Surgical Treatment for Spine Conditions

The cervical spine is located in the neck region and consists of seven bones arranged one on top of the other. Cushioning tissue called vertebral discs located between the vertebrae act as shock absorbers, allowing easy movement of the neck. Wear and tear and advancing age can damage these discs, leading to pain and disability. Artificial cervical disc replacement surgery is a procedure where the damaged intervertebral disc is removed and replaced with an artificial implant. The surgery relieves neck pain as well as restores the normal range of motion of the neck.

Cervical disc replacement surgery is an alternative to the traditional cervical spine fusion surgery, which involves the permanent fusion of two vertebral bodies, eliminating movement between them. Artificial cervical disc replacement is usually indicated when conservative treatments do not help relieve the following:

• Neck stiffness and pain
• Pain, weakness or numbness of the arms and legs
• Difficulty walking
• Headache

Artificial cervical disc replacement is contraindicated in the presence of rheumatoid arthritis, pregnancy, morbid obesity, significant osteoporosis or an active malignancy, insulin-dependent diabetes and allergies to stainless steel.

The procedure is performed under general anesthesia and is guided with the help of X-ray imaging (fluoroscopy). You will lie face up on the operating table. Your surgeon approaches the cervical spine from the front or side of your neck through a small incision. The important structures in your neck are gently moved to the side to access the cervical spine. The damaged disc along with any loose disc fragments or bone spurs are identified and removed. The artificial disc device is sized and placed in the prepared disc space, restoring its normal height and relieving any pressure over the spinal nerves. The incisions are closed and covered with a dressing.

Following surgery, your neck may be immobilized in a collar. You will need to keep the incision area clean and dry. Refrain from hot tubs, swimming, heavy lifting, driving and smoking. You can initiate physical therapy as directed by your surgeon. Take medications as recommended by your doctor. Arrange for a follow-up appointment with your doctor. You may be able to resume light activities in a week or two, and complete normal activities in six weeks.

The potential risks associated with artificial disc replacement surgery may include infection, bleeding, nerve injury, difficulty breathing or swallowing, change in your voice, leakage of spinal fluid, or a break or loosening of the prosthesis, requiring further surgery. Call your doctor if the incision site shows signs of infection such as pain, redness, swelling, or alteration in the quantity of smell of the drainage, or if you develop fever over 101° F.

The advantages of artificial cervical disc replacement include:

• Maintains normal neck movement
• Lowers the risk of degeneration of adjacent segments
• Does not require bone graft
• Allows early neck motion after surgery
• Faster return to daily activities

Introduction

The lower back or lumbar region is often the site of pain due to its high mobility and weight bearing. Spongy discs present between the vertebral bones of the spine help cushion the spine during stress and movement. These intervertebral discs in the lumbar region may undergo damage due to stress, causing them to herniate or rupture, and compress adjacent spinal nerves. This can lead to lower back pain, as well as pain, weakness and numbness in the lower legs. A lumbar discectomy is a surgical procedure to treat a herniated or ruptured disc, and relieve pressure on the spinal nerves.

Procedure

To perform lumbar discectomy, your doctor makes a small incision in your lower back over the affected spinal disc. Some vertebral bone and ligament may need to be removed to expose the disc. A microscope is used to visualize the disc and the adjacent spinal nerves. The spinal nerves are protected, and the affected disc completely removed. The surgical site is then irrigated with antibiotic solution and closed.

Post-operative care

Following surgery, activities such as bending, lifting and sitting for prolonged periods should be avoided for four weeks. Your doctor will advise you about exercises to improve the strength and flexibility of the lower back. You may be able to return to work in 2-6 weeks depending on the level of activity involved.

Risks & complications

Lumbar discectomy as with any invasive surgery may be associated with certain complications, which include nerve and spinal cord injury, infection and ongoing pain.

The human spine provides support to the body allowing you to stand upright, bend, and twist. The spine can be broadly divided into cervical, thoracic and lumbar spine. Thoracic spine lies in the mid back region between the neck and lower back and is protected by the rib cage.

24 spinal bones called vertebrae are stacked on top of one another to form a spinal column. Between two vertebrae there is a disc of cartilaginous tissue called intervertebral disc. Intervertebral disc acts as a shock absorber and protects the spine from the strong forces of movement during activities such as jumping, running and lifting.

Wear and tear can occur in the disc with age and may cause the soft spongy tissue in the center of the disc to squeeze (herniate) from a tear on the side of the disc. Disc herniation may also occur due to an injury such as during a car accident or a fall; a sudden and forceful twist of the mid-back or disease of the thoracic spine such as Scheuermann's disease.

