SAFE AND EFFECTIVE SPINAL SURGERY IN GERMANY – Dr med Andrej Bitter

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Dr. med. Andrej Bitter is an expert with more than 30 years of experience in conservative and surgical treatment of spinal diseases. For the last 20 years, his clinical activity has focused on operations. The doctor is a member of the German Society of Neurosurgery (DGNC), the German Society for Spine Surgery (DWG), and the AO Spine.

When performing operations, Dr. Bitter uses modern equipment, such as neuronavigation systems, the O-Arm intraoperative imaging device, and a surgical microscope from ZEISS. He also successfully performs endoscopic operations, specializing in technically complex interventions on the cervical spine.

Currently, Dr. Bitter sees his patients at the Hospital Neuwerk Moenchengladbach. For more than 10 years, he has been heading the Department of Spinal Surgery at this hospital, which is part of a large specialized Center for Musculoskeletal Disorders. In the interview, the doctor tells us about the safe and effective spinal surgery that his medical team successfully performs.

Hello, Dr. Bitter! Thank you very much for agreeing to the interview!

We are very happy to meet you. Could you please tell us about yourself?

I would also like to thank you for your interest in me and your offer to have an interview! My name is Andrej Bitter. I am a neurosurgeon and a spinal surgeon. I was born in Russia but have been living in Germany for over 20 years. I started studying medicine in Russia and practiced manual therapy there for a long time. Perhaps not everyone knows what manual therapy is. This is a conservative treatment method for spinal diseases. Later on, the focus of my clinical training was neurosurgery. I completed a full course of study in this medical specialty and trained with the famous Prof. Hassler at the hospital in Duisburg. I then took over as a Senior Physician at the Bethel Clinic in Bielefeld, after which I returned to the hospital in Duisburg, where I also worked as a Senior Physician. And for more than 10 years now, I have been the Head Physician of the Department of Spinal Surgery at the Hospital Neuwerk Moenchengladbach.

Dr. Bitter, could you please tell us what makes you different from other neurosurgeons in Germany?

I believe that the main difference is that I am not only qualified to perform neurosurgical interventions and operations on the spine but also possess the necessary knowledge and professional skills in the field of conservative treatment of spinal diseases. This is due to my experience as a manual therapist at the beginning of my clinical practice. I have deep knowledge not only in the field of neurosurgery but also in the field of conservative therapy. Therefore, I know exactly when a patient needs surgery and when it is possible to cope without it. In my opinion, a doctor who specializes only in the field of manual therapy or only performs neurosurgical procedures lacks an understanding of when it is worth crossing the fine line and prescribing an operation to the patient and when they can only use conservative treatment. A neurosurgeon often believes that surgery is the best treatment option, and a manual therapist is convinced that it is better for the patient to be treated without surgery. It is important to offer the patient the best treatment option, which the specialist will determine during therapy planning.

Dr. Bitter, how long have you been seeing foreign patients?

As I said before, I worked for a long time in the hospital of the city of Duisburg, and during my work with Prof. Hassler at the time of my internship, I treated many foreign patients. We provided these patients with the medical care they could not get in their native country. At that time, most foreign patients came from the countries of the former Soviet Union, and since my native language is Russian, I had a chance to communicate with them a lot, support them, and delve into their needs and wishes. Since then, of course, I have become very aware of the needs of foreign patients, and I know about the problems they face during their treatment abroad. Over time, I took on the post of Senior Physician and then Head Physician, and all this time, foreign patients came to me to get medical care, including on the recommendations of those whom I had previously treated. Thus, since the beginning of my clinical practice in Germany, I have been constantly dealing with the treatment of patients from abroad.

From which countries do patients come to you?

Previously, most patients came from the countries of the former USSR, in particular Russia, Kazakhstan, Ukraine, and Georgia. Now the situation has changed, and most patients come to us from the Middle East.

Dr. Bitter, what common conditions may require spinal surgery?

Before I answer this question, I would like to note that spinal diseases are divided into separate groups. There are degenerative spinal diseases, spinal deformities, and inflammatory spinal lesions, including spinal tuberculosis.

