Advanced Spinal Surgery

"Spine surgery" is a surgical specialization that deals with the conservative / interventional / surgical treatments of spinal and spinal cord disorders that occur in children, adolescents, and adults. Physicians who specialize in this medical field are called "spine surgeons". "Spine centers" are advanced medical units where coordination is done by a spine surgeon and health professionals such as orthopedists, neurosurgeons, neurologists, rheumatologists, physiotherapists, and nurses provide multidisciplinary services with a joint approach All the needs of spine patients can be met under one roof in these centers with the help of current scientific knowledge and advanced technological capabilities. 

The spine has two main functions: The first important function is to provide both mobility and upright posture for the body. The second function is to protect the "neural highway" that communicates between the brain and organs, i.e., the spinal cord, from traumas. Therefore, disorders that occur in the spine can manifest themselves in a variety of symptoms (pain, postural abnormalities, numbness in arms and legs, tingling, limited mobility or loss of strength, urinary incontinence, paralysis, etc.).The pathologies that can cause these complaints can be classified into several main categories:

• Spinal Deformity

The term deformity can be defined as "the distortion of the normal shape". Sometimes deformity may not be accompanied by functional impairment. However, a spine that deviates from its normal structure can generally cause pain, neurological problems, and functional disorders, as well as disrupt the entire body balance.Scoliosis, kyphosis, or trauma are significant causes of deformity. Some deformities arise due to congenital defects, while others develop due to acquired defects later on.The severity of the deformities and the complaints they cause also determine the form of treatment. While some deformities can be managed with conservative methods, surgical correction is required for some severe deformities.

• Degenerative Diseases of the Spine

Degenerative diseases are conditions that disrupt normal functions by altering the anatomical structure.Examples of degenerative spinal diseases include intervertebral disc injuries, disc herniations, and osteoarthritis of the spine joints.In these types of diseases, compression on the neurological structure can lead to symptoms such as pain, weakness, sensory loss, and urinary incontinence. When conservative treatments are not enough to provide comfort for patients in their daily lives, surgical intervention may be necessary.Before making a surgical decision, the patient's age, socioeconomic status, clinical condition, and expectations should also be taken into account.

• Spine Injuries

Minor or major traumas can cause damage, sprains, and fractures in the structure of the spine. Major traumas can cause serious clinical problems and almost always require surgical intervention to restore stabilization.

• Tumoral Lesions in the Spine

In addition to tumors that originate in the spine itself, tumors that start in other parts of the body and spread to the spine are also commonly encountered. Tumoral lesions can sometimes have an invasive and destructive character for the spine. In such cases, a multidisciplinary approach is required: in addition to treatment methods such as chemotherapy and radiotherapy, surgical procedures are performed.Surgical procedures can help reduce tumor mass, relieve pressure on affected tissues, and restore stability that has been compromised.

• Infections of the Spine

The spine can be the target of various infectious diseases. While most of these diseases can be corrected with corset and medical treatment, surgical intervention is performed in some cases. 

The main surgical methods used in spinal diseases can be summarized as follows:

• Decompression (Relief of Compression)

It is the process of relieving the structures (neurological, vascular, etc.) under compression in the spine.In recent years, decompression procedures are generally performed with closed, endoscopic "microsurgical" methods. The recovery process is faster with microsurgical methods.

• Stabilization (Fixation)

• Generally refers to the procedures for restructuring and stabilizing the static balance of the spine, which is disrupted by traumatic, degenerative, and inflammatory diseases to make it balanced and stable again. Stabilization can be achieved with different surgical fixation methods using different materials. Lumbar shift (spondylolisthesis) is a good example of spinal disorders in which stabilization is frequently used.  Spinal fusion surgeries are specialized stabilization methods where two or more bones in the spine are permanently connected to each other.

• Reconstruction

In some advanced cases where correction is not sufficient, reconstruction may be necessary to rebuild the movement of the vertebrae, discs, and spine. In this case, the spinal surgeon can choose one or several different surgical methods that provide reconstruction. There are different surgical techniques available for these surgical purposes.

