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About spine surgery
What you need to know
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.
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here to learn more about SpineNevada's minimally invasive
surgical techniques.
Common back surgeries
Lumbar Discectomy | Cervical Discectomy | Lumbar spinal fusion | Anterior cervical fusion | Posterior cervical decompression and fusion | Lumbar laminectomy | Rhizotomy | Scoliosis Surgery | Dorsal Column Stimulation | Posterior Cervical Foraminotomy
"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.
Technique
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.
Risks
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.
Expectations
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.
Recovery
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.
[Top]
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.
Technique
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.
Risks
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.
Expectations
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.
Recovery
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.
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.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). Technique 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. |
Click on image to enlarge |
Risks
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.
Expectations
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.
Recovery
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.
Nonsurgical options
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.
Other points
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.
[Top]
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.
[Top]
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.
[Top]
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.
[Top]
Posterior Cervical Foraminotomy
Background
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 operationCervical 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.
Risks
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.
Expectations
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.
Recovery
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.
Nonsurgical options
Despite the lengthy discussion about surgery, most patients get better without surgery.
Conservative therapy comprises:
- Analgesia with NSAIDs (e.g. Mobic, Voltaren or Celebrex)
- Analgesia with other medications such as Tramadol
- Avoidance of bending/lifting and ergonomics at work
- Physiotherapy (traction may help)
- Perineural steroid and local anesthetic injections (these can be very helpful)
- Possibly acupuncture
Other points
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.
[Top]
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