The herniated disc protrudes into the hollow tube of the spinal column called the spinal canal and directly pushes against the spinal cord passing through the spinal column. This can injure the spinal cord. Herniated discs can also block blood flow from the one and only blood vessel going to the front of the spinal cord in the thoracic region of the spine, causing nerve tissues in the spinal cord to die.

Symptoms of thoracic disc herniation vary depending on the position and size of the disc herniation, nerve irritation or nerve injury, and damage to the spinal cord. Symptoms may include mid-back pain, pain around the front of the chest that may mimic heart problems, groin pain or pain, numbness and weakness in the legs and arms. It may even affect bowel and bladder function.

Usually thoracic disc herniation is treated conservatively with rest, back brace, medication and physical therapy. Surgery is considered when long term conservative treatment does not relieve pain or the condition is rapidly getting worse or is affecting the spinal cord.

The goal of the surgery is to remove all or part of the herniated disc pressing on the nerve root or spinal cord and is called discectomy. Thoracic discectomy can be performed either through the anterior approach (front side) or posterolateral approach (behind and to the side).

Anterior approach: This approach usually involves open thoracotomy in which the herniated disc is accessed through the chest cavity. An alternative to open thoracotomy is Video Assisted Thoracic Surgery (VATS). VATS is a minimally invasive surgery that is done through several small incisions and involves the use of a thoracoscope, a surgical tool with a tiny camera. Thoracoscope is inserted into the side of the thorax through a small incision to provide real images of the surgical area on a TV screen. These images guide the surgeon to remove the herniated disc using instruments inserted through other small incisions. VATS is minimally invasive and results in quicker recovery than open thoracotomy.

Posterolateral approach: This approach is also called as costotransversectomy. The herniated disc is accessed through an incision on the back of the spine. A window through the bones that cover the herniated disc is created by removing a small part of rib where it connects to the spine (costo means rib) and transverse process (a small bone attached to the spine). The discectomy is then performed with the small instruments.

Spinal fusion is the surgical technique of combining two or more vertebrae. Fusion of the vertebrae involves insertion of secondary bone tissue obtained either through auto graft (tissues from the same patient) or allograft (tissues from the other person) to augment the bone healing process.

Lumbar (lower back) region of the spine are more prone to spine fusion when compared to the other regions such as cervical (neck) and thoracic (mid back) parts of the spine. Usually spinal fusion is recommended in patients with neurological problems or severe pain that have not responded to conservative treatment.

Indications for lumbar spinal fusion

Various spinal conditions may be treated though lumbar spinal fusion such as:

• Spinal stenosis
• Damaged disc
• Spinal tumor
• Fractures of the spine
• Scoliosis and Kyphosis (abnormal curvatures of the spine)

Procedure:

Spinal fusion can be performed through different angles depending upon the specific advantages of each and the choice of your surgeon. It may involve interbody fusion where bone graft is placed in the space present between the two vertebras. Other techniques may also be employed for spinal fusion that involves the entire removal of the disc between the affected vertebrae. A specially designed device made either from plastic or titanium may be placed between the vertebrae. This helps in maintaining spine alignment and normal height of the disc.

The fusion process is followed by fixation that involves fitting of metallic screws, rods, plates or cages to stabilize the vertebrae and accelerate bone fusion. After surgery, 6-12 months is the ideal time for complete fusion to take place.

Complications:

The complications associated with spinal fusion include infection, nerve damage, blood clots or blood loss, bowel and bladder problems and problems associated with anesthesia. The primary risk of spinal fusion surgery is failure of fusion of vertebral bones which may require an additional surgery.

Talk to your surgeon if you have concerns regarding spinal fusion procedure.

Artificial cervical disc replacement is a spine surgery to replace a degenerated (deteriorated) disc in the neck with an artificial disc. Disc degeneration reduces the height of the disc and may cause a herniated disc. Herniated disc refers to a condition in which the inner central portion (nucleus pulposus) of the spinal disc is forced out through a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc. Herniated disc is also called bulging disc, ruptured disc or slipped disc. Disc herniation causes compression of the spinal cord and/or spinal nerves. Spinal cord compression can cause pain in the arm and legs. In rare cases, it can lead to permanent damage and even paralysis.

An artificial disc, similar to the natural healthy disc is used to replace the degenerated disc. It restores the height between the two cervical vertebrae, enlarging the neural foramen (nerve passageway in the spine) and relieving the pressure on the spinal nerves. This stabilizes the cervical spine and restores normal mobility of the neck.

