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Lateral Lumbar TDR (XL-ADR) and Anterior Lumbar TDR AT L5-S1

Artificial disc replacement is a procedure that involves replacing a painful disc that is causing chronic back pain with an artificial disc that provides pain relief without compromising the spines natural anatomical structure.Artificial disc replacement surgery may be performed on the lower back or the neck. Artificial discs are structurally similar to the damaged discs that are replaced and share similar functions, including acting as shock absorbers in the back or neck.

The development of the lateral approach for fusion allows today the possibility to offer TDR by this approach when the disc to be replaced is above L5-S1. The risks of the anterior approach are eliminated and the neurophysiological monitoring of the nerves decreases the risk of traction injuries of the lumbar plexus in its transpsoas trajectory.

The XL procedure is what is termed as “minimally invasive” procedure. This means that instead of a traditional, larger single incision, the procedure is performed through one or more small incisions and an instrument known as a retractor is used to spread the tissues so that the surgeon can see the spine. This is made possible by the use of a dilator and retractor system, MaXcess®, developed by NuVasive®, Inc, in San Diego, CA. This system allows the surgeon to reach the spine via lateral access (from the side of the body).

Previous lumbar Total Disc Replacement (TDR) devices require an anterior approach for implantation. This approach has inherent limitations, including risks to abdominal structures and the need for resection of the anterior longitudinal ligament (ALL). Placement of a TDR device from a true lateral (extreme lateral [XL]) approach is thought to offer a less invasive option to access the disc space (reduced risk of interrupting blood circulation in the left leg, significantly reduced risk of arterial thromboembolism, reduced risk of plaque embolism with arteriosclerosis), preserving the stabilizing ligaments and avoiding scarring of anterior vasculature.

When L5-S1 has to be included in the surgical treatment an anterior TDR procedure is performed. Some patients benefit from hybrid procedures; for example, a fusion performed anteriorly ALIF or transforaminal lumbar interbody fusion [TLIF] with cages and pedicles screws at L5-S1 and XL-ADR at the other lumbar levels or Posterior Dynamic Stabilization with Dynesys at L5-S1 and TDR at L4-5 or/and L3-4 could be performed.

Total Disc Replacement.
Extreme Lateral Artificial Disc Replacement Cervical Disc Replacement (ADR)

An artificial disc surgery may be engaged instead of an anterior cervical discectomy and fusion. The theoretical advantages of the artificial cervical disc over a fusion include:

1. Maintaining normal neck motion
2. Reducing degeneration of adjacent segments of the cervical spine
3. Eliminating the need for a bone graft
4. Early postoperative neck motion
5. Faster return to normal activity

ADR treats symptomatic degenerative disc disease more effectively while maintaining spinal motion following anterior discectomy.

The artificial disc is designed to take the place of the real intervertebral disc and be placed between two vertebral bodies, where the disc has been surgically removed, in order to decompress the spinal cord or nerve root in the neck. Ideally the artificial disc acts like a normal disc, providing motion while acting as a shock absorber in the spine (unlike a fusion, which eliminates both motion and shock absorption in the fused segment of the spine). The indications for a cervical disc replacement are generally the same as for a cervical discectomy and fusion. A person must have a symptomatic cervical disc, which may be causing arm pain, arm weakness or numbness with some degree of neck pain. These symptoms may due to a herniated disc and/or osteophytes compressing adjacent nerves or the spinal cord. This condition typically occurs at cervical spine levels C4-5, C5-6, or C6-7.

The standard surgical procedure for a disc replacement is an anterior (from the front) approach to the cervical spine. This surgical approach is the same as that presently used for a discectomy and fusion operations and performed microsurgically with delicate instrumentation. The affected disc is completely removed including any impinging disc fragments or osteophytes (bone spurs).

Motion preservation procedures for the spine are a newer set of operations that have been devised to correct some of the problems we have had with previous spine surgeries.

