The overall goal of spine surgery is to get to the root of the problem, while at the same time causing the least amount of disruption to the patient’s lifestyle. Spine surgery is typically a choice of last resort, after all nonsurgical methods have been exhausted, or when problems like severely herniated discs or damaged vertebrae simply will not respond to nonsurgical treatments. While studies show that more than half of back surgeries are unnecessary, there are times when surgery is the answer.
When surgery is the right course of action, it is essential for you to play an active role in selecting the best spine surgeon for you. You should look for a surgeon that specializes in spine problems rather than one that spends time treating patients with other needs, such as head, knee and shoulder injuries. As with anything else, practice makes perfect. The more a person does something, the better they get at it. The ideal spine surgeon is one who is fellowship-trained, spine-specialized and proficient in minimally invasive techniques.
Click here to learn more about Swift Spine Institute’s minimally invasive surgical techniques.
Common back surgeries
“Lumbar discectomy” encompasses a number of terms including discectomy, microdiscectomy and laminectomy/discectomy. The typical patient presents with pain down one leg which may radiate from the buttock to below the knee. The usual pain is either to the back of the calf and to the sole of the foot, or to the outside of the shin and top of the foot. Back pain is not usually a feature, however it may initially occur. Lumbar disc problems are exceedingly common, and it is important to realize that in the vast majority of cases, non-operative management works very well. Most patients settle within 6-12 weeks after the onset of symptoms. The pathophysiology of why a patient experiences symptoms of disc protrusion is complex.
Reason for operation
Lumbar disc protrusions are not usually operated upon early, but there are some clear situations when a surgeon may recommend early surgery. If there is evidence of severe weakness, early surgery may be offered. If the pain in the leg is so severe that narcotic analgesia is not controlling the pain, early surgery may again be an option. Finally, if there is a suggestion of problems with the nerves that supply the bladder or bowel, early surgery is advocated. In the latter situation, an inability to pass urine may be evident, or there may be numbness in the crotch area, buttocks or when passing urine. This situation usually necessitates emergent or early surgery.
If a patient has pain that is not too severe, conservative management is typically initiated. Remember that the vast proportion of patients will settle with time, and as long as improvements are noted at 6 weeks, there is minimal or no weakness, and the pain is not excruciating and is manageable with oral analgesia, then waiting and continuing with conservative therapy is a good option. If weakness occurs and is not improving, surgery is usually offered. Similarly, if symptoms are not improving at 6 weeks then surgery is an option.
In most cases, when managing only leg pain, surgery is a treatment option that speeds up the rate of recovery, keeping in mind that most cases will improve by themselves. Again, specific recommendations are tailored to the patient. In the vast number of cases, the goal is control of pain, and an intervention that achieves this and is less invasive than surgery is a reasonable option.
If surgery is undertaken, it is usually performed as a minimally invasive procedure. The procedure can be performed as day surgery, but most patients stay in hospital for 1-2 nights. General anesthesia is utilized, and the surgery is performed through an incision of 3-5 cm. Much emphasis is placed on performing the surgery through tiny incisions (called “microendoscopic” discectomy) although, for the most part, the surgery can be performed more safely and quickly via a standard approach with little tangible gain through a slightly smaller incision. Usually a small window is made on one side of a spinous process through the removal of some bone and ligament to allow visualization of the disc bulge and involved root.
Through gentle dissection under illumination and magnification, the interface between the root and disc bulge is identified, and the offending fragment is removed. Only a small portion of disc is removed. The whole disc is not removed, although any loose fragments felt through the hole in the annulus are removed. The tear in the annulus is not repaired. After the nerve is freed completely, the operation is completed. Typically this takes 1-2 hours to perform.
The greatest risk is injury to one or more nerves, and this is typically 1-2%. The risks of infection, bleeding, etc., are similar to those for a laminectomy, as are the risks of general complications. Ten percent of patients will have a recurrent disc protrusion, either at the same side and level or at different levels or the opposite side. The greatest risk for this is in the first 6 weeks after surgery. The minimal but real risks from surgery are the reason why all patients with disc protrusions do not immediately have surgery.