For the procedure, the cervical spine is approached through an incision in the front of the neck. The affected disc is identified with the help of imaging studies and removed. The artificial disc is then placed precisely in the disc space between the vertebrae. After checking the range of motion of the neck and confirming proper fit of the artificial disc, the incision is sutured closed.

As with any surgery, artificial cervical disc replacement may be associated with certain complications which include infection, bleeding and nerve injury causing temporary hoarseness of the voice and difficulty in swallowing.

Spinal decompression is treatment to relieve pressure on one or many “pinched nerves” of the spinal column. It can be achieved either surgically or by non-surgical methods. It is used to treat conditions which cause chronic backache such as herniated disc, disc bulge, sciatica, and spinal stenosis.

Non-surgical method:

A safe and non-invasive form of spinal decompression therapy is performed by a professional qualified to use a decompression machine. By this method, more room is created within the spinal column thus relieving the spinal cord and nerves from pressure. It takes nearly 15-24 treatment sessions to achieve the best results.

The DRX 9000 Spinal decompression machine is widely used to relieve chronic lower back pain. It works by creating space between the vertebrae and damaged spinal discs, helping them to heal.

The Process:

When undergoing spinal decompression, you will be made to rest on a therapeutic table that is connected to a computer which sends electronic information to stretch and decompress the spinal structure. A padded harness is worn and during the spinal decompression session, gentle force is applied to the spinal column, focusing on the area for treatment. Pressure is applied decompressing the spine, the intervertebral discs and the joints. You will experience multiple cycles of treatment lasting 2-3 minutes in each spinal decompression session. The machine is monitored by a technician. Even though you may get relief in a single therapy session, you should complete the full treatment cycle plan to gain complete healing of the injured disc.

Surgical Method:

Surgical spinal decompression is performed by two procedures:

1) Microdisectomy/microdecompression

2) Laminectomy/open decompression

Microdiscectomy: This is a minimally invasive procedure which involves removal of a portion of a herniated nucleus pulposus by a surgical instrument or LASER.

Laminectomy: This is a procedure in which a small portion of the arch of the vertebrae is removed to relieve pressure on the pinched nerve. This is performed as a last resort, when conservative treatment fails to provide relief from back pain.

Thoracic corpectomy is a procedure performed to relieve pressure on a nerve at the thoracic region (upper and middle back) by removing the source of the compression. It is indicated for conditions such as degenerative disc disease, spinal stenosis, bone spurs, tumor, fracture and infection leading to spinal compression, which cause pain, weakness and numbness in various parts of the body.

Thoracic corpectomy is carried out under general anesthesia. You will lie on your side during the procedure. An oblique incision is made. Important organs are moved aside to protect them during the surgery. The surgery involves two stages – decompression and fusion. To decompress the nerve, the presence of bone spurs, tumors or fractures causing the compression are removed. This is followed by fusion, where deformed or diseased vertebrae are removed along with the intervertebral discs, and the adjacent vertebrae are then fused. A bone graft is placed in this region to provide stability and a metal plate with screws may be used to provide added support. The procedure typically takes 3-4 hours to complete. Following surgery, you will remain in the hospital for 2-3 days.

You may notice immediate improvements in symptoms and may be able to walk the same day. Further improvement takes place over time. Your doctor will advise you when it is safe to return to work.

Risks and complications may be associated with this procedure, which is common to all spine surgeries. These include bleeding, infection and nerve damage.

Thoracic Vertebroplasty

Osteoporosis is a “silent” disease characterized by weakening of bones, making them more susceptible to fractures, typically in the hip and spine. Elderly people and especially post-menopausal women are at greater risk of developing osteoporosis.

The mid to lower back area of the spine is mainly involved in weight- bearing, making these regions of spine more prone to collapse when bone weakness is present.  This can lead to spinal (vertebral) compression fractures in these patients. Many of these vertebral compression fractures occur by minimal trauma or by no trauma at all. They can even occur while doing simple activities, like bending or twisting. Symptoms range from severe pain in the back, arms and legs to no pain at all. Most patients suffering from such a fracture may believe that their back pain is just a part of ageing, letting these vertebral compression fractures go undiagnosed. However, a single vertebral fracture significantly increases a person’s risk of further fractures. When multiple fractures occur, it causes the spine to become rounded and bent forward resulting in loss of height and a hunchback appearance. This forward curvature of the spine negatively affects the quality of life of the patient and makes it more difficult for them to breathe, eat, walk, or sleep. Vertebral compression fractures can also occur in patients suffering from conditions such as metastatic tumor, multiple myeloma, and vertebral hemangioma.