In fact, the most common spinal diseases that require surgery are tumors. But if we analyze the statistics and look at what pathologies patients most often come to the clinic with, the most common are degenerative spinal diseases. In some cases, operations are also required for spinal injuries, but degenerative spinal diseases still occupy the first place in terms of prevalence.

Spinal disc herniation and spinal stenosis are ranked second in terms of the prevalence of spinal diseases. If we talk about which segment of the spine is most often affected, the lumbar spine is in the first place, the cervical spine is in the second, and the thoracic spine is in the third.

Dr. Bitter, many patients think that online consultations are not informative. What would you say about it?

As a physician with over 25 years of experience, I cannot agree with this. In my opinion, about 30 years ago, when the rapid development of the Internet began, many people realized that the modern world offered unlimited possibilities and that you could simply send your personal data and medical reports to a doctor anywhere in the world.

Even comparing modern online consultations with those that we held 20 years ago, it should be noted that even at that time, they were quite effective. Today, patients have the opportunity to provide the doctor with the results of their diagnostic imaging and laboratory tests, as well as discuss with the specialist any questions of interest to them. In addition, modern computer programs allow patients to send their diagnostic results to the doctor and be sure that the physician will receive them. Nowadays, patients can always contact their doctor via Skype if necessary, ask all their questions, clarify the necessary information with the specialist, and discuss their concerns. If the patient still wants to ask some questions after the consultation or wants to discuss some details with the physician, it is always possible to contact the doctor repeatedly and discuss everything again.

It has been a fact of life for a long time that medicine is very well developed in Germany. Hospitals in Germany use modern and innovative equipment, and doctors and medical staff constantly undergo advanced training. Do you agree with this? What is your opinion about this?

I agree with this. When I attend international congresses, I constantly note for myself the excellence of medicine in Germany. When I discuss medicine in Germany with my colleagues from other countries, they also agree that Germany offers advanced medicine. The constant exchange of experience with foreign colleagues gives a clear understanding that hospitals in our country have state-of-the-art equipment, the effectiveness of surgical treatment is at a very high level, and, comparing the professional qualifications of doctors in Germany and other countries, I can confidently say that it is one of the best throughout the world.

Dr. Bitter, do you have any cases in your practice where patients seek medical help from you after a failed surgical procedure?

Yes, cases where patients seek medical help from us after failed surgery are common in our practice. In such situations, patients have to look for another, more experienced specialist. The fact is that the first operation for a spinal disease is mostly relatively simple because the doctor has wide possibilities for effective treatment, but if after the first surgical intervention the patient has complications, from which, unfortunately, no one is safe, the treatment options will already be quite limited. In such cases, the patient should be very responsible in selecting a surgeon because, first of all, the specialist must have impressive experience in their field of competence.

Dr. Bitter, what are the most common complications after spinal surgery?

It is rather difficult to answer this question in general terms because the topic of complications after spinal surgery is very complex and extensive. I will try to formulate my answer in a slightly different way. The doctor's task is to study the patient's case and the complications that have developed, thereby assessing the essence of the health problem. Suppose we are performing an operation on the cervical spine. Everything is clear here. We use an anterior approach so we can suspect damage to the blood vessels or a violation of the integrity of other segments of the spine. And, finally, the most dangerous complication can be paraplegia, which is partial or complete paralysis of the lower body. When spinal surgery is performed through a posterior approach, the complications are quite different than when the surgeon uses the anterior approach, and although paraplegia is considered to be the most severe of them, complications will still not be as severe when performing surgery on the lumbar spine as in the cervical region. It is this integrated approach that should be used when assessing complications after spinal surgery. But I would like to emphasize once again, as I said before, that each clinical case is unique and the patient needs a detailed medical consultation.

Dr. Bitter, what unique spinal surgery techniques do you use in your practice?