In uncomplicated cases, the likelihood of good/excellent relief of leg pain is 80-90%. Numbness is slow to recover and may persist. Weakness also may take 6-12 weeks to return to normal. Pins and needles usually begins to improve immediately.
Patients who have a lumbar discectomy are typically in hospital for 1-2 nights. They are advised not to work for 2 weeks, and recommendations on back and wound care are the same as for lumbar laminectomy. It is notable that bending, lifting and twisting may increase the recurrence rate in the first 6 weeks, so patients should not do any other exercise other than walking during that time period. After 6 weeks, a return to normal activities is initiated. It is important to remember that the back is not normal after disc surgery and that care needs to be taken in the future. Bending, lifting and twisting need to be avoided, as these activities ultimately may have precipitated the initial event. Recovery from surgery is not a licence to return to normal. Good back care is the rule for life. Again, as is the case after lumbar laminectomy, no surgeon can guarantee risk-free surgery or a 100% positive outcome. [Top]
Cervical is the medical term for “neck.” Just as in a lumbar discectomy, the surgeon will remove a piece of damaged disc tissue in the neck area to relieve pressure on the spinal cord or nerve roots. In some cases, by removing a piece of the shock-absorbing disc that separates the two vertebrae, the structures may become less stable. Consequently, when the disc is removed, a surgeon may recommend “fusing” the vertebrae to prevent instability. This fusion surgery may require a second incision in the front of the neck to gain access to the disc area. A cervical discectomy is best left to surgeons who specialize in spine.
Lumbar Spinal Fusion
Fusion literally translates “to join,” and in spine surgery this means that twovertebrae are joined together to make one. There are many reasons why one would perform a fusion (see below), but in essence, the surgeon endeavors to trick the body into thinking that the two bones to be fused are a single bone that has broken and then sets up the right conditions so that in healing, the bones heal as one. Just as if you broke your arm, two bones with sticky ends would become one. In the case of a broken arm, a plaster cast is applied to hold things in place until the bones are healed, which typically takes 6 weeks. In the lower back, screws, plates, rods, cages and an external brace take the place of the plaster cast, and full fusion occurs after 3 months. The “sticky ends” in the case of the spine are the roughened surfaces of bone.
Typically, bone graft (usually the marrow) is taken from the hip and placed between the roughened surfaces. When bone healing occurs, new bone comes out of the roughened surfaces and migrates along the transplanted bone to bridge the area to be fused. Ironically, at 3 months all the transplanted bone has been replaced by new bone. Understanding all of the above, it becomes clear that although there are a lot of screws and hardware involved, the operation essentially joins bone to bone, which takes a full 3 months to heal. Patients cannot smoke for 1 month prior to and 3 months after the surgery, as the healing rate of the bone (i.e. the success of the fusion) drops from 90% to 40-50%. Similarly, NSAIDs such as Celebrex or Mobic must not be taken for 3 months after surgery, as they also reduce the fusion rate by 20%.
Reason for operation
The two least controversial reasons for a lumbar fusion are in cases that involve trauma or tumor. In both of these cases, either the situation in the spine appears unstable (meaning the spine is prone to unusual movements under normal conditions which can damage tissues or cause pain or deformity) due to the underlying pathology, or the surgery required to decompress the neural structures is deemed to render the spine to unstable once this is achieved. Fusion for degenerative disease (“wear and tear”) is more controversial but is commonly performed. In this setting, fusion can also be performed for many reasons. The most common reason a fusion is performed is in the case of spondylolisthesis. This is where one vertebra is slipped forward in relation to another. Not only does this throw the back out of alignment (so-called “sagittal balance”), but it can place pressure on nerves, particularly when they exit through their neural foramina.
One of the more common reasons to develop a spondylolisthesis is the development of pars defects. Pars defects occur in 6% of the population, and the vast number of cases do not need intervention. When they do become symptomatic, with either leg or back symptoms, surgery is often the end result. If the degree of slippage becomes progressively worse, this may require intervention as well. Degenerative spondylolisthesis is also common, most commonly occurring at the L45 level. The decision to perform a fusion in addition to a laminectomy is more complex. Lumbar fusion for “discogenic” back pain is very controversial. In general, orthopedic surgeons tend to believe this entity occurs with a greater frequency than neurosurgeons, who generally believe that the disc is a primary pain generator in only a few select cases. The decision to fuse for back pain is dependent on a number of factors including the history, physical examination, MRI result and discography result.
