Prof. Dr Oliver P. Gautschi is a leading expert in the field of spinal surgery, with an impressive career and extensive experience in the treatment of spinal conditions. He began his medical career after studying medicine at the University of Basel, where he also obtained his PhD. As a specialist in neurosurgery, he specialized in spinal surgery early on and has continuously expanded his expertise in this field.
His expertise covers the entire spectrum of spinal surgery, ranging from minimally invasive procedures to complex operations for spinal tumors and trauma. In doing so, Prof. Dr Gautschi places particular emphasis on motion-preserving procedures (whenever possible) and minimally invasive techniques to ensure patients achieve the best possible recovery. His expertise also extends to navigation during spinal procedures, enabling him to ensure exceptional precision and safety in treatment.
A key focus of his work is also clinical research in the field of spinal surgery. As a member of the Clinic for Neurosurgery and Spinal Surgery of Central Switzerland at the Hirslanden Clinic St. Anna in Lucerne, Prof. Dr. Gautschi works within an interdisciplinary team of highly qualified doctors and nursing staff to provide patients with comprehensive and personalized care. The clinic is equipped with state-of-the-art technology and first-class facilities to ensure precise diagnosis and treatment.
Through his empathetic care and personal commitment, Prof. Dr Gautschi plays a key role in ensuring that patients feel well looked after and that optimal treatment outcomes are achieved. His aim is to enable patients to enjoy an improved quality of life through high-quality medical care, to make everyday activities easier, to alleviate pain and to promote their long-term health.
Revision surgeries are particularly demanding and generally require a very high level of expertise. The editorial team of the Leading Medicine Guide spoke to the specialist Prof. Dr Oliver Gautschi about this.
The spine is a complex and heavily stressed system that is subjected to the forces of gravity on a daily basis. Over time, various factors such as implant failure, infections or osteoporosis can lead to complications that necessitate further surgery. These so-called revision procedures present a challenge and require experienced surgeons as well as specialized facilities. Spinal surgery is often preceded by long periods of severe discomfort. Patients have high expectations of the procedure, and thanks to state-of-the-art techniques and highly specialized surgery, treatment outcomes are generally above average these days. Performing revision surgery is more demanding than the initial procedure, as scar tissue or changes resulting from the previous operation are often present, and the anatomy is usually altered as well. Depending on the cause of the problems, various techniques can be used to relieve pressure on nerves, stabilize vertebrae with screws, or promote the healing process of the bone.
Following an initial spinal operation, various complications may arise that could necessitate revision surgery.
“In principle, the same symptoms may occur after spinal surgery as before the operation. These include pain, and motor and sensory deficits. These symptoms (particularly the pain) can usually be treated with medication initially. However, depending on the severity of the symptoms, revision surgery may need to be considered. One of the most common causes is fusion failure, where the fusion of two or more vertebrae does not heal completely, leading to pain and instability. Implant problems, such as screws, plates or rods becoming loose, breaking or shifting, may also necessitate further surgery. Furthermore, excessive scar tissue around the nerve roots can cause pain or neurological symptoms. Conditions such as herniated discs or spinal stenosis may recur after a successful initial operation. Inadequate stabilization of the spine can lead to mobility and instability in the operated area, which may cause further discomfort. “Infection is no longer as common as it used to be, thanks to established treatment protocols such as instrument sterilization, perioperative antibiotic prophylaxis and early preparation of the skin and nasal mucosa (keyword: decolonisation),” explains Prof. Dr Gautschi at the start of our conversation.
The diagnostic procedures for revision surgery following a previous spinal operation are crucial for identifying the exact cause of persistent symptoms or complications.
Compared to the examinations prior to the initial operation, these procedures can be tailored more specifically to the symptoms present and potential problems. “The patient is usually referred back by their GP with the explanation that there is a new or increasingly treatment-resistant pain situation. As regards the necessary imaging, an MRI is usually the imaging method of choice, as, for example, in the case of a herniated disc, a standard X-ray would reveal nothing other than a loss of disc height. Nerve compensation cannot be visualized. The individual segments are also less clearly visible on a CT scan. However, if the patient has already undergone spinal fusion surgery, a SPECT-CT (Single Photon Emission Computed Tomography-Computed Tomography) scan can also be performed; this is a hybrid imaging technique that combines two different technologies: SPECT and CT. In this procedure, radioactive tracers are injected into the body. These tracers emit gamma rays, which are detected by a special camera to create three-dimensional images of organ function. This provides information on where there is hypermetabolism, or overactivity, which may indicate active spondylarthrosis or osteochondrosis – a degenerative process involving active inflammation in the facet joint or intervertebral disc. Two scans are performed within three hours. “Depending on the intensity of the colors in the scan results, the extent of the activity can be identified,” says Prof. Dr Gautschi regarding the unique possibilities within diagnostics.