Many times in an attempt to treat pain, we look for the pain area, whether it’s coming from the joints or the problem relates to pressure on the nerves, rather than the disc itself.We can sometimes help stabilize the motion without taking the disc away, using some special flexible rods in the back of the spine with the same goal of helping to relieve pain, but maintaining some element of motion to help patients function better and still treat their pain. Posterior dynamic stabilization devices are analogous to an internal brace on the spine. The goal of posterior dynamic stabilization devices is to allow controlled motion in such a way as to achieve a more normal movement of the spine. These devices have been typically used in Europe to treat patients with degenerative disc disease as dynamic stabilizers for the last 20 years.

Dynesys and Globus Medical devices are the only devices that allow multilevel stabilization in more than two segments. These systems are added to the spine without damaging the normal structure and are inserted by a Minimal Access Technique splitting muscles, not cutting them. It is the only technique with such versatility, non-compromising any other future options.

We have been using this technique for more than 12 years in more than 500 patients with excellent results in the following indications:

1. Young people with invalidating low back pain and DDD with black disc and fissures.
2. Elderly patients with canal stenosis for stabilization.
3. Recurrent disc herniation.
4. Mild segmental instability like retrolisthesis or grade I degenerative spondylolisthesis.

Lumbar spinal fusion is designed to stabilize or stop the motion of the vertebral segment where the degenerated disc is located. The operation involves accessing the segment through a back incision.

Presently percutaneous techniques have minimized the soft tissue damage to a minimum. The hardware (such as pedicle screws, interbody cage, spacers, or structural bone graft) used to temporarily immobilize the affected segment while the fusion is healing, is inserted through this minimal access technique.We prefer percutaneous pedicles screws with XLIF (extreme lateral interbody fusion) in the majority of cases, but TILF transforaminal (removing one entire facet joint) interbody lumbar fusion and ALIF (anterior incision in the abdomen) anterior lumbar interbody fusion remain the best option in selected cases.

The XLIF procedure for lumbar fusion was developed to overcome the obstacles of both anterior (front) and posterior (back) approaches to access the spine.

XLIF avoids significant musculature disruption by utilizing a natural path from the side of the body to the spine and provides significant benefits to patients, including reduced surgery time, less blood loss, shorter hospital stays, and significantly faster recovery time.

The XLIF approach does not require back muscle and bone dissection or nerve retraction; it also allows for a more complete disc removal and predictable implant insertion, compared with traditional posterior procedures. XLIF also does not require the delicate abdominal exposure or present the same risk of vascular injury as traditional anterior procedures.

Because the procedure is less disruptive than conventional posterior or anterior surgery, most patients are able to get up and walk within approximately a day of the surgery.

In general, XLIF surgery results in faster recovery and the patient is able to get up the next day and return to normal activities shortly after.

Cranial Procedures

At least 20% of epilepsy cases remain intractable even with the best medication treatment that in addition often lead to very disturbing side effects.

The consequences of this include: denied driving license, social isolation, job loss and, more importantly, real life threatening situations due to the injuries produced by the patient’s seizures.Recurrent seizures cause neuronal loss function, which almost always results in the deterioration of the memory function. It is particularly damaging in early childhood where repeated seizures stop psychomotor development. It is a priority to control seizures before the child reaches eight years of age, at which point the brain has almost completely developed, in order to avoid permanent psychomotor impairment. When seizures remain refractory for more than one year, a presurgical evaluation is recommended. The main component of this evaluation is a video-EEG monitoring during several days to allow seizure recording for computerized analysis in order to disclose and localize the origin in the brain of those seizures.

Other components of the presurgical evaluation are:

– Brain imaging particularly MRI with special protocols.
– Metabolic functional imaging techniques such as PET or SPECT that overlap with the MRI. 
– SISCOM (when needed).
– Computerized reformatting techniques of brain electrical activity (EEG) to localize electric dipoles that are superimposed on the MRI.
– Magnetoencephalography (MEG) to show the magnetic dipoles of seizure activity on the RM.
– Neuropsychological evaluation.