A lumbar fusion is a big operation. Screws are placed between the vertebrae that are to be fused. The bone graft is placed around these. These screws are made of titanium and usually stay in for life. These screws are typically placed into the pedicles at each level. In some cases, titanium cages filled with bone graft, or spacers with bone graft around them, are placed in the intervertebral disc space.
Lumbar fusions are big operations, and the risks are much greater than simple laminectomies or discectomies. The risks are higher, and recovery is longer. With that said, the vast number of patients undergoing this operation do well. Because they are longer operations, there is more blood loss, and blood transfusion is almost always required. Often, however, this can be blood that is autologously donated by the patient in preparation for surgery.
The risks of nerve injury, hardware problems, infection, etc., are probably in the range of 5-15%. The risks of general complications are slightly higher than those for a simple laminectomy. Despite this daunting prospect, most patients do well. Typical operating time can be anywhere from 4-8 hours. Each operation is different. Most patients will spend 1-2 nights in ICU. Patients may be given an epidural anesthetic after surgery to ensure that there is virtually no pain for the first 24 hours. A bladder catheter is usually in place. The patient will usually have a button for pain control (PCA). On the second or third day after surgery, the patient is mobilized in a lumbar brace with the assistance of a physiotherapist.
It is difficult to predict success rates when the indications for surgery are quite varied. This is something that the surgeon will discuss with the patient prior to surgery. It is important to remember that with cancer or trauma, there is often little choice to having surgery, but in the case of degenerative disease, surgery is always a treatment option. The patient must weigh the risks and benefits of surgery beforehand.
Most patients spend 5-10 days in hospital. They are mobilized in a lumbar brace (which is basically a support for the lower back and is worn like a girdle) every time they are out of bed for a total of 3 months. The back is quite sore for 1-2 weeks after surgery, but this improves. At discharge, patients are only allowed to walk. They cannot bend, lift, twist or sit for prolonged periods of time. Bending and lifting are particularly bad, as they can lead to screw breakage and failure of fusion. Physiotherapy is not started for 6-12 weeks after surgery, although in the hospital, the physiotherapist will teach you how to get out of bed and perform your daily activities. You should see your family doctor one week after surgery to ensure proper wound healing, and then it is important to look after the wound. Typically, I advise my patients not to rub any creams on the incision and to keep it dry. Bathing is to be avoided, as is swimming, but showering is okay. It is important that the wound is allowed to heal. Any signs of redness, discharge, swelling, etc., need to be reviewed by a doctor. Follow-up with the specialist is usually arranged for 6 weeks after surgery. Repeat X-rays of the spine are done at 6 weeks, 3 months, 6 months, 1 year and 2 years after surgery.
As stated in the introduction to this section, it is important not to smoke or take NSAIDs for 3 months after surgery, as bone healing is occurring. Good back care is the rule for life after this surgery as, and this must be stressed, the back has not been returned to normal after a fusion.
A lumbar fusion is not a small operation. Just as in lumbar discectomy, there are non-operative options that include any or all of the following, and these should be aggressively pursued to try and expedite improvement in symptoms.
Conservative therapy comprises:
- Analgesia with NSAIDs (e.g. Mobic, Voltaren or Celebrex)
- Analgesia with other medications such as Tramadol
- Avoidance of bending/lifting/twisting/sitting for prolonged periods
- Physiotherapy (traction may help)
- Hydrotherapy (particularly if back pain is a problem)
- Perineural and intrafacet steroid and local anesthetic injections
- Possibly acupuncture
- Weight loss
- Bracing (controversial)
Fusing two bones puts stress on adjacent levels, which can accelerate wear and tear at these levels. This is important as patients can develop symptoms months or years later, which may require further surgery. Artificial disc replacement is the lumbar spine is still not routinely available and redo surgery can be a very arduous in this scenario. Learn more about artificial disc as an alternative to fusion surgery.