• Discectomy and Microdiscectomy

It is the partial removal of damaged discs/pads that act as shock absorbers between the vertebrae. It is especially applied to reduce the pressure caused by the discs on the nerve roots coming out of the spinal cord (decompression).

• Disc Prosthesis Applications

It is a reconstruction procedure where an artificial disc is placed in the removed disc's place. It can generally be applied for neck surgeries and in some cases for the lumbar region.

• Laminectomy, Laminoplasty

It is the procedure of removing a portion or all of the bone structure at the back of the spine to increase the diameter of the canal in cases where the spine canal is narrowed.

• Corpectomy

It is the procedure of partially or completely removing one or more vertebrae. It is applied to selected cases where spinal integrity cannot be restored.

• Vertebroplasty

It is a surgical procedure where a cement-like substance is injected into the vertebrae. It is applied in cases where the spine is affected by cancer or fractures. 

• Can be defined as the right or left curvature of the spine when viewed from the front or back. However, it is actually a more complex deformity that affects the entire spine. In addition to moving sideways, the vertebrae also rotate in three dimensions, both upwards and downwards, and inwards and outwards. 

 While scoliosis can occur in people of all ages, it is more common in childhood and adolescence, especially during periods of rapid growth. Problems originating in the spine itself can cause scoliosis, as well as other health issues that can indirectly affect the spine and lead to scoliosis. When considering childhood and adolescence, scoliosis causes can be examined in four main groups:

• Idiopathic Scoliosis   (Cause Unknown Scoliosis)

The most common type of scoliosis among all scoliosis types (approximately 80%). It is 4 times more common in girls. Although there are various opinions on initiating factors, the exact cause has not yet been fully elucidated.Idiopathic scoliosis, which generally has the potential to worsen over time with growth, has 3 subtypes: infantile (up to 3 years old), juvenile (3-10 years old), and adolescent (10-18 years old) scoliosis.

• Congenital Scoliosis  

It occurs due to problems that arise during fetal development in the mother's womb. Malformations such as underdevelopment or partial development of the vertebrae are important causes of scoliosis in this group. Patients may also have accompanying spinal cord, kidney, and heart problems in addition to scoliosis.It can progress rapidly in the first years after birth and may require a more aggressive treatment plan.

• Neuromuscular Scoliosis                

Spina bifida, cerebral palsy, muscular dystrophy, and some other neurological disorders can lead to secondary scoliosis. Due to the natural course of these diseases, the spine loses its muscle and nerve support, causing a loss of physiological structure and resulting in scoliosis. In addition to treating the underlying condition, the complications of scoliosis should also be addressed.

• Functional Scoliosis                        

Functional scoliosis is a type of scoliosis that does not cause structural damage to the spine, and therefore, the spinal curvature is not permanent (at least initially). Deformity does not develop. Temporary scoliosis can occur due to reasons such as poor posture, psychological factors, muscle strains and pains, and differences in leg lengths. Although it is more easily correctable, it requires proper monitoring and treatment plan, and it is important to distinguish it from other types of scoliosis. In contrast to childhood and adolescent scoliosis, adult scoliosis is generally degenerative in nature. Degeneration in the structures that make up the spine (such as discs, ligaments, joints, and muscles) over the years affects the alignment and leads to scoliosis. It gradually appears from the age of 50, more commonly in women.Osteoporosis can be considered as an important predisposing factor. Pain is at the forefront and is often accompanied by other degenerative spinal symptoms (such as leg pain, numbness, decreased walking distance, etc.). 