Vertebroplasty is a minimally invasive procedure which is performed to reduce or eliminate pain caused by vertebral compression fracture. It stabilizes the fracture and prevents further collapse of the vertebra averting deformity. The vertebroplasty procedure involves injection of bone cement into the fractured vertebra under high pressure. The procedure is done under general or local anesthesia. You will be lying face down on the operating table. Your doctor will make a very small 1/2 inch incision in the skin over the fracture site. Under live X-ray guidance, a hollow needle called a trocar is introduced through the back and is positioned within the fractured vertebrae. Next, bone cement is injected into the area through the trocar under high pressure. After the vertebral body is filled completely with the bone cement, the needle is withdrawn before the cement hardens. X-rays or CT scans may be done to confirm the effective spread of the bone cement into the fractured vertebra.  The skin incision is closed using steri-strips.

Contraindications

The procedure cannot be performed under the following situations:

• Compression fracture is stable and does not cause any pain
• A fractured fragment or tumor is present in the spinal canal
• Presence of a bone infection or bleeding disorder

Risks and complications

As with any surgery, some risks can occur. General complications include bleeding, infection, blood clots and reactions to anesthesia. The specific complications following a thoracic vertebroplasty include leakage of the bone cement into surrounding soft tissues or veins and damage to the spinal cord or spinal nerves leading to numbness or paralysis.

Balloon Kyphoplasty

Balloon kyphoplasty is a spine surgery that relieves back pain caused by a vertebral compression fracture. Osteoporosis (bone disease) is the primary cause of vertebral compression fractures. Other causes include trauma such as a fall or motor vehicle accident, and some types of cancers affecting the spinal vertebrae. The aim of balloon kyphoplasty is to relieve pain, stabilize the fracture and restore the vertebral body height.

Your doctor recommends balloon kyphoplasty if you have severe pain and deformity that is not relieved by non-surgical treatment modes including rest, pain medications, and braces.

The surgery is performed under general anesthesia. During the procedure, you will lie face down on the operating table. A small incision is made in the back through which a narrow tube is inserted into the compressed vertebra under the guidance of live X-ray. Then a special balloon is inserted through this tube and carefully inflated. This elevates the fracture and restores the vertebra to its original height. The balloon is then deflated and removed leaving behind an open cavity. The cavity is filled with bone cement with the help of miniature surgical instruments. The cement hardens within a few minutes and stabilizes the bone.

You may experience significant pain relief following surgery and will be allowed to get up and walk. Your doctor will prescribe pain medication if necessary and recommend a rehabilitation program to strengthen your spinal muscles. You should avoid strenuous activities for at least 6 weeks.

As with any surgery, balloon kyphoplasty may be associated with certain complications which include infection, nerve or spinal cord injury and cement particles entering the blood or spinal fluid.

Spinal fusion, also called arthrodesis, is a surgical technique used to join two or more vertebrae (bones) within the spine. Lumbar fusion technique is the procedure of fusing the vertebrae in lumbar portion of the spine (lower back).

Lumbar fusion surgery may be used to treat spondylolisthesis (slipping of the spine bones), degenerated discs, scoliosis or kyphosis (abnormal curvature of the spine), spinal infections or tumors, traumatic injury of the spine, recurrent disc herniation, and unstable spine.

The surgery can be done as an open or laparoscopic (keyhole) surgery.

Your surgeon may approach your spine from the back, abdomen or neck, depending on the area to be treated.

In spinal fusion, a piece of bone, taken from other parts of the body or donated from a bone bank is transplanted between the adjacent vertebrae. Screws, plates, or cages may be used with the bone graft to help hold the spine.

During the surgery, your surgeon performs a discectomy where a portion of the diseased or damaged disc material is removed. After the removal the roof of the vertebra will be trimmed or removed to relieve the pressure on the nerve and this procedure is called as laminectomy. Following laminectomy, the bone graft (small chips of bone) will be placed alongside of the vertebrae between the vertebrae to be fused. Screws are placed into the vertebrae to be fused. Rods are attached to connect the screws, to stabilize and hold the bones together while the fusion heals.