Anterior Cervical Fusion
Anterior cervical decompression and fusion is removal of disc and/or bone through an approach through the front of the neck. It is performed by filling the cavity with bone from the hip and possibly placing screws and plates to hold the whole construct into place. The typical patient presents with either arm symptoms such as pain, weakness, numbness or pins and needles, or symptoms and signs of spinal cord dysfunction, called “myelopathy.” Myelopathy can manifest in a number of ways including generalized stiffness, difficulty walking, loss of fine motor control in the hands, etc. Compression of nerves or spinal cord is typically caused by disc material or bony spurs.
A disc protrusion per se may not cause symptoms. If the anulus is acutely torn, neck pain may result, but the management is usually not operative. If the disc pushes on a nerve, then symptoms down one or both arms may result. The symptoms can include pain, numbness, “pins and needles” and weakness.
Reason for operation
Cervical disc protrusions are not usually operated upon early, but there are some clear situations when a surgeon may recommend early surgery. If there is evidence of severe weakness, early surgery may be offered. If the pain in the arm is so severe that narcotic analgesia is not controlling the pain, early surgery may again be an option. If there is spinal cord compression, typically early surgery is also offered.
If a patient has pain that is not too severe, conservative management is typically initiated. It must be remembered that the vast proportion of patients will settle with time, as long as improvements are noted at 6 weeks, there is minimal or no weakness, and the pain is not excruciating and is manageable with oral analgesia. Then waiting and continuing with conservative therapy is a good option.
If weakness occurs and is not improving, surgery is usually offered. Similarly, if symptoms are not improving at 6 weeks, surgery is an option. In most cases, when managing arm and/or leg pain, surgery is a treatment option that speeds the rate of recovery, remembering that most cases will improve on their own. Again, specific recommendations are tailored to each patient. In the vast number of cases, the goal is control of pain, and an intervention that achieves this and is less invasive than surgery is a reasonable option.
The main reason this form of surgery is performed is to try and reduce the risk of deterioration in spinal cord function. At the extreme end, bad myelopathy patients are wheelchair bound. Coupled with this, even patients with little in the way of symptoms are more at risk of spinal cord injury. This is because the space for the spinal cord is reduced and an accident as trivial as a minor car accident can transiently narrow this space via ligamentous buckling, injuring the cord. Consequently, this surgery is primarily performed as a prophylactic procedure to stop deterioration in the future.
The operation is preformed under general anesthesia, and as shown above, a cut is made in front of the neck. The food and wind pipe are shifted over, and the operation is performed between these and the blood vessels to the brain. The disc is removed in entirety, and after the spinal cord and nerves have pressure removed from them, bone graft (typically a 7-12 mm block) is taken from the hip and placed into the defect. A plate and screws may be placed over this to keep the graft in place. The operation takes 2-3 hours, and after surgery, a collar is in place for 6 weeks.
The greatest risk is injury to one or more nerves and this is typically 1-2%. There is a risk of death, quadriplegia or severe spinal cord injury. The risks of infection, bleeding, etc., are similar to those for a laminectomy as are the risks of general complications. There are other risks particular to this operation. Temporary or permanent swallowing problems or hoarseness of voice can occur. They are common temporarily but not so permanently. The hip graft site is more likely to get infected. The combined risks are about 5-10%. The small but real risks from surgery are the reason why all patients with disc protrusions do not immediately have surgery.
In uncomplicated cases, the likelihood of good/excellent relief of arm pain is 80-90%. Numbness is slow to recovery and may persist. Weakness also may take 6-12 weeks to return to normal. Pins and needles usually starts to improve immediately.
If the surgery was for myelopathy, as a rule:
- 40% improve
- 40% stay the same
- 20% continue to deteriorate
The hip graft site is quite for after surgery and is the main slowdown to mobilization. Some pain on swallowing is not uncommon. Most patients spend 1 night in a HDU setting and mobilize the next day. They typically go home within 3-5 days. A collar is worn for 6 weeks. At this time, repeat X-rays are done, which if satisfactory, lead to discontinuation of the collar.