Scoliosis can cause many symptoms and complaints in the clinic. However, in particular, in mild cases, it can progress for a long time without causing any complaints. The location and severity of scoliosis involvement, as well as accompanying diseases, will change the characteristics of the symptoms. Some of these complaints and symptoms are as follows:

• Curvature and hump of the spine
• Difference in hip and shoulder levels
• Asymmetric appearance of body curves
• Asymmetric appearance between the body and arms
• Disproportionate appearance of the ribs
• Asymmetry of the chest
• Deepening of the lumbar curvature
• One scapula being more protruding than the other
• One shoulder being forward during walking
• One leg feeling longer than the other when walking
• Back and/or waist pain
• Shortness of breath
• Clothes that do not fit the body properly, do not fit properly

 Scoliosis diagnosis, grading, and monitoring are done using direct radiographs (x-ray radiographs). In direct radiographs, the angle of asymmetry in the spine (Cobb angle) is measured to grade scoliosis. Spine curvatures of less than 10 degrees can be named "asymmetry" rather than scoliosis. As the degree of curvature increases, the severity of scoliosis also increases. According to severity, scoliosis can generally be classified into 3 groups:

• Mild scoliosis             (10-20 degrees of curvature)
• Moderate scoliosis    (20-40 degrees of curvature)
• Severe scoliosis        (>40 degrees of curvature)

 In addition to x-ray radiographs, advanced tests such as MRI, CT, EMG (nerve conduction studies), respiratory function tests, and bone mineral measurements (DEXA, QCT) may also be requested by the physician if deemed necessary. 

The treatment and management of scoliosis is carried out through a personalized program with a multidisciplinary approach for each patient. The scope of treatment is determined by the patient's age, the cause of scoliosis, the rate of progression of the deformity, and the degree of curvature of the spine (Cobb angle).Scoliosis treatment is a long-term process that requires strict monitoring. This already causes great concern and stress for the patient and their family. So it is very important for the physician and healthcare team to provide family support.In some cases, only monitoring and exercise programs may be sufficient for treatment, while in some patients, up to 24-hour corset use may be required. In advanced cases, surgical intervention becomes inevitable.

• Usually involves radiological imaging and examination at certain intervals for curvatures smaller than 20-25 degrees. Regular exercise should be performed during this period. During monitoring, treatment options are evaluated based on the progression of scoliosis and are explained to the patient in detail by the physician.

 Exercise programs for scoliosis are based on stretching and strengthening of muscles through a well-planned program, correcting posture, and increasing mobility. In addition, breathing exercises are included in exercise programs to increase lung capacity and function. It is very important for patients to adhere to the exercise program for treatment success. Schroth exercises are specific scoliosis exercises applied for reorganizing the disrupted balance of the spine with a 3-dimensional approach. It is performed with the guidance of a trained and certified physiotherapist in individual and group therapy sessions and is supported by home programs.  Corset is effective in children with a curvature of 20-40 degrees that is still growing. It is used to prevent the progression of deformity. However, in order for it to be effective, it must be worn all day long (at least 18 hours) until growth is complete. There are specially sized corset available depending on the severity and type of curvature. Its use can be quite challenging and requires patience. Corset treatment during adolescence loses its effectiveness when growth stops, while shorter-term corset use in adult-onset scoliosis can reduce pain by supporting the spine. Non-surgical treatments cannot reverse the degree of scoliosis already present, so early diagnosis in these patients is of great importance to prevent disease progression. Surgical treatments are preferred to prevent further worsening of curvature in the spine and to return the existing deformity as close to normal as possible. However, it is not a suitable treatment method for every patient. It is preferred in aggressive scoliosis where corset use cannot stop the curvature or when the curvature is above 40 degrees. In such cases, the advanced deterioration of the spine and chest can cause complications that threaten life by impairing the functions of the heart and lungs.For surgical procedures, lung and spine development is generally waited for a certain stage, but in special cases, surgical intervention may be required at earlier stages. Classical scoliosis surgery, known as "spinal fusion," involves straightening and stabilizing the spine by placing metal screws and rods in the vertebrae.  This method has been successfully applied for many years. In recent years, tethering (tensioning) methods such as VBT (vertebral body tethering) and anterior scoliosis correction surgery have been more frequently and successfully applied as an alternative surgical method. Since this method is non-fusion (), it allows the patient to continue growing by utilizing the spine's growth potential. Additionally, compared to fusion surgery, it allows for greater flexibility and comfort in the patient's daily activities.From a surgical technique point of view, it is a very complex and experience-requiring procedure. It is of great importance for the success that the entire team that will undergo the operation is experienced in this regard. The Emsey Hospital Spine Center, the first and only center of excellence in Turkey and Asia, has successfully performed this surgical intervention for many years and has made significant scientific contributions to the world literature on the subject. 