By comparing the images with those taken before the initial operation, doctors can identify changes such as implant failure, loosening, spondylolisthesis, infections, haemorrhages, scarring or signs of compression. A neurological examination is also of great importance for assessing the extent of any neurological symptoms that may have arisen following the operation. This involves checking reflexes, sensation, muscle strength and coordination to identify any potential nerve damage or functional impairments. Particular attention is paid to symptoms such as numbness, tingling, weakness or paralysis, which could indicate nerve compression or damage. Functional tests such as flexion-extension X-rays can provide information on how the spine behaves under load. These dynamic images show whether there is instability or restricted movement in the operated area, which could indicate fusion failure or loosening of the implants.
Revision surgery in spinal surgery presents a complex challenge associated with a variety of risks and difficulties, particularly when compared to initial procedures.
One of the key difficulties lies in the altered anatomy and tissue quality following previous operations. A high level of expertise is absolutely essential to perform a revision operation successfully and safely. “Every revision surgery poses a greater risk to the patient and presents an extremely high challenge for the entire team in the operating theater. Scarring and changes in tissue texture can complicate the surgical approach and hinder the identification of anatomical structures. A further risk relates to the increased complexity of the operation itself. Previous procedures may have impaired the surgical view, making navigation within the surgical field more difficult. Landmarks are often no longer present, meaning that the natural anatomy we are familiar with from our training is no longer recognisable. “It may therefore be the case that the patient is left with nothing but a vast scarred area, making it difficult to identify boundaries, so that the risk of muscle and/or nerve injury from the sharp instruments used is high,” explains Prof. Dr Gautschi, adding: “If the anatomy is no longer normal due to previous operations and the bone structures are no longer really visible, then you usually need computer-assisted navigation technology or a 3D image-guided surgical technique to have a better view of the surgical site and, if necessary, to make precise corrections. In my opinion, this should be standard practice in revision surgery, not least for the patient’s safety,” says Prof. Dr Gautschi.
A commonly used technique is the removal of scar tissue and adhesions to improve the view of the relevant anatomical structures. This enables more precise placement of implants and more effective treatment of nerve compression. In addition, the stability of the spine can be improved by correcting misalignments and using additional instrumentation. To strengthen bone substance and promote fusion, bone substitute materials, growth factors or biological substances such as bone morphogenetic proteins (BMP) can be used. These help to accelerate the healing process and improve the integration of implants.
“Revision surgery always takes a little longer because the anatomical structures have changed and you are dealing with scar tissue. We sometimes have patients here who have already undergone surgery many times, who have infections, hematomas or recurrent disc herniations. The more often a patient has been operated on, the more scar tissue they have (as a rule), which prolongs the duration of each operation. The length of the hospital stay depends on the extent of the revision surgery. As a rule, the patient can go home after 1–3 nights. If spinal fusion has been performed, they stay in hospital a little longer, especially if the patient is older,” explains Prof. Dr Gautschi.
The recovery time and rehabilitation phase following revision surgery on the spine differ in several respects from those following an initial procedure.
Patients requiring revision surgery often have a more complex medical history and a higher risk of post-operative complications such as infections or bleeding. Treating these complications may prolong the rehabilitation phase. Furthermore, it may be necessary to manipulate muscles and tissues that are already weakened, leading to a longer healing process. This may require more time to strengthen the muscles and restore mobility.
