Advances in Surgical Techniques for Lumbar Interbody Fusion

One of the most common musculoskeletal conditions is lumbar spinal disorders. The occurrence rate for first-time episodes of low back pain (LBP) ranges from 6.3% to 15.4%, with 3/4 to 4/5 of adults experiencing LBP at some point in their lives.

LBP can be primary (non-specific/idiopathic) or secondary, resulting from known causes. Non-surgical approaches are mainly used for primary LBP, while surgery is often considered for secondary LBP that doesn’t respond to conservative treatments.

Lumbar interbody fusion/arthrodesis (LIF) is a treatment method that involves stabilizing the painful motion segment, correcting deformity, restoring lordosis, and providing indirect decompression of the neural elements.

There are various surgical techniques available for lumbar interbody fusion (LIF), including the anterior approach known as anterior LIF (ALIF) and the posterior approach called posterior LIF (PLIF). The TLIF technique has become more popular than PLIF due to its advantage of involving less nerve retraction.

Alternative methods such as extreme or lateral LIF (XLIF/LLIF) and oblique LIF (OLIF) have been developed and used to reduce spinal and paraspinal muscle dissection. Recently, minimally invasive approaches like MI-TLIF have been developed and gained popularity in clinical practice.

Advancements in surgical technology and interbody fusion cage design have led to an increase in the number of lumbar fusions performed over the past decades. Non-union or pseudarthrosis after lumbar interbody fusion (LIF) remains a major surgical complication, with rates ranging from 7 to 20%.

Patients with osteoporosis have been reported to have a non-union rate of 29% even in one-level lumbar interbody fusion (LIF).Autogenous iliac crest bone grafting (ICBG) has been utilized as a means to improve bony fusion, however, it comes with significant risks and complications.

Surgical Techniques And Clinical Outcomes

To perform LIF, the intervertebral body space is prepared and a bone graft or cage containing osteogenic materials is inserted to cover the bony endplates. The interbody cage or graft is braced and compressed by “wires” on three sides, acting as a central pole.

Most surgeons typically add supplementary posterior or anterior fixation to provide additional stabilization to the construct. Recent studies discuss different surgical techniques for lumbar fusion, their advantages and disadvantages, indications, and outcomes.

Posterior LIF (PLIF)


The PLIF is a LIF technique that involves accessing the intervertebral disc through posterior laminectomy. It is beneficial for certain patients with segmental instability, recurrent disc herniation, symptomatic spinal stenosis, and pseudarthrosis. However, it has contraindications, including extensive epidural scarring, arachnoiditis, and active infection.

The PLIF technique involves decompression, complete removal of the intervertebral disc, and spinal fusion with or without additional stabilization using transpedicular screw/rod. The fusion is accomplished by using iliac crest autograft, allograft, or cages that are filled with bone graft.

  • Advantages: this method provides a broad view of the posterior area and allows for the complete release of pressure on the nerve elements without needing a separate incision as the spine is already exposed for decompression. The fusion process involves applying pressure.
  • Disadvantages: Epidural bleeding, cage displacement, particularly without posterior instrumentation, cage sinking due to excessive removal of the endplate during surgery, formation of scar tissue around nerves causing ongoing pain in the back and/or legs, and impairment of the nervous system.

Surgical and Clinical Outcomes

The attainment of solid spinal fusion is possible in a large number of cases, which can be identified by the presence of a characteristic radiographic indicator known as the “sentinel sign.”

The presence of persistent pain, development or progression of deformity, loss of disc height, vertebral displacement, implant failure, haloing, migration or resorption of the bone graft, pedicle screw loosening, and movement on flexion/extension views are potential indicators of pseudarthrosis or non-union.

Adjacent segment degeneration (ASD) is a possible long-term complication of PLIF that may result in the need for reoperation. According to literature, symptomatic ASD may require reoperation and reported reoperation rates increase over time: 9.6% at 5-year follow-up, 24.6% at 10-year follow-up, and 37.5% at 15-year follow-up.

