. I have done now several thousand of these cases where we have introduced this transarticular screws, and as I have mentioned to you, I can do them very quickly. In 15 minutes, five level fixation is very easily possible after the exposure has been done, and as you can imagine, these are the spinous processes here. These are the facetal articulation. You introduce the screw in this direction, and you see the joint is oblique, and you can get a very solid purchase once you have done, and it can be done under vision. I don't need any CM or radiographic navigation or any other kind of monitoring, there's no need. The only need is to understand this concept, understand the beauty of the facets. You see four or five levels can be done in quick time. So I go to the next slide. So now it is very important when we are doing only stabilization for spinal degeneration to identify what are the indicators of spinal instability. One is presence of osteophyte will indicate instability. Presence of ligamentum flavum buckling will indicate instability, but even when there is a symptom of radical apathy or myelopathy, it can indicate unstable spine. And it is important to know, like in this patient, you see there are two level of osteophytes, and there is quite a severe compression, and I have done four level of fixation, and if you see here after some time, the whole system has changed, and more important than that, you must read my article on the subject. In the immediate postoperative period, you do stabilization. This Camille's technique has some kind of magic. You see you do pedicle fixation difficult here and there. Anterior surgery do fixation, you expose. Other thing which I have to say is you see all the muscles are located behind anteriorly. There is just some longer scoli, very thin muscle. You do anterior fixation, these muscles on the behind can can break your implant. So anterior fixation is, of course, very popular. ACDF is a very popular surgery, but facetal fixation after muscle cutting is an absolutely philosophically the best way of doing spinal stabilization, and of course, in this situation, arthrodesis is the aim, decompression is not. You see, there is no need. Spinous processes are all intact, lamina is intact. There is no need for any decompression. So these are multi-level compression, only stabilization, and you see the whole system has changed. This is another case where I have done Camille's technique of fixation. There is no decompression, and there is no question that this is most beautiful. Now I go to central instability in craniovertebral junction instability and subaxial instability, which is quite a common phenomena, and a quite a neglected phenomena. Now you see this slide, there is no compression at the craniovertebral junction. There is multi-segmental spinal degeneration, multi-segmental bulges, and spinal degeneration. You see there is a facetal type two instability, and you have to include atlantoaxial stabilization and subaxial stabilization in the fixation construct. There is no need for any kind of decompression, even when there is no facetal malalignment. Multi-segmental degeneration indicates the presence of atlantoaxial instability, and you must consider, you must read my article on the subject, and you must know that if you ignore atlantoaxial instability, you can have a negative outcome and a negative result. In severe myelopathy, when a patient comes with severe myelopathy, there is almost always the presence of atlantoaxial instability, and you have to treat. You see there is no compression, but there is atlantoaxial instability. You have to include atlantoaxial joint in the stabilization construct, and there is no decompression, and you have to see only one thing, and that is a magical treatment. Now we have introduced another technique of C one C two fixation without doing anything to C one. What we do is we cut the muscles around the C two spinous process, and do C two-three fixation. Like here, you see there is no compression. What I have done is C two-three fixation transarticular, and I have cut all the muscles of the C two spinous process and this is a beautiful way of doing atlantoaxial fixation and subaxial fixation in multi-segmental, and you retain the rotatory movement. You must read this article also of mine, which I believe is quite a beautiful technique of retaining rotation and stopping anterior-posterior movement of the odontoid process by this technique. So we have done several cases, and you can introduce two screws. You can introduce, you see, to modify this Camille's technique, and you can use, and you see multi-segmental degeneration, only Camille's technique. Similar concept we talked about in lumbar canal stenosis. So this article was published in "Neurosurgical Focus," and you read the title, Lumbar canal stenosis, analyzing the role of stabilization and futility of decompression. You see, such a radical revolutionary kind of statement, but I have no hesitation, no question that this instability is the issue. Stenosis is not the problem, decompression is not the treatment, stabilization is the treatment. So for this multi-segmental lumbar canal stenosis, I have done only stabilization without any kind of decompression in a very large number of patients now, and I have to only tell you, my dear friends, this is a certainly a different concept, certainly a revolutionary concept. But I wish that you understand this concept, and look at the subject in a different perspective, and I am sure a magic can be seen by you with your own eyes, and the patient will have complete, and you see I have got several hundred patients now