When the presurgical evaluation discloses a unique epileptogenic zone as the origin of the patient’s seizures, and has no functional risk of resection and correlates with a morphological abnormality detected on MRI, the patient is a good candidate for resective epilepsy surgery with excellent prognosis. 

Epilepsy Surgical Procedure:

Many patients are diagnosed of Temporal Lobe Epilepsy (or other forms of partial epilepsy) with very good surgical prognosis, and could proceed to a resection of their epileptogenic area, frequently an anterior temporal resection or an amigdalo-hypocampectomy. We started the epilepsy surgery program in 1987 and since then we have treated over 600 patients using different surgical techniques with results within international standards. Our experience is particularly broad and with exceptional results in difficult cases of children with tuberous sclerosis. There are different surgical techniques that apply specifically to the different diagnoses of the patients undergoing epilepsy surgery, and also have different prognoses according to these diagnoses. The most common are: minimally invasive craniotomy with cortical resection (epileptogenic area) in the temporal lobe, selective amygdalohippocampectomy and frontal lobe resections. Resective surgery can be performed in any location of the brain, provided cortical functional localization is used to tailor it. Functional hemispherectomy is very useful in pediatric epilepsy with unilateral motor deficit. Other palliative surgeries are: corpus callosotomy, vagal nerve stimulation, and DBS (Deep Brain Stimulation) stimulation (anterior thalamic nucleous). Palliative surgery is mainly designed to prevent sudden falls with injuries. Since the introduction of computer-guided surgery at our center in 1997, intraoperative neuronavigation has greatly facilitated the registration of any brain structure that is required. It has facilitated the identification of brain areas to preserve their functional importance and the location of any anomaly that has small size. Some cases need an awake craniotomy to study the cortical activity, and localize speech cortical areas and subcortical pathways to preserve brain function.

Groups with better prognosis after epilepsy surgery are:

Intractable epilepsy associated with a small lesion as benign tumors or vascular malformations. In this group 87% of patients remain seizure-free when the removal of the lesion and the epileptogenic area is performed. Another set of excellent results is medial temporal lobe epilepsy with mesial sclerosis, the most common type between the non-lesional epilepsies treated surgically, with over 70% of seizure-free cases. Pediatric epilepsies associated to unilateral brain atrophy and hemiplegia treated by functional hemispherectomy reached more than 85% seizure-free. Non-lesional extratemporal epilepsies have a worse prognosis, but still a benefit is obtained from an improved quality of life in 75% of cases and the seizure-free patients arrive to 50%.
Complications are rare, with a mortality rate of less than 0.5%, which is much lower than the mortality figures for injuries sustained during the seizures observed in drug-resistant patients left to their evolution without surgery. In our experience, for example there are 12 times more deaths from accidents in patients with uncontrolled seizures than in the surgical series. From 1987 to 1997 our team performed 234 intractable epilepsy surgical therapeutic and diagnostic procedures. From 1997 to 2012 we performed 372 additional epilepsy surgery procedures with large increase of complex cases without visible lesions in cranial MRI or multiple lesions in the cases of tuberous sclerosis. We can account for a total of over 600 procedures, accumulating the most extensive experience in Spain and one of the largest in Europe.

Epilepsy Surgery and Intracranial Recording Studies:

Some patients need a further evaluation during several days with intracranial implanted electrodes to disclose the seizures origin between two possible zones, which are not discernible from the study performed with scalp electrodes. Additionally, stimulation studies are performed to localize functions in cortical areas of the brain. In these cases a first operation is performed to implant the electrodes, and a second one to withdraw the electrodes and resect the seizure origin zone.Intracranial recordings are performed with depth electrodes implanted with the neuronavigation system in different brain’s areas to allow an SEEG (stereo-encephalography) recording or with subdural grid, when a more localized area of the brain has to be studied and cortical functional mapping is needed.

We routinely use a purely endoscopic technique to remove pituitary tumors. The endoscope has revolutionized the surgical treatment of pituitary tumors.