  In cases where kyphosis is increased, the most common reason for a patient to seek medical attention is due to the noticeable deformity in the back. In addition, pain in the back, shortness of breath due to chest involvement, fatigue, and secondary signs of underlying disease may also be seen.A detailed examination after the hyperkyphosis diagnosis is usually sufficient with X-ray radiographic examinations of the spine. However, in some cases, the physician may also need additional tests such as CT, MRI, EMG (nerve conduction studies), bone mineral measurements (DEXA, QCT), and respiratory function tests. 

The treatment for kyphosis depends on the cause of the condition, the severity of the deformity, and the patient's age. In postural kyphosis, which is caused by poor posture, regular exercise programs and lifestyle modifications (such as correcting sitting position, ergonomic adjustments, regular exercise like swimming or pilates, etc.) to improve posture may be sufficient to correct the condition. Medical and physical therapy treatments can also be helpful for pain relief. This treatment program may be effective for mild Scheuermann kyphosis as well, but corset use and surgical intervention may be necessary in advanced cases. Corset use is ineffective in cases where growth has already stopped.The classic method that has been successfully used in kyphosis surgery for many years, similar to scoliosis surgery, is spinal fusion surgery, where the spine is fixed with metal rods and screws.In recent years, there have been significant developments in non-fusion surgeries for kyphosis treatment. Tethering methods, like in scoliosis surgery, can also provide promising results in selected cases of kyphosis. The Emsey Spine Center team has made significant scientific contributions to the medical literature regarding this current surgical procedure and has achieved a prominent position in the world. 

• First and only "spine excellence center" certification in Asia and Turkey
• An academic team that leads the way in spine surgery in the medical literature
• Innovative and multidisciplinary approach: Scientific council in all fields related to spine health, such as spine surgery, orthopedics and traumatology, brain and neurosurgery, physical therapy and rehabilitation, neurology, rheumatology, and algology.
• Holistic treatment approach: Providing psychological, nutrition and diet, and rehabilitation support for patients under one center during postoperative process.
• Experienced healthcare staff in preoperative and postoperative preparation and care.
• 24/7 uninterrupted service throughout all diagnosis and treatment processes.

Orthopaedics and Traumatology

ORTHOPAEDICS AND TRAUMATOLOGY
Our experienced academic staff and specialist physicians, who benefit from vast opportunities of the modern technology, provide all patients with world-class medical and surgical treatments through a scientific approach.Our physicians examine congenital or developmental abnormalities of the musculoskeletal system through a multidisciplinary approach. Moreover, our center, that offers a healthcare service in a wide range of fields such as spinal surgery, hand surgery, bone tumors, hip and knee arthroplasty, sports injuries, fractures and dislocations, and pediatric orthopaedics, successfully performs diagnostic and treatment procedures of all musculoskeletal diseases, especially the diseases related to Orthopaedics and Traumatology. In general, the fields of study can be summarized as traumatology (musculoskeletal system disorders occurred due to hit-impact-accident), arthroplasty (joint replacement surgery), arthroscopic surgery (closed surgery procedures performed for intra-articular problems), hand surgery-microsurgery (including repair of severed organs through sutures), spinal diseases and surgery, pediatric orthopaedics (including congenital musculoskeletal disorders), musculoskeletal tumour surgery, and sports medicine.