where I have done only stabilization, and we have published on several occasions in various journals, and I invite you to read these articles. Now the question is the whole world of spine, the focus is osteophyte, and focus is removal of osteophyte. You do corpectomy, you do discectomy. The entire focus is on removal of the osteophyte. As I mentioned to you that osteophytes are secondary, they are protective, and they're reversible. So my concept is instability is the cause, and stabilization is the treatment. So this article I published in "World Neurosurgery." When you do only fixation, what happens to osteophytes? And you can read the article that the osteophytes disappear. In six months, majority of osteophytes will disappear. The question is whether they disappear or not, that is not the issue. The question is compression is not the issue, decompression is not the treatment. Compression is protective, and compression is reversible. This concept is difficult to, you know, because whole life in spine, we have been talking of compression, our psyche is made for compression and decompression. You look towards spine in a different perspective, and you have only to gain. You see this kind of multi-segmental degeneration, and there is no compression, and only fixation I have done as a treatment, and there is no other treatment. So is the term spinal canal stenosis wrong? I have no question it is a misnomer. It should be called multi-segmental spinal instability, because when there is stenosis, you have to do decompress. But if there is instability in the term, then you have to do stabilization. Now about spinal deformity, when you see a deformity like this, you see many people will do trans, you know, cervical corpectomies and decompression, and osteotomies, and things like that. You identify in this case there is atlantoaxial instability. This is chronic instability, leads to kyphotic deformity. There is no need to touch this. This is secondary. Do atlantoaxial stabilization, and that is the treatment. In this group, you see here is a curvature, this kyphotic that you don't have to do corpectomy or decompression. This is due to unstable vertical instability, and stabilization is the treatment, and which segments have to be stabilized, which segments have to be treated? I have mentioned in this article of mine. I wish that you please read it. Another thing is you see there is a big kyphotic deformity, and there is central instability. You have to do atlantoaxial and subaxial stabilization. And I can tell you, you will see such a magical clinical outcome that you have never done with decompression. So this kind of kyphotic deformity, there is no role for decompression. This is a result of unstable spine, and the treatment is Camille's technique of transarticular fixation is an absolute. Of course, you can do with other techniques. Now I take you to another concept which you may have some lot of difficulty to really get this, but I am introducing you, please think about it. Herniated disc and extruded disc, you see extruded disc, my concept is that disc herniation is a result of unstable spine or disc herniation causes unstable spine. Unstable spine is an issue. So when there is a herniated disc, you give a collar. Collar means you are stabilizing, and the pain goes. You give lumbar belt, that is a stabilizer. So my concept is instability is the issue in spinal degeneration, in herniated disc, and only spinal fixation can be a beauty without touching the disc, so like microdisectomy using endoscope and all those things. I will say that this kind of, you see the whole world will come from front and do ACDF and all those things, so what has been done here is transarticular fixation without any kind of decompression, without touching the disc. And this is the preoperative disc, and the disc has gone after six months. So it is like an internal collar or internal stabilizer rather than using collar. And this is the instability is the issue. and stabilization is the treatment is a quite a concept. I know it is very difficult to get this suddenly, but you have, these are all published in various journals. I wish you read them. So this was published in "World Neurosurgery," Facetal Fixation Arthrodesis as a Treatment for Cervical Radiculopathy. There is no decompression, no disc, similar concept we introduced for lumbar disc. There is no disc removal, no disc decompression, no endoscope. See, this is the disc, only fixation. This is the herniated disc. This herniated disc is gone. And this herniated most important is like you use lumbar belt, you stabilize. Similarly, this stabilization from interior is a foolproof, solid facetal fixation, and there is absolute relief for pain in the immediate postoperative period. I wish that you please read my articles on this subject. This is the disc herniation. This disc herniation is finished, and you have to identify which levels are unstable, but direct manipulation of spinous process, and identification by clinical. So this kind of disc herniation, this kind of multi-segmental disc herniation should not be treated by decompression, should not be treated by anterior surgery. They have to do only stabilization. Instability is the issue, and stabilization is the treatment. So we have got several cases and several publications on this subject. Now this is deformity. You see this is deformed lumbar spine. And in this kind of thing happens in old age, and many people treat this by decompressions and things like that, but what we have said that these kind of lumbar kyphotic deformities are due to an unstable spine, and only stabilization is the treatment. There