To begin with, I want to say that, as a spinal surgeon and a neurosurgeon, I simply must have the necessary professional skills in all treatment methods currently available at our clinic. The unique methods of spinal surgery in my clinical practice include the use of neuronavigation, which provides the highest accuracy of surgical manipulations. Neuronavigation systems have been available on the medical market for about 10 years. With their help, we can provide the patient with the best possible safety of surgical treatment, which makes me very happy.

Our clinic regularly receives state-of-the-art equipment. One of the striking examples is the O-Arm intraoperative imaging system, which we have been using in our clinical practice for several years and without which we simply cannot imagine our work now. The O-Arm system provides the highest precision of surgical interventions and is of particular value when performing operations to implant screw fixation systems for spinal stabilization. The value of using the O-Arm system during such operations is explained by the fact that it eliminates the risk of damage to the spine. You can see the images on the screen, and these allow you to accurately determine the optimal trajectory for inserting the screw fixation system into the spine, after which the surgeon can assess the result of the manipulation using repeated images. Previously, doctors had only 2D intraoperative imaging systems to choose the trajectory of inserting the screw fixation system into the spine, but now we have systems with 3D images, which ensure the highest accuracy of screw positioning in the spine. If we still have doubts, even directly during the operation, we can always discuss our further actions with the surgical team and obtain appropriate images to make sure that our choice is correct. The images are transmitted to the screen, on which the surgeon can see exactly where the screws will be fixed, and if necessary, their position can be corrected. The use of the O-Arm intraoperative imaging device in our work thus gives us the opportunity to save time, and more importantly, this system eliminates the need for a second operation due to a medical error.

We also use microsurgical techniques, which will become the standard treatment in neurosurgery in the near future. At the moment, these are already available in almost all countries. The operating rooms at our clinic are equipped with two surgical microscopes from ZEISS.

A surgical microscope from ZEISS is an indispensable and versatile tool in my work. We have two such devices at our clinic. This model is the most advanced. I will be happy to show you how it works.

As I said, real-time images are transmitted to the monitor. The surgeon performs the operation based on these images. Other members of the surgical team can also monitor the progress of the operation in real time. The difference between what the surgeon can see on the operating field with the naked eye and the images on the monitor is huge. For example, when examining a small hole for inserting a screw fixation system into the spine with the naked eye, the surgeon would not be able to see almost anything, but the images on the monitor make it possible to see this hole at multiple zooms. The use of the surgical microscope during interventions thus ensures high accuracy of surgical manipulations, up to a millimeter. It goes without saying that the use of the surgical microscope helps us a lot in our work, especially when we perform operations on hard-to-reach areas of the spine. Another advantage of this microscope is the ability to generate images that can be subsequently provided to the patient.

It is not always possible to perform an endoscopic intervention, but if the patient's clinical case still allows for such an operation, it is as safe as possible. Endoscopic surgical techniques are of great value for young patients. They are also an excellent treatment option for overweight patients. Of course, there are also cases where it is necessary to perform operations for very complex spinal diseases or defects, during which any damage to the functionally important anatomical structures of the spine has to be excluded, and then the neuromonitoring system, which our clinic's team of surgeons also has at their command, comes to the rescue.

Dr. Bitter, could you please tell us about the benefits of using the O-Arm system in the operating room for the patient?

As I said, the main benefit of using the O-Arm device is the highest precision of each surgical manipulation. With the O-Arm system, the surgeon can clearly see the best trajectory for the insertion of the screw fixation system into the spine, due to which the high efficiency of the surgical intervention is ensured. Another benefit of the O-Arm system is the low level of X-ray radiation because the diagnostic imaging of the spine is performed only once, during preparation for the operation, and the surgeon uses the same images during the intervention.

We also perform quite extensive operations at our clinic, during which 10-20 screws are implanted in the patient's spine. Even such a large number of screws can be implanted through a single incision, after which follow-up images are made. This approach to the treatment of spinal instability allows the patient to avoid many problems, including the need for a second or even a third surgical procedure in the case of a failed primary operation, which is excluded at our clinic.

What operation is of particular interest to you?