Posterior Cervical Decompression and Fusion
A posterior approach to the cervical spine is generally reserved for patients with myelopathy. Myelopathy literally means “sick spinal cord” and can be caused by many things, some of which are irreversible. Compression of the cord can cause myelopathy and is the most common reason for surgical intervention. The approach is also gaining popularity for the management of trauma and tumor conditions, but it is really in the management of myelopathy secondary to degenerative disease (so-called “wear and tear”) that a posterior decompression and fusion is most frequently utilized.
Cervical myelopathy does not typically cause pain. Myelopathy can be asymptomatic or can cause dysfunction in the upper or lower extremities. Typical symptoms include loss of hand control, a feeling of heaviness in the hands or legs, stiffness in walking and unsteadiness in walking. In the degenerative spine, it is typically caused by pressure on the spinal cord. This can occur because wear and tear leads to bulging of the discs, facet joints become larger and intrude into the space for the spinal cord, and also, some people are born with a narrow space for their spinal cord.
The spinal cord lives in a bony hole, the spinal canal. A posterior cervical laminectomy involves an incision on the back of the neck and bone is taken away over the spinal cord to its widest diameter. After that, a fusion is performed across the facet joints at these levels using local bone from the laminectomy, screws and plates or rods.
This is the extent of bone removal and decompression from a posterior approach, allowing for excellent spinal cord decompression. Note that this is greater than that achieved by an anterior approach (orange arrows) where the position of the vertebral arteries limits lateral exposure.
Reason for operation
The main reason this form of surgery is performed is to try and reduce the risk of deterioration in spinal cord function. At the extreme end, bad myelopathy patients are wheelchair bound. Coupled with this, even patients with little in the way of symptoms are more at risk of spinal cord injury. This is because the space for the spinal cord is reduced, and an accident as trivial as a minor car accident can transiently narrow this space via ligamentous buckling, injuring the cord. Consequently, this surgery is primarily performed as a prophylactic procedure to stop deterioration in the future.
The added fusion has several benefits:
- It allows for a much wider decompression.
- It prevents the spine falling into kyphosis, which is literally a reversal of the normal curve of the spine, a situation which leaves the spine more prone to injury.
The procedure is performed under a general anesthetic on a special table called an Jackson Operating Table which allows safe positioning of the patient as well X-ray to be used throughout the procedure. Typically it takes 2-4 hours. The head is held in a special device the keep the neck still.
A cut is made in the back of the neck, and the thick muscles in the back of the neck are stripped away but reattached again at the end of the operation. The most important part of the case is now removal of the bone and ligaments overlying the spinal cord. This is done very carefully with drills and fine bone-biting instruments.
Once the bone is removed along with the ligaments, screws are placed through plates (or else connected via titanium rods). X-ray guidance allows for precise screw placement. The screws, rods or plates (so-called “hardware”) hold the bones still whilst the fusion occurs. The bone removed in the laminectomy is crunched up and placed in around the facet joints which have been roughened up and form the bed of the future fusion. This operation does not typically require a blood transfusion.
The most disastrous complication that can occur from a posterior cervical decompression and fusion is injury to the spinal cord or death. This risk is approximately 1%. Every spinal operation has a risk of leakage of spinal fluid, infection, bleeding, hardware related problems, etc., and these would sit at approximately 5%. There are also general risks of clots in the legs or lungs, pneumonia, heart attack, etc., which are again at about 5%. All in all, 90-95% do well from surgery with no complications, but no surgery can be performed with zero complications.
Unlike anterior cervical fusions, posterior fusions have not been shown to be associated with as much adjacent segment wear and tear. It may be just that this technique is new. Nevertheless the joints above and below the fusion are prone to wear and tear and may require additional surgery in the future. This is uncommon.
The aim of surgery is typically to stop progression of myelopathy, and any gains are a bonus.
- 40% improve
- 40% stay the same
- 20% continue to deteriorate
The operation is best performed before the myelopathy has progressed too far. The patient who starts in a wheelchair will probably stay there. Most patients do note some improvement.
The main advantage of doing a posterior decompression with a fusion is that a wide laminectomy can be performed, and consequently the compression is relieved via a single-stage procedure, and a further anterior approach is not required.