The ability to directly see and remove a tumor in an otherwise difficult to reach area, as the cavernous sinus, allows a more complete resection of the tumoral tissue and also to distinguish better the normal pituitary gland to be preserved, which decreases the postoperative hormonal deficits and increases the total resection of tumors.The endoscopic technique provides a wide-angle vision field and a greater detail than microsurgical techniques. The superb visualization opens a new world for endonasal surgery making that an expanded endonasal approach (EEA), which represents the procedure of choice to resect intracranial tumors previously operated through a craniotomy, resulting in an increase in patient comfort and safety, early hospital discharge and, more importantly, a more complete resection with easier identification and preservation of normal brain structures.

By operating through the natural pathway of the nose and nasal sinuses, this surgery can be performed without a visible scar on the face or scalp. There are typically fewer, if any, lingering side effects compared to traditional craniofacial surgery. Patients can often be discharged the day after surgery or in a few days in more complicated procedures.

The Endoscopic Pituitary Adenoma/Skull Base Surgery program, currently led by Dr. B. Oliver and Dr. H. Massegur, has refined numerous surgical techniques for complex lesions of the skull base treated transnasally using the endoscope as the sole visualization tool. This “inside-out” approach reduces the morbidity associated with traditional open skull base approaches.

Our center combines the expertise of neurosurgeons, otolaryngologists, plastic surgeons, radiation oncologists, and interventional radiologists to facilitate interdisciplinary treatment of complex tumors and vascular lesions at the base of the brain.

The base of the skull has proven to be one of the most challenging anatomic regions to access. In the late 1980s and early 1990s significant breakthroughs were made, but those approaches involved facial disarticulations and removal of the bones and facial skeletons. In the latter part of the 1990s decade it became apparent that the morbidity related to gaining access to this space was very significant.

The incorporation of endoscopy into neurosurgery was adopted and changed the way skull base surgery is performed nowadays.

In 2005 the skull base program at Neuroinstitute Oliver-Ayats made a formal commitment to take advantage of this technology to access the skull base, and then progressively for other brain areas. Much work had been done before in the ENT field in using the nose to access the region, but had stopped short of the skull base. We now extend this to approach and resect tumors of the skull base and then access the brain itself. In fact there is no need for incisions at all because the nose provides the passage.

Specifically, using this approach we have been able to progressively access the entire skull base. So far (until May 2012), we have undertaken 312 operations, and have been able to extend this technique to reach central brain tumors and remove them completely through the nostril.

In essence the procedure allows both the approach and resection of the tumor to be done with minimal disturbance to the surrounding tissues.

Our Pituitary Adenoma and minimally invasive Skull Base Center has an accumulated experience in the treatment of around 1,000 pituitary adenomas and some 500 skull base tumors.

Cranial base surgery involves treatment of the congenital, vascular, neoplastic, endocrine and traumatic lesions involving the basi cranium.

This surgery is the brainchild of three specialties: craniofacial surgery, neurosurgery and neuro-otology. Anatomically the skull base is divided into three subdivisions. The anterior skull base, the lateral skull base and the posterior or extreme lateral skull base.Anterior Skull Base 

The anterior skull base is further subdivided into midline and paramedian regions. Midline lesions include congenital encephaloceles, craniofacial clefts, or tumors (such as pituitary lesions or craniopharyngiomas). Paramedian lesions include orbital tumors and locoregional extensions of paranasal sinus and head and neck tumors. 

Lateral Skull Base 

The lateral skull base involves lesions in the infratemporal fossa as described. These consist of glomus jugulare tumors, clival tumors and petrous apex lesions such as cholesterol cysts. Other lesions are further anterior extensions including juvenile angiofibromas and nasopharyngeal carcinomas. Lateral skull base surgery also includes transtemporal lesions (middle cranial fossa) including sphenoid wing meningiomas, neuromas of the trigeminal nerve and vascular lesions such as internal carotid artery aneurysms. We have engaged in more than 500 of thes type of operations.

Posterior or Extreme Lateral Skull Base 

Surgery of the extreme lateral skull base involves the cerebellopontine (CP) angle including acoustic neuromas, microvascular decompression of cranial nerves, meningiomas of the posterior fossa, and surgery of the craniocervical junction. 