is no role for any kind of decompression, and a magical result, that magical result you have to imagine. And if you have any issues, I will be able to, you know, take you around if you come and spend few days with me. Another absolute difficult dangerous issue in spine surgery is OPLL, and those who are in spine, they know that how difficult it is to treat that bone in front of the cord. So my concept is very clear. My concept is that OPLL and cervical spondylosis instability is the cause, and stabilization is the treatment. There is no role for any kind of decompression. So this is quite a revolutionary kind of statement. And I have to tell you that I was myself doing anterior corpectomies and all those things for various kinds of OPLL, and I first described, this was the first article of oblique corpectomy as a treatment for OPLL, which I described several years ago. And so you know that I was familiar with corpectomy and all those things, and this you see corpectomy and removal of these compressive agents. But now, but today I am saying that there is, only stabilization is the ideal treatment for OPLL. There is no need for any kind of decompression either from front or from behind. And more recently, I published my series of 52 cases where there was no decompression, only fixation. And you see how easy it can become, how safe and simple it can become. On the other hand, suppose, suppose my only fixation does not work, or the patient does not improve, the midline is open for you. You can come and do decompression. I have to tell you I have never done decompression after a fixation. Anterior, the whole anterior thing is open for you. Suppose you have done fixation, and the patient has not improved, you can any time come and do anterior decompression. My answer to this question, decompression will not be required. Compression is not the issue, and decompression is not the treatment. Stabilization is the treatment. Instability is the issue. Another fantastic thing, atlantoaxial instability can be associated very frequently with OPLL. If you neglect it, you have not done a complete treatment. You see instability at the facet high OPLL. High OPLL, there is no need to do any kind of decompression. You have to include atlantoaxial joint in the stabilization construct, and without any decompression. So this kind of compression, you see the cord is compressed? You will say clearly compress, I will clearly do decompression. You clearly do not do decompression. You include, you see when there is high atlantoaxial craniovertebral OPLL, or even when the OPLL comes up to this level, you include atlantoaxial joint in the fixation construct. No need for any midline, no need for anterior corpectomy. So this is quite a revolutionary form, simple form of treatment, and a magical clinical outcome. So this is multi-segmental OPLL treated with only fixation. And I have got, as I mentioned, you see such severe compression, you will say I will certainly do decompression. There is absolutely no need for decompression. It should not be done. Compression is secondary, compression is protective, and compression is reversible. So atlantoaxial and subaxial spinal fixation, can it revolutionize the treatment of OPLL? And I have the answer is absolutely clear in my mind that yes is the answer. So Camille's technique is the most beautiful, astounding technique that you have to learn, and we have got now, as I mentioned, several screws. I have introduced double insurance screws like two screws in one facet. It is possible, and it is not necessary in majority because it is such a strong fixation under vision, such a, you know, even I don't want to, normally I work in a public hospital which is completely free, but I never talk of because it is, you know, less expensive and things like that. It doesn't matter to me, but these screws are so economical, so easy to acquire, and I can introduce three screws in the one facet. I call it triple insurance. It is not necessary, but in lumbar, I introduce at least two screws. So facetal fixation that I introduced for a clamp to axial joint is a beautiful technique for subaxial spine. So now my concluding statements are, can decompressive laminectomy for degenerative lumbar and cervical canal stenosis become historical? I'm saying absolutely yes. For radiculopathy, for myelopathy, for OPLL, decompression is not the treatment. Instability is the nodal point of pathogenesis of cervical spondylotic myelopathy and OPLL. So all my statements which I'm making are all published. Another, you see we said that transoral surgery, like transoral surgery, we completely set this into history books. Will anterior spinal cervical spinals, as we like, corpectomy, diskectomy find space in the history book? So this is a very interesting title for you, and I wish you take this in a different perspective. You don't start suddenly, you know, because it is different. You don't start revolting. Think about it, try to analyze, learn more about it, and I am sure in my mind that all the muscles are located in the posterior aspect of the spine. Any entire anterior surgery for stabilization, this posterior muscles will remove, will completely demolished that implant. So from and only decompression to only fixation, a century long journey of treatment of cervical and lumbar spondylosis. Atlantoaxial and subaxial spinal fixation can certainly revolutionize that treatment. So the final word is compression is never primary. Decompression is never the treatment. Instability is the issue and stabilization is the treatment. So this is the card that one of my patients had sent to me. So thank you very much.