As with every surgery, lumbar fusion surgery is associated with certain complications and they include:

• Spine infection
• Damage to the spinal nerves
• Loss of sensation
• Problems with bowel or bladder control
• Dislocation of the implant
• Pseudarthrosis, a painful condition occurring as a result of non-healing of the bone effusion, and a false joint grows at the site
• Blood clot formation in the legs
• Pain at the bone graft site

Spine osteotomy is a surgical procedure in which a section of the spinal bone is cut and removed to allow for correction of spinal alignment. Spine osteotomy is usually needed for correction of severe, , rigid and fixed spinal deformity when nonsurgical treatments do not relieve symptoms such as numbness, weakness, or pain due to nerve compression or when deformity is getting worse over time. A mild or flexible deformity is usually corrected through positioning and instrumentation.

Severe spinal deformity may occur in conditions such as Scheuermann's kyphosis, iatrogenic flat back, post-traumatic, neuromuscular, congenital, degenerative disorders and ankylosing spondylitis. Severe deformity causes symptoms that may include a subjective sense of imbalance, leaning forward (stooping), early fatigue, intractable pain and difficulty of horizontal gaze. A spine osteotomy procedure significantly improves these symptoms. A spine osteotomy reduces pain and restores balance so that the patient can stand erect without the need to flex his/her hips or knees. It also improves the gross appearance (cosmesis) of the patient and even makes a horizontal gaze possible. Functional improvement of the visceral organs may also occur.

Spine osteotomies can be broadly divided into three main types. The type of osteotomy used depends on both the location of the spinal deformity and on the amount of correction that is required. A spinal fusion with instrumentation may also be performed along with spine osteotomy to stabilize the spine and prevent further curvature. The three main types of osteotomy are:

Smith-Petersen Osteotomy (SPO): SPO is recommended in patients in whom a relatively small amount of correction (approximately 10-20° for each level) is required. In this procedure, a section of bone is removed from the back of the spine causing the spine to lean more toward the back. The posterior ligament and facet joints are also removed from this area. Anterior bone graft is not used in this procedure as motion through the anterior portion of the spine or the discs is required for correction. SPO may be performed at one or multiple locations along the spine to restore lordosis.

Pedicle Subtraction Osteotomy (PSO): PSO is recommended generally in patients in whom a correction of approximately 30° is required mainly at the lumbar level. PSO involves all three posterior, middle, and anterior columns of the spine. It involves the removal of posterior element and facet joints similar to a SPO and also removal of a portion of the vertebral body along with the pedicles. PSO allows for more correction of the lordosis than SPO.

Vertebral Column Resection Osteotomy (VCR): VCR involves the complete removal of a single or multiple vertebral bodies. It allows for maximum correction that can be achieved with any spinal osteotomy. As VCR introduces a large defect in the spine, spinal fusion is also performed over these levels for reconstruction. Spinal fusion may involve the use of a structural autograft, structural allograft or metal cage. Initially, VCR was performed through a combined anterior and posterior approach but now it can also be performed through only a posterior approach.

Back and leg pain often have causes which either improve on their own or which the surgeon can correct. Sometimes there is no easily correctable cause of the pain.

Among other things, scar tissue around the nerves or chronic inflammation of the nerves such as arachnoiditis may cause leg and back pain. When the neurosurgeon feels that open surgery to decompress the nerves is unlikely to help the pain, an operation to implant a spinal cord stimulator may be very beneficial for the patient.

For reasons not completely understood, the stimulator sends electrical impulses to the areas of the spinal cord causing the pain and interferes with the transmission of pain signals to the brain. It blocks the brain's ability to sense pain in the stimulated areas, thus relieving pain without the side effects that medications can cause. The electrical impulses can be targeted to specific locations and, as pain changes or improves, stimulation can be adjusted as necessary.

Before implanting a permanent stimulator, the patient will undergo a trial stimulation period to see if the stimulation helps with their pain. If it does, a permanent stimulator may be implanted. A battery pack will also be implanted to provide charge to the stimulator.

Procedure

There are several ways of implanting the stimulator. The initial implantation of the trial is generally done with the patient awake so that it can be determined in the operating room if the stimulator is covering the appropriate spot of the spinal cord in order to give the patient pain relief.

Either a paddle lead is placed over the spinal cord through a small open incision and removal of lamina, or a percutaneous insertion of a lead is performed through the skin. The permanent implant will be fixed several days later if the patient achieves good pain relief with the trial stimulator.

Post-operative Care

Patients are generally discharged on the same day or the following day of the procedure. They should keep the wounds very clean and dry.

Risks

Risks for the procedure are low. Potential risks include bleeding, infection, injury to nerves, injured spinal cord, paralysis, and death.