The Minimally Invasive Skull Base Center incorporates an innovative microneurosurgery program offering minimally invasive craniotomy procedures when appropriate. This allows a non-biased approach whereby the appropriate surgical approach is selected based on patient, tumor and anatomical factors rather than surgeon preference or training.

Our multispecialty team allows a multimodality approach incorporating endonasal and craniotomy surgical procedures along with endovascular interventional approaches and Novalis radiosurgery, all with the ultimate goal of patient’s safety and best treatment.

Neuroinstitute Oliver-Ayats has extensive experience treating such conditions as: acoustic schwannoma (neuroma), meningiomas, chordomas, chondromas, craniopharyngiomas, epidermoid cysts, and many others.

A craniotomy is a procedure to remove a lesion in the brain through an opening in the skull (cranium). A craniotomy is a type of brain surgery and is the most commonly performed surgery for brain tumor removal.

It also may be done to remove a blood clot (hematoma), to control hemorrhage from a weak, leaking blood vessel (cerebral aneurysm), to repair arteriovenous malformations (abnormal connections of blood vessels), to drain a brain abscess, to relieve pressure inside the skull, or to perform a biopsy.The procedure is engaged through a glioma resection with fluorescence guidance in high-grade tumors, neuronavigation and functional mapping.

Through the administration of ALA preoperatively, tumoral cells in high-grade gliomas are able to synthetize a fluorescent substance that can be visually detected with the help of a specially designed light, which enables the surgeon to differentiate between red colored tumoral tissue from blue normal brain parenquima.

Without this technology is difficult to define the resection limits of some infiltrative tumors.

Microvascular Decompresion for Trigeminal Neuralgia is performed through a small cranial opening that allows the separation from the trigeminal nerve of the offending vessel by means of a piece of Teflon.

Patients are put to sleep using general anaesthesia and are positioned on their back with their head turned or on their side with the symptomatic side facing up. Electrical monitoring of facial function and hearing is used.A straight incision is made two finger-breadths behind the ear about the length of the ear. A portion of the skull the size of a half-dollar is removed exposing the underlying brain covering known as the dura. The dura is opened to expose the cerebellum. The cerebellum is allowed to fall out of the way exposing the side of the brainstem. Using a microscope and micro-instruments, the arachnoid membrane is dissected allowing visualization of the 8th, 7th and finally the trigeminal nerve. The offending loop of blood vessel is then mobilized.

Frequently a groove or indentation is seen in the nerve where the offending vessel was in contact with the nerve. Less often the nerve is thin and pale. Once the vessel is mobilized a sponge like material is placed between the nerve and the offending blood vessel to prevent the vessel from returning to its native position.

After the decompression is complete, the wound is flushed clean with saline solution. The dura is sewn closed. The skull is reconstructed and the overlying tissues are closed in multiple layers.

The patient is allowed to wake up and is taken to an intensive care unit or other close observation unit. The hospital stay lasts approximately 3 days in total.

Vestibular neuroctomy consists in the cutting of the affected vestibular nerve. 

A vestibulary neurectomy is a surgical procedure that may be used to correct vertigo problems caused by Ménière’s disease.

The operation severs the vestibular nerve in the ear.

Deep brain stimulation (DBS) is a surgical treatment involving the implantation of a medical device called a brain pacemaker, which sends electrical impulses to specific parts of the brain.DBS in select brain regions has provided remarkable therapeutic benefits for otherwise treatment-resistant movement and affective disorders such as chronic pain, Parkinson’s disease, tremor and dystonia.

Despite the long history of DBS, its underlying principles and mechanisms are still not clear. DBS directly changes brain activity in a controlled manner, its effects are reversible (unlike those of lesioning techniques) and is one of only a few neurosurgical methods that allows blinded studies.

Other Procedures

Other treatments and techniques offered are:

-Fluorescence-guided surgery for brain tumour
-Cerebral mapping
-Neurosurgical treatment of pain