After the surgery, typically 1-2 nights are spent in a HDU/ICU setting. An ASPEN collar is placed, and this is worn for 6 weeks. Patients may remove the collar for showers, as long as they hold their head still. There is marked muscle spasm in the first 1-2 weeks after surgery, so headaches and neck pain are common. These are usually managed by the use of muscle relaxants and analgesia, and in almost all cases, the neck pain resolves in a few weeks. Typically, 4-7 nights are required in hospital to allow the pain to settle. X-rays are taken of the neck on the second or third day postoperatively.
At discharge, the collar is worn for a total of 6 weeks. At that time, flexion/extension X-rays of the cervical spine are taken, and if these are satisfactory, the collar is discontinued over a period of 1-2 weeks. Initially, the neck is very stiff at this point, but with physiotherapy, much of the movement returns. Because the operation is a fusion, there will always be some restriction in movement when compared to an earlier date, but most patients do not find this restriction interferes with day-to-day life.
Typically, patients will be followed for 12 months with repeat X-rays to ensure no hardware-related complications. After that time, investigations are only performed if problems occur.
There are very few nonsurgical options in terms of the management of cervical myelopathy. The only real option is to defer surgery if the patient feels the risks outweigh the benefits. There is no guarantee that they will deteriorate if they decide not to have surgery. Because the compression of the spinal cord is structural lesion, no physiotherapy, diet or alternative therapy will relieve the compression. Chiropracty is contraindicated, as spinal manipulation can lead to spinal cord injury.
Myelopathy is common and becomes more so as the population ages. Cervical laminectomy with lateral mass fusion is the most recent operation available to the spinal surgeon in the management of multilevel spinal cord compression. Because the compression is from the back as well as the front, artificial disc surgery may not be adequate to deal with this pathology in some patients, in which case a laminectomy and fusion may indicated.
A lumbar laminectomy involves removal of the bone and ligaments that are causing compression of the spinal nerves in the lower back (spinal stenosis). Typically, when these nerves are being compressed, it is due to a combination of enlargement of the facet joints, thickening of the ligamentum flavum and bulging of the intervertebral discs. The classical symptoms are what is termed “neurogenic claudication” where there is pain on walking in the calves or buttocks. Usually back pain is not a feature, and the pain is related to standing or walking and relieved with rest. Sitting or lying improves the pain. Bending forward, such as with a shopping trolley also improves the pain. Occasionally the pain is almost entirely in one leg and typically this is due to lateral recess stenosis, where the nerves on one side are compressed more than the other side. If spinal stenosis is not treated, it may progress or it may stay the same. Rarely, it will improve. Like most degenerative conditions, it is not fatal and the patient is unlikely to end up in a wheelchair if not operated upon. Surgery is usually aimed at improving pain.
Reason for operation
The indication for surgery is failure of conservative management for neurogenic claudication. It must be stressed that surgery is an option, not a necessity, once spinal stenosis is diagnosed. Typically, a laminectomy is performed, and the neural foramina, through which the nerves exit, are enlarged (foraminotomy).
The procedure is quite straightforward and involves the removal of the spinous processes, laminae and ligamentum flavum with a combination of biting instruments of various size and configuration, and sometimes small high speed drills. At the end of the decompression, the neural foramina are palpated to ensure the nerves move out easily. A multilevel laminectomy can lead to moderate blood loss, and occasionally a blood transfusion is required. Typically, however, this is not the case.
The risks of the operation relate to specific risks from this kind of surgery as well as general risks that are independent of the type of operation performed. General risks include the risks of death, heart or lung problems, pneumonia, bleeding, infection, clots, etc. Typically, this is <5-10%. The specific risks include the risks of nerve injury, spinal fluid leakage, instability (increased ‘floppiness’ which may cause problems later on and require further surgery), etc., would also be at approximately 5-10%. The risk of death or ending up in a wheelchair is low, but both can happen.
The likelihood of a good outcome is always tailored to the individual patient, but in a typical scenario, the chances of good or excellent improvement in symptoms, including possibly complete resolution of pre-op symptoms, is 80-90%. No one can guarantee a 100% risk-free operation, and no surgeon can perform an operation with no risk. Most patients do well from this surgery. This is not a good operation for back pain.
