Spinal Treatment and Surgery
Is spinal or back surgery necessary? While it is true that a number of back conditions resolve on their own, some more serious conditions, as well as those that cause unresolved pain, can be dealt with by a variety of surgical methods.
Spine Treatment Options
At ANA, we first exhaust the most conservative treatments to solve spine problems. However, when surgery is indicated, we have the knowledge of and experience with the most cutting-edge procedures, including the latest minimally invasive surgical techniques.
Minimally Invasive Spine Surgery (MISS)
Minimally invasive spine surgery is a technique that is used for a wide range of spine procedures. It replaces the need for the more traditional open surgery as an alternative when possible.
Due to technological advances and a list of significant advantages, minimally invasive surgical techniques have been commonly used for spine surgery since the 1990s.
A main characteristic of MISS is that it does not involve a long incision, such as open surgery. Open surgery typically includes a five- to six-inch incision, as opposed to MISS, which requires an incision of only about two centimeters, less than an inch.
With MISS, the traditional movement of muscles and soft tissues (and even possible removal of some tissue) surrounding the spine is avoided. In MISS, the surgeon can work around those structures, thus leaving them intact and with a lower risk of damage.
A microdiscectomy and discectomy both refer to the surgical removal of an entire or partial intervertebral disc. Discectomy is often done as a microdiscectomy, a minimally invasive procedure using a microscope. Minimally invasive surgical techniques utilize tiny incisions (or portals) made in the skin through which small, specialized instruments are inserted.
This procedure is typically performed when non-operative measures have not been successful on a herniated lumbar disc. In microdiscectomy spine surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve impingement and pain.
The objective is to remove the herniated portions that are compressing the exiting spinal nerve but not necessarily remove the entire disc. The procedure also enables more room for the nerve to heal.
A special microscope to view the disc and nerves is used in a microdiscectomy. This magnified view allows the surgeon to make a smaller incision, and thus, the procedure results in less damage to surrounding tissue.
Minimally invasive techniques also allow access to the herniated disc fragment with a reduced amount of muscle and soft tissue disruption. This innovative technique also reduces post-operative pain and discomfort, and significantly reduces recovery time.
Laminectomy is surgery to remove the lamina, which is a portion of the vertebral bone that covers the spinal canal. Also known as decompression surgery, a laminectomy enlarges the spinal canal to relieve pressure on the spinal cord or nerves.
A laminectomy is also done to create a better view of a herniated disc, and most commonly, a laminectomy is performed to treat spinal stenosis.
Fusion creates a solid connection between bones, such as vertebral segments in the spine, to halt movement in that section of the spine. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
At the time of the fusion surgery, instrumentation (e.g. screws and rods) typically provides stability for several months following surgery. Over time, the bone heals, creating a solid fusion, and thus, providing stability.
A bone graft and/or bone graft substitute is needed to create the elements of fusion. The bone graft does not form a fusion at the time of the surgery. Instead, the bone graft provides the foundation to allow the body to grow new bone into the desired bond, or shape.
There are several methods of bone graft: an autograft bone graft (when the patient’s own bone is used, usually taken from the pelvis), an allograft bone graft (bone obtained from cadavers via a bone bank), and bone graft substitutes (products that either assist or replace the need for autograft or allograft bone).
The cervical spine is comprised of the first seven spinal vertebrae. It starts just below the skull and ends just above the thoracic spine (located in the upper back). The cervical spine has a lordotic curve, resembling a backward C-shape. The cervical spine, much less fixed than the other areas, allows for the wide range of motion in the neck.
The neck, or cervical spine, consists of bones, nerves, muscles, ligaments and tendons. In addition, the cervical spine is a unique structure which houses the spinal cord.
Though the cervical spine is very flexible, its location and function makes it at high risk for conditions such as herniation, stenosis, degenerative disc disease and osteoarthritis. It is vulnerable to injury due to its limited muscle support, as well as the fact that it must support the weight of the head. Thus, sudden, strong head movements, such as from whiplash, can cause significant injury.
The purpose of a cervical fusion is to connect damaged vertebral column segments in the neck. Injury or chronic wear-and-tear can damage the cervical vertebrae as well as the discs that lie between each vertebrae.
During surgery, the disc(s) (or disc fragments) between the vertebrae are removed, and the adjacent vertebra are linked together by a process which stimulates bone growth following surgery. Often, metal instrumentation is utilized to stabilize the fusion until the bone growth is solid and functional.
Anterior Cervical Fusion
Most neck pain is due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints between each vertebra. If non-operative treatments fail to control neck pain, an anterior cervical fusion may be suggested in the hope it will reduce neck pain.
An anterior cervical fusion, performed from the lower front of the neck, is done for two reasons: to remove pressure on the nerve roots caused by bone spurs or herniated disc material, and to stop the motion between two cervical vertebrae.