Thank you for an interesting question! Perhaps of particular interest to me is cervical spine surgery, or rather, surgery for foraminal stenosis, which is a pathological narrowing of the intervertebral foramen. In most cases, patients with severe forms of foraminal stenosis require an operation called uncoforaminotomy, which is a high-precision operation during which surgical manipulations are performed in close proximity to the blood vessels and nerve endings. This surgical intervention is of particular interest to me.

There is a paired artery in the cervical spine that runs from the left and right sides, and damage to it during the surgical procedure will cause severe consequences, even death. However, this rather complex form of stenosis is still treatable. Uncoforaminotomy can be performed through a posterior or anterior approach. When choosing an anterior approach, the operation provides the most effective outcomes, but from a technical point of view, this is a more complex intervention. It is important to understand that such surgery will only be successful if performed by an experienced surgeon with the necessary professional skills and provided that the operating room is equipped with an advanced surgical microscope. As for uncoforaminotomy through a posterior approach, it is indicated in certain cases. Additional implantation of the screw fixation system may then be required, with the help of which adjacent vertebrae of several spinal motion segments are fastened. It is therefore extremely important for the surgeon to insert the screw fixation system into the target area, following the chosen trajectory as accurately as possible, and securely fix it in the spine. When performing such surgical procedures, one cannot do without the O-Arm intraoperative imaging system, because when inserting a screw into the intervertebral disc millimeter by millimeter, the surgeon must be 100% sure that he is doing everything correctly and that his actions will not cause any severe consequences for the patient.

Endoscopic surgical techniques are the best option for lumbar spine surgery. Interventions of this kind are not particularly complex and also provide a high level of safety because the spinal cord does not occupy the entire cavity of the spinal canal and, accordingly, there are no spinal nerves in the lumbar spine.

Using this model as an example (see video), it will be easier for you to understand what I am talking about. The spinal canal has a fairly large cavity in which the nerve endings are located. The spinal cord ends at the level of the first lumbar vertebra, and nerve endings predominate in the lumbar spine itself, so even if a patient develops a severe herniated disc in this area, it does not pose a particular danger compared to the same prolapsed intervertebral disc in the upper parts of the spine. This is due to the fact that in the area of localization of the spinal cord, even a slight prolapse may lead to severe disorders and pathological changes. But, as I said, lumbar spine conditions are much more common than diseases affecting the cervical and thoracic spines.

What is the standard for herniated disc surgery?

As I have already mentioned, most surgical interventions in spinal surgery and even neurosurgery are performed for degenerative changes in the spine, that is, spinal disc herniation. When performing all operations of this kind, microsurgical techniques are used, which have been the gold standard in this area for at least 30 years, and today this approach does not lose its relevance. In addition, the surgical microscopes used for such operations are becoming more and more high-tech, which contributes to the constant improvement of microsurgical techniques, so most of my colleagues prefer this particular standard of treatment for spinal disc herniation. Nevertheless, about 15-20 years ago, endoscopic techniques appeared in the arsenal of doctors. I mean endoscopic techniques designed specifically for the treatment of spinal disc herniation, especially in the lumbar spine.

What are the features of endoscopic operations?

First of all, a feature of endoscopic operations is that the surgeon makes a miniature skin incision, but at the same time, they can approach distant anatomical structures of the spine without damaging healthy adjacent tissues. It goes without saying that the possibility of using endoscopic techniques is a great advantage for young and obese patients. In addition, I am always very happy when the patient can leave the clinic the very next day after the endoscopic operation, and there are cases when the patient can even be discharged on the day of the operation.

Endoscopic equipment allows for the insertion of special instruments and an optical system through a small incision. With their help, the surgeon can implant the screw fixation system in the spine with millimeter accuracy. The specialist uses a special bone drill to create a hole into which the screw is then placed.

What does the screw fixation system look like?

There were times when the stabilization screw system for the spine was simply placed in a special container, but now that everything has changed and it is necessary to strictly observe hygiene and safety standards, the screw fixation system can only be brought to the operating room in a special sealed package. The patient can be confident in the safety of the device used, and the risks of infection of the surgical wound are almost zero. Absolutely sterile conditions have been created at our clinic, allowing us to comply with modern standards when working with screw fixation systems for the spine.