Surgery typically takes 1-4 hours, and in an uncomplicated case, the patient is mobilized the next day. A tube may be placed in the bladder, and this is usually removed once the patient is mobilized. After surgery, the patient is usually mobilized the following day, and if things are going well, is discharged from hospital 2-5 days after surgery. The back is sore where the incision is, but this settles. Dissolving sutures are usually placed in the wound. Once home, it is important to avoid bending, lifting, twisting and prolonged sitting for 4 weeks post-op. You should see your family doctor one week after surgery for an inspection of the wound. You need to look after the wound to ensure good healing. Do not to rub any creams on the incision, and keep it dry. Bathing is to be avoided, as is swimming but showering is okay. It is important that the wound is allowed to heal. Any signs of redness, discharge, swelling, etc., need to be reviewed by a medical practitioner. Follow-up with the specialist is usually arranged for 6 weeks after surgery.
Unfortunately, no good nonsurgical options are available. Walking is certainly helpful and advisable, and physiotherapy and hydrotherapy can help any associated back pain. Weight loss may also help, and avoidance of bending, lifting and twisting is important as well. All the previous measures may help, but in dealing with a structural lesion, it is understandable why failure of conservative treatment can occur. Because spinal stenosis is not a life-threatening condition, the decision to have surgery is entirely up to the patient; if the patient can live with the pain, then surgery can be avoided.
Lumbar laminectomy is a common operation and is performed regularly in patients over the age of 65. Age itself is not a contraindication. Although no guarantees can be made, most patients do well with no complications. The results are poorer and the risks higher with redo surgery, and each reoperation has greater risks and a worse outcome than the previous operation.
Rhizotomy is a procedure in which the physician may use heat or cold to intentionally damage the ability of a problematic nerve to telegraph pain signals to the brain. While pain signals serve to warn us about danger or injury, sometimes a nerve can end up in a “stuck” position, sending a continuous pain signal to the brain.
“Neuroablation” is another word used to describe the surgical procedure to purposely inhibit the nerve’s ability to transmit a pain signal. During the procedure, the spine surgeon can destroy the problematic nerve by cutting it or by using extreme heat or cold. This intentional “short circuit” can be temporary or permanent, depending upon the procedure.
Trying to mask this signal with drugs can have damaging long-term implications. Drugs can have dangerous side effects to internal organs. By using rhizotomy, the pain signal is turned off at the source.
Through the placement of hooks, rods and screws, a spinal curve can be corrected and stabilized. A fusion often follows scoliosis surgery, in order to maintain the correction permanently.
Scoliosis is not the result of an injury and usually appears without cause. It can be inherited, and it usually affects more women than men. In the case of most spinal curves, the spine is not only bent but twisted like a bent corkscrew.
Some cases of scoliosis are not serious. Over time, if a curve worsens, surgery may be required to correct the curve. In extreme cases, if the curve is not corrected, the spinal deformity can place pressure on internal organs, which can shorten a person’s life expectancy. (Learn more about scoliosis)
During scoliosis surgery, the surgeon may use special instruments that hook onto various vertebra segments. These surgical rods are the adjusted to “de-rotate” the twisted and bent corkscrew.
Decades ago, Harrington Rods were used to surgically straighten the spine. However, this technique did not untwist or correct the spine. Current state-of-the-art instrumentation achieves much better spine correction than older rods did.
Generally speaking, the younger the patient, the more flexible the spine and the better the result from scoliosis surgery. As the patient becomes older, say over 40 years old, the spine is less flexible, and there may be a greater risk involved in attempting to correct the curve. Because the spinal cord is involved, only spine surgeons who specialize in scoliosis should perform scoliosis surgery.
Dorsal Column Stimulation
Dorsal column stimulation, also known as spinal cord stimulation, is used in complex cases of back pain that cannot be resolved nonsurgically or with another surgery. In most cases, it is used when leg pain is worse than back pain. The intent of dorsal column stimulation is to use an electrical signal, instead of drugs, to mask pain that cannot be removed any other way.
During this procedure, the patient is awake, and the surgeon delicately places tiny electrodes under the skin in the back. At that point, a tiny electrical current is transmitted through the wires to the desired location in the back. This sensation feels like a tiny tickle, as the electrical current interrupts the pain signal that may be sent to the brain from the damaged nerve. The patient helps instruct the surgeon as to which electrical setting and placement of wires produces the most pain relief. It is important to note that this technique is only used in the most extreme cases of back and leg pain.