The Spine or backbone provides stability to the upper part of our body. It helps to hold the body upright. It consists of several irregularly shaped bones, called vertebrae appearing in a straight line.  The spine has two gentle curves, when looked from the side and appears to be straight when viewed from the front. When these curves are exaggerated, pronounced problems can occur such as back pain, breathing difficulties and fatigue and the condition will be considered as deformity. Spine deformity can be defined as abnormality in the shape, curvature and flexibility of the spine.

The different types of spinal deformities include scoliosis, lordosis and Kyphosis. Scoliosis is a condition where the spine or back bone is curved sideways instead of appearing in a straight line. It curves like an “S” or “C” shape. Lordosis is a condition characterized by abnormal excessive curvature of the spine, sometimes called swayback. Kyphosis is a condition where an abnormal curvature of the spine occurs in the thoracic (chest) region resulting in round back appearance.

There are different surgical approaches to repair these deformities and the choice of the approach to the spine is based on the type of deformity, location of the curvature, ease of access to the area of the curve and the preference of the surgeon.

Anterior approach – In this procedure, the surgeon will approach the spinal column from the front of the spine rather than through the back. The incision is made on the patient’s side, over the chest wall or lower down along the abdomen, depending on the part of the spine that requires correction. The lung is deflated and a rib is removed in order to reach the spine. After the exposure of the spinal column, the disc material between the vertebrae involved in the curve is removed. Screws are placed at each vertebral level involved in the curve, and these screws are attached to a single or double rod at each level. After instrumentation a fusion is performed, the bony surface between the vertebral bodies is roughened and bone graft is placed. A combination of compression along the rod and rotation of the rod will correct the spine deformity. The incision is closed and dressed.

Posterior approach- It is the most traditional approach and the approach is made through the patient’s back while the patient lies on his or her stomach. The incision is made down the middle of the back. Hooks are attached to the back of the spine on the lamina, and screws are placed in the middle of the spine. After the placement of hooks and screws, a rod that is bent and contoured into a more normal alignment for the spine is attached and the correction is performed. After the final tightening, the incision is closed and dressed.

Anterior and posterior approach – This approach is used in cases where the curve is stiff and severe. The first approach to spinal column is made from the front. The incision is made on the patient’s side, over the chest wall or lower down along the abdomen. Disc material between the vertebrae is removed. This procedure requires removal of a rib, which is later used for bone grafting.

After the anterior procedure, the wound is closed and the patient is positioned for the posterior approach. The incision is made down the middle of the back. Hooks are attached to the back of the spine on the lamina, and screws are placed in the middle of the spine. After the placement of hooks and screws, a rod that is bent and contoured into a more normal alignment for the spine is attached and the correction is performed. After the final tightening, the incision is closed and dressed.

Video-assisted thoracoscopic surgery (VATS) –This is a minimally invasive technique performed using a small video camera. The patient lies on his or her side; four incisions of 1 inch are made on the side of the chest wall. A thoracoscope, a thin instrument with a tiny camera and light at its end, is inserted through one of the incisions. The thoracoscope transfers images of the inside of the chest onto a video monitor, guiding the surgeon to perform the procedure. Retractor, suction and other surgical instruments are inserted through other incisions. Steps involved in the anterior approach are performed which involves intervertebral disc removal, bone grafting and instrumentation. Lung is deflated to gain access to the spine. The incisions are closed with an absorbable suture and the deflated lung is reinflated.

Your spine consists of a spinal cord supported by a series of interlocking bones called vertebrae. The cervical spine is the upper part of the spine situated in the neck region. It has seven vertebrae, separated and cushioned by spongy intervertebral discs. The vertebrae and discs may get damaged by injury, disease or wear-and-tear, compromising the cervical spine. Cervical spine fusion is a surgery performed to fuse weak cervical vertebrae with adjacent vertebrae to provide stability and prevent injury to the spinal cord.

A cervical spine fusion may be indicated to stabilize injuries and prevent fracture and spinal cord damage, and to treat misalignment of the vertebrae, herniated discs, arthritis, tumor, deformities and infection.

Different techniques may be used to fuse cervical vertebrae. The surgery is performed under general anesthesia. An incision may be made on the front or back of your neck, and muscles and tissues separated to expose the damaged vertebrae. The entire vertebrae or the spinal disc may be removed and the adjacent bones fused. Your surgeon may take bone graft from another part of your body or use an artificial bone material and place it in between the vertebrae to form a bridge and stimulate new bone growth. The vertebrae may be stabilized by metal implants or plates and screws while new bone grows.