“What the patient is and isn’t allowed to do during the rehabilitation period depends, once again, on the reason for and extent of the revision surgery. For example, anyone who lifts heavy loads too soon after repeat disc surgery risks an early recurrence. Physical activities, and in particular straining the back, should be strictly avoided in the first few weeks. The muscles need time to recover, which works well with physiotherapy. Unlike in the past, rapid mobility is now always encouraged, so that younger patients are put on their feet on the very day of the operation, while older patients are sometimes only able to do so on the second day. Effective pain management is initiated so that the patient can move around as much as possible. I perform a great many revision operations and also receive many patients referred from other cantons and from abroad. On average, one can say that 10–20% of all patients who have previously had back surgery will undergo at least one revision operation in the course of their lives. This is not necessarily due to initial operations going wrong, as the spine naturally ages too, and degeneration progresses. Some patients even sometimes need more than one revision operation – that is simply the nature of things and is partly genetic as well. Fortunately, the healthcare system in Switzerland is structured in such a way that every patient has access to spinal surgery within a reasonable timeframe and distance. However, in smaller centers or private practices, the local infrastructure and post-operative monitoring facilities are often too limited to allow, for example, complex revision surgeries involving long incisions to be carried out safely and effectively,” notes Prof. Dr Gautschi.
Psychologically, revision surgery can place a greater burden on the patient. The disappointment that the first operation was not successful, and the uncertainty about the outcome of the revision, can affect motivation and the course of rehabilitation. It is therefore important that patients and their doctors set realistic expectations and draw up an individual rehabilitation plan to achieve the best possible results. Overall, revision surgery on the spine often requires a longer recovery time and more intensive rehabilitation compared to the initial procedure, as it involves additional challenges.
“The success rate following revision surgery does not depend solely on the operation itself. If the operation has gone well and the bone substrate is solid, the screws are firmly anchored, the results look good, the spine is aligned and the patient is doing well after 3–6 months, then there is a very high chance that the spine will hold. However, if, for example, a fall occurs and the spine becomes unstable, or the patient develops increasing osteoporosis or muscle wasting and a vertebra collapses, then the whole process can start all over again. “I always recommend that my patients come for a check-up every 1–2 years. And if patients notice new problems, they should always get in touch in good time, which they do if they feel well supported,” says Prof. Dr Gautschi, speaking from experience.
A second opinion prior to revision surgery, particularly in the case of instrumented procedures, is important and advisable in certain respects.
Firstly, it enables the patient to make an informed decision about their treatment plan by taking various medical opinions and options into account. This promotes patient autonomy and trust in the medical process. Furthermore, a second opinion can help to avoid potentially unnecessary procedures. In some cases, an alternative treatment method or a more conservative approach may offer an equally effective solution without incurring the risks and burdens of another operation. A second opinion can also help to clarify diagnostic uncertainties and ensure that the planned procedure is truly the best option for the patient. Despite these advantages, there are also some challenges associated with seeking a second opinion.
On the subject of second opinions, Prof. Dr Gautschi states clearly: “A second opinion usually makes sense in the case of revision surgery. Because if two colleagues confirm a course of treatment, then the patient is, so to speak, ‘reassured’. The problem arises when the patient is in pain and it is not entirely clear why. And if the patient then goes from doctor to doctor, and each one says something different, that does not help the patient and tends to lead to even greater uncertainty. On the other hand, I believe that every surgeon should be open to the idea if the patient wishes to seek a second opinion. After all, not every opinion is always 100% right or 100% wrong. In spinal surgery in particular, there are many options that can lead to a good overall outcome. Ultimately, it is always about finding a sensible solution for the patient. The challenge here is to reach the right consensus. Sometimes it also helps to consult the GP as a mediator when there are two completely opposing opinions. In such cases, a third opinion often makes sense.”
Well advised at the Neuro and Spine Center at St. Anna Clinic – Hirslanden Clinic!
“There should always be a clear goal: we want the patient to experience a significant or complete reduction in pain through our treatments and therapy, to achieve an improvement in everyday activities with enhanced mobility, and to attain a higher overall quality of life. Of course, all this is only possible if the clinical and radiological conditions are met. At the same time, the treatment should be chosen in such a way that there are as few risks and complications as possible, with minimal blood loss. This means operating with the smallest possible incisions, making full use of the infrastructure with 3D navigation, monitoring, intraoperative imaging and adapted pain management, and only operating once all conservative therapies have been exhausted. Unfortunately, many patients undergo unnecessary surgery. It is a matter of performing the right operation on the right patient at the right time. And then there is a good chance that the patient will have a positive outcome,” says Prof. Dr Gautschi, and with that we conclude our interesting conversation.
Thank you very much, Professor Dr Gautschi, for the fascinating insight into spinal surgery!