Posterior Cervical Foraminotomy
Cervical disc protrusions, if they compress the nerves in the neck typically cause arm pain. There are a number of operative ways that this can be managed but, if suitable, a posterior cervical foraminotomy is a vastly under-rated operation which avoids some of the shortcomings of other disc operations and yet still has an excellent outcome in terms of symptom relief, in a minimally invasive fashion.
The typical patient presents with pain down one arm which may radiate to the hand. Cervical disc problems are exceedingly common and it is important to realize that in the vast majority of cases non-operative management works very well. Most patients settle within 6-12 weeks after the onset of symptoms. The pathophysiology of why a patient gets symptoms is disc protrusion is complex, as not all disc patients get pain.
A posterior cervical foraminotomy is a minimally invasive procedure designed to enlarge to space through which the nerve root exits from the spinal cord (the so-called “neural foramen”), and at the same time, try to remove any piece of disc which is pushing on the nerve. Interestingly, sometimes the foraminotomy alone can alleviate symptoms without a discectomy being needed. The whole disc is not removed, just the fragment pressing the nerve root. A fusion is not performed, and most patients typically do not require a neck collar after surgery.
A disc protrusion per se may not cause symptoms. If the anulus is acutely torn, neck pain may result, but the management is usually not operative. If the disc pushes on a nerve, as shown in the previous scans, then symptoms down one or occasionally both arms may result. The symptoms can include pain, numbness, “pins and needles” and weakness.
Reason for operation
Cervical disc protrusions are not usually operated upon early, but there are some clear situations when a surgeon may recommend early surgery. If there is evidence of severe weakness, early surgery may be offered. If the pain in the arm is so severe that narcotic analgesia is not controlling the pain, early surgery may again be an option. Finally, if there is a suggestion of spinal cord compression, and myelopathy, early surgery is advocated. A posterior cervical foraminotomy is not the operation of choice if a disc protrusion is causing myelopathy, as this typically indicates that the compression of the spinal cord is from disc material in front of the cord. Consequently, a posterior approach such as for a cervical foraminotomy is not suited for spinal cord compression and myelopathy.
If a patient has pain that is not too severe, typically conservative management is initiated. It must be remembered that the vast proportion of patients will settle with time, as long as improvements are noted at 6 weeks, there is minimal or no weakness, and the pain is not excruciating and is manageable with oral analgesia, then waiting and continuing with conservative therapy is a good option. If weakness occurs and is not improving, surgery is usually offered. Similarly, if symptoms are not improving at 6 weeks, then surgery is an option.
In most cases, when managing just arm pain, surgery is a treatment option that speeds up the rate of recovery, remembering that most cases will get better by themselves. Again, specific recommendations are tailored to the patient. In the vast number of cases, the goal is control of pain, and any intervention that achieves this and is less invasive than surgery is a reasonable option.
The greatest risk is injury to one or more nerves or spinal cord and this is typically 1-2%. The risks of infection, bleeding, etc., are similar to those for a any other spinal operation as are the risks of general complications. A small proportion of patients will have a recurrent disc protrusion, either at the same side and level or at different levels or the opposite side. This operation will not alter the future likelihood to get neck pain. The small but realistic risks from surgery are the reason why all patients with disc protrusions do not immediately have surgery.
In uncomplicated cases. the likelihood of good/excellent relief of arm pain is 80-90%. Numbness is slow to recovery and may persist. Weakness also may take 6-12 weeks to return to normal. Pins and needles usually starts to improve immediately.
After surgery, patients are monitored on the ward overnight. A soft collar is worn for comfort if desired, and typically patients are discharged within 1-2 days. While at home for the first 6 weeks, nothing greater than 5-10 lbs must be lifted, and after this, a return to normal activities can be effected. The sutures do not require removal and dissolve with time.
A posterior cervical foraminotomy is an excellent operation for the patient with arm symptoms secondary to a cervical disc protrusion, which avoids implantation of foreign devices and spinal fusion. Not all patients are suitable for this operation, but those who are generally do very well.