First, the disc is removed between the vertebrae. Then, a cervical fusion is performed by using a bone graft to fill the space left by the disc removal. Placing a bone graft between two or more vertebrae causes the vertebrae to fuse together.
The goal of spinal fusion is to stop the motion caused by the instability of the segments in the spine. This reduces the mechanical neck pain caused from excess motion in the spinal segment. Anterior cervical fusion may also be done in a way that slightly spreads the vertebrae apart in an attempt to restore the space between them.
Posterior Cervical Fusion
Posterior cervical fusion, done through the back of the neck, consists of joining together the bones in the back of the cervical spine. During the healing process, the vertebrae grow together, creating a solid piece of bone out of the two vertebrae.
Posterior cervical fusion is most commonly used to treat neck fractures and dislocations and to fix deformities in the curve of the neck. A serious fracture or dislocation of the neck vertebrae poses a risk to the spinal cord. The goal in this case is to protect the spinal cord from additional injury by fusing these bones together.
Surgeons also use posterior cervical fusion to help patients who have mechanical neck pain (pain in the spine or its supporting structures). Extra movement within the parts of the cervical spine can be a source of this type of neck pain. Fusing these bones together prevents the extra movement, easing pain.
Spinal (Lumbar) Fusion
An unstable spine can result from an injury, disease, infection, tumor, fracture, scoliosis, other deformity or the natural aging process. When these conditions cause abnormal movement of the vertebrae to rub against or compress one another, back, leg, or arm pain may result.
Lumbar fusion is a surgical procedure performed to permanently join together two or more bony vertebrae of the spine. Fusing bones together can prevent painful motion and provide stability.
Metal plates, screws and rods may be used to hold the vertebrae together, so the vertebrae can heal into one solid unit. Bone graft material may also be used. Fusing the vertebrae stabilizes and aligns the spine, maintains the normal disc space between the vertebrae, and prevents further damage to the spinal nerves and cord.
Spinal fusion may be indicated for a broken vertebrae (when it causes spinal instability, spinal deformities (scoliosis or kyphosis), spinal weakness or instability (such as resulting from severe arthritis), spondylolisthesis, or herniated disc(s). Unresolved chronic lower back pain may also be addressed by spinal fusion.
Spinal Cord Stimulation (SCS)
In spinal cord stimulation, soft, thin wires tipped with electrical leads are placed through a needle in the back near the spinal column. A small incision is then made and a tiny, programmable generator is placed under the skin in the upper buttock or abdomen which emits electrical currents to the spinal column. This electrical current treats chronic pain as these pulses interfere with the nerve impulses that cause that pain.
Nerve stimulation is done in two steps. A trial is first conducted to see if a SCS is effective in relieving a patient’s pain. The doctor inserts a temporary electrode through the skin connected to a stimulator controlled by the patient.
If this experimental stimulation by the patient is successful, the doctor can implant a stimulator. With the feedback of the patient, the doctor then determines the most optimum pulse strength. The patient is then instructed in the use of the device independently at home.
Since its approval by the FDA in 1989, SCS has become a standard treatment for patients with chronic back or limb pain who have not found relief from other treatments. Most patients who receive spinal cord stimulation report a 50% to 70% reduction in overall pain, as well as an increased ability to participate in normal daily activities.
Pain Pumps/ Intrathecal Drug Delivery
A pain pump, technically called intrathecal drug delivery, is a surgically implanted device in the lower abdomen that provides a steady stream of medication through a catheter leading directly to the spinal cord.
It is similar to an epidural that a woman may have during childbirth. Because the medication is delivered directly to the spinal cord, the symptoms can be controlled with a much smaller dose than is needed with oral medication.
A pain pump may be used if all other traditional methods have failed to relieve long-term symptoms, oral pain medication has proved successful, and when no further surgeries are indicated.
The goal of a pain pump is to better control symptoms and to reduce oral medications and their potential side effects. In fact, a patient generally needs about 1/300th of the amount of medication (typically morphine for pain, or baclofen for spasticity) with a pump than when taken orally.
Baclofen Pumps for Treatment of Spasticity
When tight, stiff muscles make movements difficult, it can make everyday life a challenge. This condition is called severe spasticity and can be caused by stroke, cerebral palsy, multiple sclerosis, brain injury, or spinal cord injury.
Electrical signals come from the spinal cord through the nerves and then to the muscles. These signals tell the muscles when to contract and relax. Spasticity is a result, causing an imbalance of these electrical signals, hyperactivity in the muscles, and resulting in involuntary spasms.
Baclofen, a medication commonly used to decrease this spasticity, works by restoring the normal balance and reducing muscle hyperactivity, allowing for more normal muscle movements.