Dr. Bitter, does your clinic have equipment that allows you to minimize complications during spinal surgery?

I should say that our clinic always receives the necessary equipment that meets the highest international standards. First of all, this includes surgical microscopes, endoscopic devices, and intraoperative imaging systems for implanting stabilization screw systems in the spine, for example, such as the O-Arm system. Of course, there is other equipment that can be used in a similar way, but the O-Arm system is the best of its kind. In complex clinical cases, it is the O-Arm intraoperative imaging system that makes it possible to clearly see whether the screws have been properly fixed in the spine. The use of the O-Arm system thus contributes to the best effectiveness of surgical treatment and, of course, eliminates the risk of the need for revision spinal surgery.

Why is it dangerous for the patient to delay the operation if it is already required?

There are cases when the patient definitely needs surgery, and there are cases when the operation is recommended to the patient but there is no urgent need to perform it in the near future. In medicine, an operation that is mandatory is called a clinically indicated surgical intervention. As for the operation that is recommended to the patient but which can be postponed, the result will be as follows: it is quite possible that while the patient delays the operation, their condition will not worsen, but all this time they will suffer from pain, and there may be moments when the intensity of pain decreases, and in such cases the patient believes that they do not need surgery yet. As a result, before the patient decides to have surgery, it can take more than one year.

There are also cases when the patient has absolute indications for surgery, for example, with the sudden development of paralysis when a person is unable to move their leg or arm. If a patient with a spinal disc herniation has such a condition due to myelopathy and two, three, or all four limbs are affected at once, they need urgent surgery.

Dr. Bitter, can a spinal disc herniation progress, and why is it dangerous for the patient?

Each spinal disc herniation has its own characteristics. It is important to understand that the patient's condition does not depend on the size of the hernia but on its localization and the degree of protrusion of the inner part of the disc, because a small hernia can be localized in a miniature and narrow anatomical structure of the spine, and such cases are complex. For example, cervical foraminal stenosis due to even a very small herniated disc progresses extremely quickly and may provoke the development of paralysis of the upper extremities, while a rather large lumbar herniated disc can be almost asymptomatic for many years, and the only manifestation will be backache.

This device (see video) is typically used for routine operations, which are not very complex, but it does not provide the same high accuracy as the O-Arm system. However, the device is a perfect option for simple surgical interventions, such as operations for cervical spine disorders, operations for small spinal disc herniations, etc.

Dr. Bitter, what advice would you give to patients who find it difficult to decide to have surgery?

First, I would like to say that a consultation with a doctor is the key step in making such a serious decision as having an operation. The patient needs to use all available treatment options, ranging from physical therapy and massage to rehabilitation activities. It is also important to take a course of drug treatment with pain medications and, if possible, use other advanced methods of conservative treatment that medicine offers today. Of course, patients should understand that some diseases require long-term treatment, so it is simply impossible to achieve an effective result in just a few days.

Secondly, I would like to mention that it is quite normal when the patient has certain fears and concerns, and in such cases, it is very important to clarify all the disturbing issues. Therefore, not one, but several consultations may take place until the patient receives exhaustive answers to all their questions. It is often the case that after the initial consultation, the patient is not satisfied with the result, so they can seek medical help from another physician, who may be able to look at the clinical case from a different angle. The practice of obtaining a second opinion is widespread today. It is now available to everyone, so patients should use all the possibilities.

Finally, I would like to say that at the moment, surgery has reached a point of development where most operations are performed using minimally invasive techniques. This contributes to the achievement of the best treatment outcomes, so patients recover extremely quickly after surgery and maintain a high quality of life: a young patient can return to their professional activity, and an elderly patient can start running again and regain the joy of life. All this is quite possible these days.

Dr. Bitter, thank you very much for the informative interview!

Contact Booking Health

Read:

Minimally invasive surgery: treatment of spinal disc herniation in Germany

Features and Benefits of Spinal Treatment in Germany

Herniated disc (Intervertebral hernia)

Endoscopy, a bright idea for brain surgery

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