Some studies have proposed that decreased disc space height at the adjacent segment does not impact patient-reported outcomes, including pain and disability. The redistribution of stress at the neighboring level, which can increase mobility and intradiscal pressure, is thought to be the underlying mechanism of ASD. ASD may also be observed in other types of lumbar interbody fusion (LIF) approaches.

Transforaminal LIF (TLIF)

TLIF is a surgical approach that combines anterior/posterior fusion techniques and is recommended for treating several degenerative pathologies. TLIF accesses the disc through the posterolateral section of the vertebral foramen and restores lumbar lordosis with an interbody spacer and pedicle screw fixation.

Unilateral laminectomy, inferior facetectomy, and partial resection of the superior facet are performed at the level of fusion to access the intervertebral disc while preserving the contralateral facet joint.

TLIF is similar to PLIF in terms of discectomy, endplate preparation, and cage insertion, but it involves less or no traction on the dura and nerve roots. However, TLIF is unsuitable for patients with significant epidural scarring, arachnoiditis, fused or conjoined nerve roots, or osteoporosis.

  • Advantages: The interlaminar surface of the contralateral side is preserved in TLIF, which can be used as an additional surface area for the fusion mass. Also, it can reduce risk of incidental neural complications because it only requires exposure of the ipsilateral neural foramen, unlike other techniques. TLIF is a safer technique above the L3 level with minimal risk of injuring the conus and is well-suited for reoperations where there is significant epidural fibrosis, as it only requires a lateral dural exposure on one side.
  • Disadvantages: Experienced surgeons can usually avoid the uncommon disadvantages of TLIF, such as incomplete removal of the intervertebral disc, incomplete preparation of the vertebral endplate, and potential injury to the exiting nerve root. However, TLIF is unable to decompress the contralateral nerve root in the classic approach.

Surgical and Clinical Outcomes

TLIF is a more effective treatment for patients with degenerative lumbar scoliosis, as compared to posterolateral lumbar fusion. It achieves better restoration of lumbar lordosis and spinal sagittal balance by using interbody distraction and resecting posterior facet joints.

It is the preferred surgical approach for lumbar spinal fusion due to its lower risk of violating the spinal canal and causing morbidity, as compared to PLIF and ALIF. Despite a 14% complication rate, which includes problems such as haematoma, nerve root lesions, dural tears, and intraoperative pneumothorax, these issues can be effectively managed with drainage and appropriate follow-up.

Anterior LIF (ALIF)

The surgical technique of anterior lumbar interbody fusion (ALIF) was introduced in 1948 and is considered a salvage technique for patients experiencing painful pseudarthrosis following posterior lumbar fusion. While the anterior approach is an effective method for accessing the L5-S1 level, it is less efficient for levels above L3-L4.

  • Advantages: direct visualization, enabling easier and complete discectomy, better distraction leading to higher fusion rates, and reduced iatrogenic trauma.
  • Disadvantages: the drawbacks of ALIF include complications related to the surgical approach, such as hernias, bowel obstruction, venous thrombosis, urological injury, and retrograde ejaculation. Additionally, a separate posterior incision is required for decompression or fixation.

Surgical and Clinical Outcomes

ALIF is associated with higher interbody fusion rates compared to posterolateral approaches, as reported by Jackson et al., who observed ALIF fusion in 95.3% of patients with only minor complications.

According to a randomized controlled trial in the literature, changes in the whole lumbar lordosis were not found to be dependent on changes in the segmental angle at the fused segment during a 10-year follow-up period.

Extreme lateral LIF (LLIF/XLIF)

The use of the LLIF approach is considered a safe and effective alternative to the anterior or posterior approaches for lumbar fusion. The LLIF approach can be used to treat several conditions, such as degenerative disc disease, adult scoliosis, spondylolisthesis, and adjacent segment disease.

The LLIF approach involves three surgical pathways: lateral flank, retroperitoneal, and transpsoas, and it is important to have knowledge of critical structures such as the lumbar plexus. The LLIF approach permits the realignment of the spine in cases of de novo scoliosis in both the coronal and sagittal planes.