Baclofen is delivered via a surgically implanted pump, consisting of a round metal disc, about one inch thick and three inches in diameter, and a catheter placed under the skin of the abdomen near the waistline. The catheter is the tube that delivers the drug from the pump to the fluid around the spinal cord.
Lumbar disc replacement, which is widely seen as an alternative to spinal fusion surgery, is a relatively new procedure to relieve back pain. It gained FDA approval in 2004. It may also be performed on the cervical spine (neck).
Artificial discs are structurally similar and perform similar functions to the damaged discs that are being replaced, including allowing motion and weight-bearing load. The goal of using an artificial disc is to provide pain relief without compromising the spine’s natural anatomical structure.
The recommendation for disc replacement may vary for each type of situation or symptoms. Pain arising from the disc that has not resolved with non-operative care such as medication, injections, chiropractic care and/or physical therapy may be resolved with this procedure.
Other indications are that the source of the pain is limited to one or two discs, that there is no significant joint disease or nerve compression, or no spinal deformity such as scoliosis. Finally, disc replacement is also an option if there is no history of spinal surgery, and the patient is not excessively overweight.
Surgery for adults with scoliosis is generally determined by the presence of pain. In fact, about 85 percent of adult scoliosis surgeries are done to relieve severe pain. Pain may be related to the actual curve of the spine or to the compression on the nerves of the spine, resulting in spinal stenosis.
Scoliosis surgery is generally recommended for those with pain and spinal curvatures greater than 50 degrees. If the curvature is over 60 degrees, surgery is almost always indicated because this deformity of the torso can lead to serious lung and heart conditions. Other indications for surgery include significant disfigurement, difficulty breathing or continued progression of the spinal curve.
Surgery for adult scoliosis includes decompression and fusion procedures. Posterior cervical fusion with instrumentation is most commonly indicated. Some candidates are eligible for minimally invasive procedures.
Minimally invasive surgery for scoliosis, done through an endoscope, allows for a few small incisions rather than one long one. It is usually done when the scoliosis curvature is present in the thoracic spine.
Although corrective spinal surgery is much more complicated in adults than adolescents, a new study shows surgical treatment can improve function and the quality of life for older people with scoliosis.
Advances in instrumentation have resulted in an increase in success rates in adults. In a recent study, for example, adults who underwent anterior fusion and instrumentation had excellent results. In another study of newer generation instrumentation, almost 90% of adult patients reported satisfaction.
When adult scoliosis requires surgery, many different procedures may be suggested. At ANA, we recognize that each case of scoliosis is somewhat different and may require its own highly specialized approach for optimal results. It should be emphasized that surgery is suggested not simply to straighten the spine, but to solve the problems brought on by scoliosis.
Back surgery is complicated, and can therefore create mixed results. It may take a few months to assess the success of a back procedure. Recurrent lumbar disc herniations happen to about 5% to 10% of patients.
Decompression of a nerve root with back surgery is not always successful, such as if a portion of the nerve root is still pinched after the back surgery and can cause continued pain. At ANA, we are experienced in the complications of back surgery, and the possible need for revision surgery.
Often, the reason for continued pain after surgery is that either the patient has a secondary problem that needs to be addressed, or the lesion operated on was not, in fact, the source of the patient’s pain. (A lesion is the term used for any abnormal change involving any tissue or organ due to disease or injury.)
Finally, improper and/or inadequate postoperative patient rehabilitation is probably one of the most common causes of continued back pain after surgery.
Unfortunately, back or spine surgery in and of itself cannot end someone’s pain. It is only able to alter the anatomy. In order to ensure success to the greatest degree possible, the actual injury, which is the probable cause of back pain, must be identified prior to, rather than after, back or spine surgery.
In most cases, the above reasons are why revision surgery, while it may be necessary, is often not technically due to an error from a prior surgery. However, there are other factors, such as a condition called pseudarthrosis (failure to achieve solid fusion) that may be a related factor to the need for revision surgery. This condition can lead to poor tissue healing and subsequent results.
Another factor to consider is that the spine is ever-changing. Even after successful surgery, it can continue to deteriorate or develop other problems.
Spinal reconstruction involves any or all parts of the spine and is used to correct significant deformities (scoliosis, spondylolisthesis, kyphosis), disc herniations, traumatic injuries to the spine, degenerative or congenital conditions, and tumor removal. These can result in an unstable and weakened spinal column or significant neurological defects.
This surgery stabilizes the newly shaped spine with rods and pins, and fuses the vertebrae together. In some cases, entire vertebrae are removed and replaced with artificial components to replace the diseased segment.
Reconstructive spine surgery is different from other types of spine surgery, such as decompressive spine surgery and spinal fusion performed following decompression. Modern reconstructive spine surgery focuses on restoring the anatomy to the degree possible to its pre-trauma or pre-degenerative state.
For more information about our Neurosurgery Spine Center, our specialists and any additional questions you may have please contact us at: (201) 457-0044.