SPINAL DISEASES AND SURGERY
Spinal diseases and surgery is our another field of study. Spinal curvatures and fractures are the main parts of the treatment. Spinal curvature disorders may be congenital or developmental. Though spinal fractures usually develop after high-energy injuries, sometimes osteoporosis or tumour dissemination may have a role in development of spinal fractures. The nerves, that pass through the vertebrae and move from the brain to the locomotor system, increase the risks of this region. Diagnosis and treatment of spinal diseases are performed successfully in our hospital. 

How is scoliosis treated?
There are many causes that may lead to scoliosis. However, different treatment methods have been developed for nearly 80 percent of patients who are diagnosed with scoliosis, in other words, spinal curvature. The methods that are commonly used for treatment of scoliosis in our day are divided into three groups as scoliosis exercises, scoliosis corset, and surgery for scoliosis. The most appropriate treatment method for scoliosis is determined after a detailed examination to be made by a specialist doctor. The treatment methods vary by person to person and the degree of spinal curvature. 

Scoliosis in Adults
Scoliosis can be seen not only in children, but also in adults. However, scoliosis in adults is usually seen as it could not be diagnosed in childhood and has been brought into adulthood. Scoliosis may also be observed after the age of 50 due to spinal degeneration. Unlike scoliosis in childhood, the most common complaint of adults with scoliosis is pain. The pain is usually relieved with painkillers and physical treatment methods. As skeletal growth has ended, brace procedure with scoliosis corset is rarely performed. Surgical treatment may be required in some cases that are resistant to the relevant treatment methods.

Surgical Treatment
Surgical treatment is preferred if spinal curvature is advanced. Surgery should be considered if an individual’s curvatures on the back are more than 45 degrees or curvatures on the waist are more than 35 to 40 degrees. It is an extremely important surgery that requires a great attention. Therefore, surgery for scoliosis should be performed by an experienced and specialist doctor.

TRAUMATOLOGY
Traumatology can be defined as a sub-branch that deals with treatment of musculoskeletal system diseases caused by hits, impacts, falls and traffic accidents that are frequently encountered especially in our country. Even though fractures are the first thing to come to mind, cranial fractures are examined and treated by different departments. Facial fractures are treated by the department of Plastic-Reconstructive and Aesthetic Surgery and the department of Otorhinolaryngology Surgery. On the other hand, fractures of other cranial bones are treated by the department of Brain and Nerve Surgery. In addition, rib fractures that are frequently seen are treated primarily by the department of Thoracic Surgery. Fractures do not always develop after trauma.  Injuries of the structures such as muscle-tendon-ligaments, that are generally called soft tissue injuries, are repaired and treated by the department of Traumatology. As we are a surgical department, surgical interventions are performed successfully by our team in cases where a surgical procedure is needed.  

ARTHROSCOPIC SURGERY
Arthroscopic surgery can be defined as a procedure that is used in diagnosis and treatment of diseases inside a joint through a closed surgical method. Closed surgery refers to an intervention in which a pen-shaped camera is entered into the joint and the procedure is performed with pen-shaped tools from the other side.  The most important advantage of the closed surgery is that it is a procedure performed without any surgical incision. The patient can return to her/his work earlier than an open surgery. Another advantage of this procedure is that it allows the doctor to make a detailed and functional examination of the synovial membrane, ligaments, cartilage structures, tendons and bone structures. Even though the interventions are most frequently performed for the knee and shoulder joints, arthroscopic interventions can also be performed for the elbow, wrist, hip and ankle joints. All arthroscopic interventions are performed successfully in our clinic.

ARTHROPLASTY
Arthroplasty can be shortly defined as joint replacement surgery that is performed with prosthesis. The word ‘’prosthesis’’ can be considered as the prostheses used in dentistry. Dental prostheses used in patients who have missing or highly deformed teeth replace the teeth and function. Similarly, prostheses are used in the treatment of cartilage degeneration that appears after the age of 40 in average or secondarily to any previous trauma. The prostheses replace the joints impaired. Though knee and hip replacement surgeries are usually more common, there are replacement procedures performed also for the shoulders, elbows, ankles, wrists and fingers. However, these prostheses should not be confused with the prostheses used to provide an appearance and function after any loss of a part of the body (amputation). For instance, the devices used externally to provide walking in a case of amputation of the leg are also called prosthesis. After the arthoplasty surgeries, the patient’s joint pain is removed and her/his mobility is increased. The prostheses can be permanent up to 15-20 years. These surgeries are performed successfully in our hospital. 

