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Tuesday, May 21, 2013
In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor's office under local anesthesia, while others require hospitalization.
It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility (either intentionally in the case of a spinal fusion, or from possible muscle scarring and deconditioning after surgery). Since invasive back surgery is not always successful, it should be performed only after exhausting other treatment options, and only after thorough discussion of all the potential risks, what the expected benefits and realistic expectations for improvement are, and only after careful evaluation of the patient's overall health and ability to tolerate the proposed operation. There are a small number of rare conditions that demand surgical treatment as the first option - in these cases, delaying surgery to try other treatments can be detrimental, and even lead to permanent loss of function. Only a qualified specialist can make this determination.
Minimally invasive outpatient treatments to seal fractures of the vertebrae caused by osteoporosis include vertebroplasty and kyphoplasty. Vertebroplasty uses three-dimensional imaging to help a doctor guide a fine needle into the vertebral body. A glue-like epoxy is injected, which quickly hardens to stabilize and strengthen the bone and provide immediate pain relief. In kyphoplasty, prior to injecting the epoxy, a special balloon is inserted and gently inflated to restore height to the bone and reduce spinal deformity.
This is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During the procedure the surgeon takes out a small piece of the lamina (the arched bony roof of the spinal canal) to remove the obstruction below.
This operation "cleans out" or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve the pressure on the nerve.
This is used to strengthen the spine and prevent painful movements. In an "interbody fusion" the spinal disc(s) between two or more vertebrae is removed and the adjacent vertebrae are "fused" by bone grafts and/or metal or plastic devices placed where the disc used to be, often supported by screws joined together by small rods. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Several types of Spinal Fusion are listed below:
Transforaminal Lumbar Interbody Fusion (TLIF): In this procedure the physician enters from the posterior (back) of the spine at an angle, thus avoiding manipulation of the spinal nerves. A bone graft is placed into the interbody space (disc space) and sometimes along the back of the vertebrae to be fused. As the bone graft heals the vertebrae will fuse together. Screws and rods are usually inserted to help the fusion heal.
Extreme Lateral Interbody Fusion (XLIF): This operation specifically for the L1 to L5 vertebrae, is a very minimally invasive procedure. It is so minimally invasive that it can be done on outpatient procedures via very small incisions. In this procedure, two very small incisions are made along the flank (side) of the patient and using a fluoroscopy machine (which provides constant X-ray feedback) a physician can insert bone graft material in plastic cages into the disc space (interbody fusion). It is also possible to secure the vertebrae with a small metal plate and screws through this approach.
Axial Lumbar Interbody Fusion (AxiaLIF): This is a new procedure that is very minimally invasive. Unlike XLIF, this procedure is designed to fuse the L5 to the S1 vertebrae. The surgeon enters the back through a very small incision next to the tailbone and the abnormal disc is taken out. Then a bone graft is placed in where the abnormal disc was and is supplemented with a large metal screw. Sometimes additional, smaller screws are placed through a small, additional incision higher on the back for extra stability.
Pedicle Screw and Rod Instrumentation: This type of treatment can occur during an open operation or it can be done in a minimally-invasive procedure ("Percutaneous" = through small punctures in the skin, rather than an incision). Screws are placed into the pedicle of the vertebrae, and a rod is placed between them. This is often used in spinal fusion surgeries for structural support and it allows the joint space between vertebrae to fuse.
Also known as spinal decompression, this treatment involves the removal of the lamina (usually both sides) to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots. This is the most common surgical treatment for spinal stenosis.
This is a spacer that can be placed in between the processes of the vertebrae that helps alleviate pressure that may be exerted on the discs. It is intended to treat "lumbar stenosis" in patients with "neurogenic claudication", and does not treat other spinal problems. This spacer is placed in through a small incision in the skin of your back and can be done under local anesthesia.
Source: National Institute of Neurological Disorders and Stroke - Low Back Pain Fact Sheet
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Last Reviewed: Oct 12, 2011
David J Hart, MD
Associate Professor of Neurosurgery
School of Medicine
Case Western Reserve University