You may experience slight stiffness of the neck as a result of cervical fusion, but it doesn’t compromise the flexibility of the neck. As with all surgical procedures cervical spinal fusion may be associated with certain risks such as graft rejection, failure to fuse, nerve injury, bleeding and infection. Overall, however, the procedure has good results and can often treat pain, prevent paralysis and provide stability to the neck.

Thoracic spine decompression is a procedure to relieve pressure on the spinal nerves in the middle portion of the back. Spine decompression surgery is indicated in treating spinal stenosis. Spinal stenosis is the narrowing of the spinal canal caused by degeneration of the facet joints and the thickening of the ligaments. These thickened ligaments narrow the spinal canal and compress the nerves causing chronic pain, numbness and tingling sensation or weakness in your arms or legs. Thoracic decompressive surgery is recommended when your pain is not relieved with conservative treatments such as physical therapy or medications.

The following are common techniques for decompression:

• Laminectomy: During a laminectomy the entire lamina, a part of the enlarged facet joints and the thickened ligaments are removed to relieve pressure.
• Laminotomy: During a laminotomy, just a section of the lamina and ligament is removed.
• Foraminotomy: A foraminotomy is increasing the space where the spinal nerve roots leave your spinal canal to avoid compression.
• Laminoplasty: Laminoplasty is a surgical procedure indicated in conditions such as cervical spinal stenosis to relieve the pressure off the spinal canal by increasing the space within the spinal canal. This is achieved by creating a hinge on one side of vertebrae and cutting a portion of vertebrae on another side. This forms the swinging vertebrae and the portions or vertebrae are held in place using small wedges. These spacers are then held in place using tiny plates and secured with screws. This widens the space of the spinal canal and relieves the pressure off the spinal cord.

These surgeries are performed under general anesthesia and your surgeon makes an incision down the middle of your back and the muscles overlying the vertebrae are spilt and moved to the side exposing the lamina of the vertebra. The lamina is the bone that makes the back of the spinal canal and forms a protective roof over the back of the spinal cord. Then the entire bony lamina and ligament is removed (laminectomy). In some cases, only a small opening of the lamina is made by removing bone of the lamina above and below the spinal nerves to relieve compression (laminotomy). Next, to remove the bone spurs and the thickened ligament the protective sac of the spinal cord and the nerve root are retracted. Then the facet joints are trimmed to create more space for the nerve roots. If compression is caused from a slipped disc, your surgeon will perform a discectomy- the removal of a portion of a slipped disc.

This surgery makes the spine unstable and therefore another procedure, spinal fusion, is performed to stabilize the spine. Spinal fusion uses bone grafts, rods, plates or screws to join together two separate vertebrae in the spine.

Thoracic facet joints are tiny joints at each section of the spine that impart stability and facilitate guide motion. The facet joints can turn out to be painful due to arthritis of the spine, a back injury or mechanical strain.

Thoracic spine injections are involved in the assessment and treatment of pain in the upper back, chest and rarely, the arm. Acute and chronic pain syndromes from the thoracic spine are much less common than with cervical and lumbar spine. This is valid both for the incidence and the intensity of the disease. Only 2% of the entire painful spinal syndromes influence the thoracic spine.

In the region of the thoracic spine, the vertebral canal is comparatively narrow and there is only a small epidural space between the spinal cord and the osseous surrounding, or the intervertebral disc. The narrowest position is located between TH4 and TH9.

Robotic Assisted Spine Surgery is a minimally invasive spine surgery where the surgeon is assisted by a robotic system (Da Vinci surgical system) to perform the surgery. Robotic systems are becoming increasingly popular in the medical fraternity owing to the unique advantages including the precision, safety and many other advantages. The da Vinci® robotic surgical system is one of the popular and widely employed robotic systems in the specialty of medicine and is used to perform various surgical procedures.

Conventional spine surgery uses a large incision and patients may experience complications such as pain, damage to the surrounding organs and nerves and long recovery period. In contrast, the da Vinci® robotic system is the most effective and least invasive technique which ensures faster recovery with minimal pain and minimal risks as compared with conventional spine surgery. Robotic spine surgery is indicated in patients suffering from chronic, debilitating back pain or restricted range of motion caused by spinal deformities and degenerative conditions.

The da Vinci® surgical system consists of a surgeon's console, a patient-side cart with four interactive robotic arms, a high-performance vision system (3D camera) and miniaturized EndoWrist surgical instruments.