MUSCULOSKELETAL TUMOURS
Diagnosis, treatment and follow-up of musculoskeletal tumours are made successfully in our clinic. The word ‘’tumour’’ refers to all kinds of cells that grow in the body. Moreover, tumours are divided into two groups as benign tumours and malignant tumours depending on their dissemination and ability to deteriorate the relevant structure. Musculoskeletal tumours can be basically classified as soft tissue tumours and bone tumours. In addition to surgical treatment, medication and radiation therapy are sometimes included in the relevant treatments.

PEDIATRIC ORTHOPAEDICS 
As the name suggests, Pediatric Orthopaedics that is a sub-branch of medicine deals with musculoskeletal system diseases of children. However, it should not be forgotten that children are not miniature adults. Diagnosis, treatment and follow-up procedures of pediatric diseases are very different from the procedures performed for adults. Moreover, there are some interrelated disorders in which the department of pediatric orthopaedics can follow together with the departments of traumatology, spinal surgery and other sub-branches. However, when pediatric orthopaedics is considered, congenital gait abnormalities such as hip dislocation, that is a common disorder seen especially in our country, come to mind. Even though the incidence rate of hip dislocation has decreased gradually in recent years, it is still a problem. However, hip ultrasonography is a revolutionary development on this matter. Early diagnosis and nonsurgical treatments can yield very successful results. Ultrasonography of the hip is performed within the standard newborn screening procedure in our hospital.

HAND SURGERY – MICROSURGERY
Even though surgical suture procedure performed for severed parts of the body with microsurgical methods primarily comes to mind when hand surgery-microsurgery is considered, it can be said that hand surgery covers a wide range of areas from the fingertip to the shoulder. When microsurgery is considered, the procedure, in which the vascular and nerve structures that are almost invisible with the naked eye are sutured with very thin sutures and special suture tools under a microscope, should come to mind. Even though this intervention has become highly popular especially in the recent years, it is not a method that can be performed for every severed part of the body. Successful results can be achieved only if this procedure is performed for appropriate patients. It is very difficult to achieve successful results in patients with highly damaged vascular and nerve structures. Hand surgery should not be understood simply as a procedure in which the severed parts of the body are sutured. In hand surgery, all musculoskeletal injuries of the region between the hand and the shoulder are also treated. In addition, many examples that include bone fractures, nerve compressions and muscle-tendon tears in that region can be given. In our department, it is possible to successfully benefit from all opportunities of hand surgery and microsurgery.

SPORTS MEDICINE
Sports medicine, as the name suggests, is a sub-branch of medicine that deals with musculoskeletal injuries in athletes. Athletes may return to sport activities only after a true diagnosis, treatment and rapid rehabilitation program. Here, the most critical problem is the shortened time for return to sport. Some musculoskeletal disorders require a surgical treatment only in athletes. Return to sport is provided only through such procedure.  

PROSTHESES (ARTHROPLASTY PROCEDURES)
Hip Replacement (Arthroplasty)
Replacement surgeries are also known as arthroplasty procedures. Hip replacement procedure is performed in cases where the hip joint is disrupted. Hip replacement surgery is necessary if the joint is disrupted due to arthritis of known or unknown origin, previous treatment performed for hip dislocation in childhood, hip-related fractures and dislocations, medication-related osteonecrosis of the hip joint, or previous Perthes disease in children. 

Knee Replacement (Arthroplasty)
Knee replacement procedure is performed to correct the knee deformities caused by calcification of the knees and rheumatic diseases in elderly patients, fractures related to the knee joint, and sometimes the use of cortisone or similar cases that result in osteonecrosis that lead to a progressive destruction of the knee bones.