- Atul, thank you so much. Very, very thought-provoking, very innovative, really a quite a different perspective. And your imaging studies demonstrate that stabilization have really, has been effective in relieving the compression. And the compression by itself is not the primary source of the problem. The biggest question is how are we gonna know how far we need to fuse, and where is the weakness in the muscles go up and down? We need an objective imaging modality to be able to diagnose patients objectively, and not put them through stabilization procedures. So there is a really objective measure on that. Can you give me some thoughts about that please?

- Yeah, Aaron, you know what? I have written on this on number of occasions. See, when I say muscle weakness, you see in lumbar spine for instance, muscle weakness cannot be in one segment. Muscle weakness, you know, when you become old, or when you disuse, or if you're not using the muscles, it may go on for two or three or more segments. So usually that lumber canal stenosis, what happens in multiple segments, multiple segments are weak, and that can be seen on imaging like L five, S one, L four, L five. But even if you are not seeing at L three-four, it may be unstable, and that you can actually, when you open the spine, and you just hold the spinous process and move it a bit here and there, you will find it entirely unstable. That instability can be identified more easily in the cervical spine. So the thing is, there are many indicators of instability. One is radiological, like when you see an osteophyte, when you see a ligament, flavum buckling, that is unstable spine. When you see, and also when you are having in cervical spine in particular, this issue of central atlantoaxial action. I have no doubt, Aaron, about this complete revolution. Central instability can be present in a huge number like OPLL. Have you ever thought of OPLL having atlantoaxial instability? Have you ever read that cervical degeneration, multi-segmental cervical degeneration can have atlantoaxial instability? Nobody has talked about it, and I have no hesitation to say that in several instances, atlantoaxial instability is present. And if you do not treat the atlantoaxial instability, you are not completely treating, and your results may not be to that extent satisfactory. And if you treat it, you get a magic, a magic that you have never seen. So that is the, see, there are many indicators. You may not see any instability on dynamic imaging. You do flexion extension, there is no instability. But these are indicators of unstable spine. That is the concept, and that is what is different from what has been said in the literature.

- Very enjoyable, very enjoyable, really enjoyed watching the thought process. Very provocative, and really has been demonstrated objectively, so I hope that more people will consider this perspective in treatment on their patients. And we look forward to having you with us for another session on cavernal sinus disease soon. Thank you, Atul.

- Thank you Aaron, my great pleasure, honor, as I said. And I wish you all the best for taking the message of neurosurgery to corners of the world, taking the message of this beautiful subject. I call it absolute fantastic subject in, you know, whoever is doing, whether he's in any poor country or rich country, that is the beauty of these webinars, that you don't have to go to US or to any other country. You sit down in the comfort of your house and watch anybody in the world doing whatever they are doing. So best wishes to Aaron in your mission of promoting neurosurgery. What you are doing with Neurosurgery Atlas, I have been watching, and I told you my daughter is a fan of yours, because she watches all your operations, and what you are doing for education. I can only convey my best wish to you, my dear Aaron. Thank you very much.

- Thank you for your kind words, very much. Thank you, Atul.

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