  • Advantages: One of the advantages of the LLIF technique is its ability to access the anterior and middle columns of the lumbar spine through a small incision with minimal blood loss during surgery. With the LLIF technique, it is possible to access multiple levels from T11 to L4 through a transpsoas approach while preserving the posterior musculature and longitudinal ligaments of the spine.
    This approach is relatively easy to use, compared to others, and has the advantage of preserving these important structures. LLIF also offers the advantage of avoiding direct trauma to important structures such as the abdominal viscera, peritoneum, great iliac vessels, and sympathetic chain. Moreover, LLIF offers minimally invasive lumbar spine access, shorter operating times, and shorter hospital stays in comparison to other techniques.
  • Disadvantages: The use of the LLIF technique is limited in cases of severe central stenosis and anatomical variations that may obstruct access to L4-5. Furthermore, due to the obstruction caused by the iliac crest, LLIF cannot be performed at the L5-S1 level.
    Furthermore, the LLIF approach has been associated with post-operative hip flexion weakness and thigh/groin pain, which may occur as a result of stretching or injury of the genitofemoral nerve during the procedure, according to reports.

Surgical and Clinical Outcomes

With optimal technique, LLIF has shown fusion rates similar to those of anterior and posterior approaches. There were no statistically significant differences observed between the different types of graft used to fill the cages.

LLIF is associated with a common post-operative side effect, known as thigh symptoms, which affects around 20% of patients. These symptoms include paresthesia, numbness, and motor weakness that affects hip flexion. The majority of these symptoms are temporary, with a recovery rate of 50% after three months and 90% after one year.

Oblique LIF (OLIF)

The OLIF approach, which stands for oblique trajectory anterior to psoas, uses a retroperitoneal plane to reach the disc through a corridor located in front of the iliac crests, between the major abdominal vessels and the psoas muscle.

The OLIF approach, unlike LLIF, does not involve the dissection and splitting of the psoas muscle, which could potentially reduce post-operative pain. The OLIF approach, which accesses the disc through a retroperitoneal plane anterior to the iliac crests between the psoas muscle and major abdominal vessels, is suitable for cases of degenerative disc disorders, discitis, pseudoarthrosis at L5-S1, and isthmic spondylolisthesis.

The approach involves inserting an intervertebral cage after disc space preparation and can be followed by posterior stabilization via open or percutaneous procedures, depending on the underlying condition.

  • Advantages: The oblique trajectory utilized in the oblique trajectory anterior to psoas (ATP) approach (OLIF) allows for the avoidance of surgical trauma to the psoas and lumbosacral plexus, while enabling efficient clearance of the disc space and placement of a large interbody device for foraminal decompression.
    Additionally, the oblique trajectory of the OLIF approach offers a distinct angle that allows for visualization of the epidural space, aiding in the removal of ventral osteophytes and disc herniation.
    The OLIF approach is viewed as a possible solution to the challenges posed by ALIF (such as the risk of injury to the iliac vessels and peritoneum) and LLIF (which requires splitting of the psoas muscle and provides limited access to the lower lumbar spine).
  • Disadvantages: Post-operative numbness, pain, and leg weakness are potential complications of OLIF. If the retroperitoneal oblique corridor (ROC) is narrow, greater psoas retraction may be necessary, which increases the likelihood of postoperative neurological complications in OLIF.

Surgical and clinical outcomes of OLIF

The success rate of achieving fusion with OLIF is high at 84% or more, and the surgery typically takes between 55 to 145 minutes with blood loss ranging from 67.8 to 260 ml.

However, there is a relatively high occurrence of perioperative complications such as endplate fracture/subsidence (18.7%), temporary psoas weakness and thigh numbness (13.5%), segmental artery injury (2.6%), surgical site infection (1.9%), and reoperation (1.9%). Permanent damage from the surgery is rare.

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I had an extremely friendly and personalized medical consult with Dr Karkare. Dr Karkare was very knowledgeable and very professional. His communication skills was extremely good and explained my medical condition in very simple words. The office visit was very helpful in understanding my medical condition. Thank you Dr Karkare
Padmanabhan Nagaraj
20:49 25 Sep 23
Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
Joseph Castelli
22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
Jazz Lorenzo
17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.