Dr. Gold's Orthopedic Surgery Blog

One of the first questions I hear from patients diagnosed with a need for surgery, “What are my options for back surgery?”

In the United States, the lumbar discectomy is the most common back surgery performed. This procedure allows the surgeon to remove the disc and other tissue that is causing pressure on surrounding nerves. The operation is often used to alleviate the symptoms of sciatica. Traditionally, the procedure was open surgery that entailed an increased risk of complications and an extended recovery period.

Over the years, new techniques have been perfected to reduce the trauma to the operative area. Minimally invasive surgical techniques employ microscopes, endoscopes and miniature instruments to visualize the spine and make the necessary repairs. The scopes and instruments are passed through one or more tiny incisions. Images are transmitted to a monitor that the surgeon uses to guide his movements. Recovery rates are faster, post-operative pain is less and the risk of complications is reduced. Many patients require only a local anesthetic and may return home the same or following day.

Laser surgery of the spine began several decades ago and has been increasing in popularity. However, many hospitals do not approve of the procedure even though a large number of these operations have been performed with few complications. The procedure is performed under a local anesthesia and the patient may be allowed up within minutes of the surgery. Patients whose occupations do not require heavy physical activity can often return to work in as little as two weeks

.

The basic technique for laser surgery utilizes the same principles as other minimally invasive procedures. A small incision is used to insert a camera and a laser. With the camera to guide him, the surgeon uses the laser to vaporize the portion of the disc causing the problem. However, the lasers are incapable of cutting through bone. This means that they can only be used on the discs.

Despite advances in microsurgery, many patients still require open surgery for back problems. One example is spinal fusion, which has an overall high failure rate when performed as a minimally invasive technique. However, some individual surgeons find their patients’ success rates are excellent. The choice of a technique is one that the patient should discuss with his surgeon and should be based on not only the patient’s preference but also the surgeon’s experience with a particular technique.

Until next time,

Stuart

Patients with sore or painful spines typically come into my office with questions about the different types of back surgery. That said, there are several key points a patient should consider as they consider back surgery types. Here are some ideas for both patients and caregivers:

Unless an emergency situation exists, few surgeons will operate on the spine without a minimum of three to six months of more conservative treatment. Patients may be advised to rest, alter their activities or attend physical therapy during this time. Aspirin or ibuprofen may be recommended to treat the pain, but the doctor may also prescribe more powerful pain relievers or muscle relaxers. Epidural or facet injections should also be considered or tried prior to considering operative intervention.

The type of back surgery needed depends on the nature of the injury and diagnosis. Both the severity and the location of the injury will be evaluated carefully before the surgeon makes a recommendation. If more than one technique is possible, the patient’s health, lifestyle and the surgeon’s preference will also be factors in the decision.

• A discectomy is a common procedure to correct a herniated disc. Discs are the fluid-filled cushions that are found between vertebrae. They act as shock absorbers and lubricate the vertebrae to assist with movement. The fluid within the discs can begin to leak after an injury or as the body ages. This fluid can leak out onto nerves, resulting in pressure, pain and numbness in the extremities. With a discectomy, the surgeon removes the herniated disc. Only rarely is it necessary to use a bone graft or plate to fuse the two vertebrae (on either side of the removed disc) in an isolated disc herniation. Depending on the patient’s condition and the technique chosen, outpatient surgery or a minimal hospital stay may be an option.

• A laminectomy is another procedure that may be an option for a herniated disc, although it is sometimes used to correct a bulging disc, or one that is not leaking but extends beyond the vertebrae flanking it. The procedure is most commonly used to correct stenosis of the spine

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  . In a laminectomy, the surgeon removes the back of the vertebra, called the lamina, as well as any portion of the disc that requires removal. By removing the lamina, the spinal canal has more space thus relieving pressure on the compressed nerve.

If a nerve is receiving pressure from a source other than or in addition to a herniated disc, the surgeon may elect to perform a foramenotomy. In this procedure, scar tissue or bone can be removed to free the nerve. The procedure is normally used to correct pressure on nerves at the points where they emerge from the spinal column.

Spinal fusion may be performed in conjunction with another surgery, such as a discectomy or laminectomy, or it may be performed to correct a condition such as an instability known as spondylolisthesis. The net effect of the surgery is that the spine can no longer bend where the two vertebrae have been fused. A relatively new procedure involves replacing the disc with an artificial prosthesis. Patients may have difficulty, however, in locating a surgeon with extensive experience with replacement surgery. The results of disc replacement are still being studied and remain unknown.

I hope this help you understand some of the different back surgery types.

Until next time,

Stuart

Discs are like pillows or donuts between the vertebrae that act as shock absorbers and also provide for movement as they are positioned between the vertebrae (bone blocks of the neck and back). These discs consist of a tough outer layer (annulus) surrounding a filling of softer spongy/jelly material (nucleous pulposis). A disc can be bulging minimally (1-3mm) or in some cases very significantly (6-10mm). A herniated disc exists when the tough outer layer of the disc ruptures and the soft spongy jelly material has been pushed out or extruded.

A bulging disc, which can affect any part of the spinal column, is one that protrudes beyond the vertebrae. The bulge is normally part of the outer layer. Many physicians consider a bulging disc as a normal part of aging. Most of the time, the patient experiences little or no pain from the bulge. However, others may find the condition painful if the bulge is in a position to exert pressure on a nerve. In many situations the soft spongy jelly material is pushed out(herniation) and places more significant pressure on the nerve root. This pressure may also cause numbness and weakness in an arm or a leg. If the pain is severe and the numbness and weakness persists and there has been no response to conservative treatments, surgery may be necessary.

One common procedure used for a large bulging or herniated disc is a minimally invasive technique called a microdiscectomy. In this procedure, the surgeon makes a small incision, normally two inches or less, and inserts a tiny microscope through which he can see the nerves and discs. He then removes a small part of the disc that is placing pressure on the nerve or spinal cord. Scarring is usually minimal, and recovery can be less than a few months in many cases. In fact, many patients are able to walk within hours of the procedure. Patients may need to start an exercise program about one month after the procedure to strengthen the back and maintain flexibility. In some case this procedure is carried out in an outpatient facility and no hospital stay is needed.

Should a microdiscectomy fail to relieve the pain or a larger procedure be necessary, there are two surgical procedures that can be used for a herniated disc, a laminectomy or a laminotmy. These procedures are performed under general anesthesia. The surgeon makes an incision near the disc problem and moves any tissue or muscles that obstruct his view. He then removes the lamina, the back part of the vertebra, and, if needed, part of the disc or damaged tissue. This gives the disc more space so that it does not press against a nerve. The second surgery is called a laminotomy. It is identical to a laminectomy except that only a portion of the lamina will be removed.

Complications from surgery for a herniated disc can happen. Potential risks include damage during surgery to nerves and dura, infection, and, if the surgery is performed on the lower back region, nerve damage that causes incontinence

. Nerve damage can be temporary or permanent, depending on which nerve suffers the injury.

I hope this helped you learn more about back surgery for bulging or herniated discs.

Until next time,

Stuart