Unlike the traditional surgery, this procedure is performed through small incisions. The surgeon sits on a console and controls the movement of the robotic arms holding the special surgical instruments. The movements of the surgeon’s hands are translated, by the robotic system, into precise movements of the miniaturized instrument that are held by the robotic arms.  Moreover, this approach also provides the surgeon with 3D, magnified view of the operating area.  The enhanced vision and superior control of the micro-instruments improves the precision of the surgery.

Being a minimally invasive approach, robot spine surgery offers the following benefits:

• Smaller incisions leading to reduced scarring and minimal blood loss
• Less post-operative pain
• Shorter hospital stay and recovery period
• Quicker return to daily normal activities
• Lower incidence of complications

The da Vinci® Robot System is considered safe and effective, but may not be appropriate for everyone. Always discuss with your doctor about all treatment options suitable for you, as well as the benefits and risks.

MISS is the latest advanced technology available to perform spinal surgeries through small, less than one inch long, incisions. It involves the use of special surgical instruments, devices and advanced imaging techniques to visualize and perform the surgery through such small incisions. MISS is aimed at minimizing damage to the muscles and surrounding structures. MISS possesses numerous benefits over the traditional spine surgery that includes:

• Small surgery scars
• Reduced risk of infections
• Less blood loss during the surgery
• Less post-operative pain
• Quicker recovery
• Shorter hospital stay
• Quicker return to work and normal activities

Procedure

Minimally invasive spine surgery is done through small incisions. Segmental tubular retractors and dilators are then inserted through these small incisions to retract muscles and provide access to the spine by creating a working channel for the surgery. This minimizes the damage to the muscles and soft tissues and decreases the blood loss during the surgery. An endoscope is inserted through one of the incisions to provide images of the operation field on the monitor in the operation room. The surgery is done with special surgical instruments passed through the working channel. Sometimes surgical microscopes may also be used to magnify the visual field. The tissues fall back in place, as the various instruments are withdrawn. The incision is then closed and dressed.

Risk and Complications

The risks and complications of the surgery may include infection, bleeding, nerve injury, or spinal cord injury. Complications due to general anesthesia may also occur.

Endoscopic spine surgery is a minimally invasive spine surgery that uses specialized video cameras and instruments to remove the herniated disc through very small incisions. The approach is made through the back, chest or abdomen, to gain access to the spine to perform the surgery.

Procedure

Endoscopic spine procedures are performed using a tool called an endoscope, a thin tube with a tiny video camera on the end of it. The camera displays the images of the inside of the body onto the television screens, helping the doctor see what is going on. During your procedure fluoroscopes (x-ray machines) are used to provide the best views of your spine. The endoscope is inserted through a small cut and guides it to the affected area. Your doctor uses x-ray and the camera to find the fragment and special instruments to remove the fragment. The incisions are closed with sutures and covered with surgical tape.

Pre-procedure preparation

Before the procedure, your surgeon may advise you to stop smoking and to exercise regularly to improve your recovery rate.  Any nonessential medications or herbal medications that increase surgical risk should be discontinued before surgery. Before your surgery you can ask your surgeon any questions you may have.

Post Procedure protocol

With endoscopic spine surgery most patients usually return home within two days after surgery. Physiotherapy and occupational therapy is given to mobilize the spine and loosen the muscles. To avoid strain injury, you may be instructed to avoid bending, lifting, and twisting for the first 2 to 4 weeks.

Endoscopic spine surgery is considered as a last resort for treating spinal conditions in the neck and back when conservative treatments have failed to improve your symptoms.

Endoscopic spine surgery is used to treat a variety of spinal disorders and conditions, including

• Degenerative disc disease
• Herniated discs
• Sciatica
• Scoliosis or other spinal deformities
• Spinal fractures
• Spinal infections
• Spinal tumors

Benefits

Traditional open surgery typically requires a larger incision, muscle stripping, longer hospitalization and increased recovery time. The advantages of endoscopic procedures when compared to the traditional procedures include the following:

• Small incision and minimal scar tissue formation
• Less blood loss
• Less damage to the surrounding tissues
• Faster recovery
• Quick return to normal activities
• Decreased hospital stay
• Less postoperative pain
• Reduce the risk of infection
• Improved function

Risks/Side effects

Like any type of surgery, there are certain risks associated with endoscopic spine surgery, such as:

• Reaction to anesthesia
• Blood clots
• Blood loss
• Infections
• Nerve injury
• Need for additional surgeries
• Pain
• Instruments can break, dislodge or irritate the soft tissues

The spinal cord is protected by a bony column of vertebral bones, arranged one above the other. Injury or wear-and-tear can cause parts of the vertebrae to compress the nerves of the spinal cord, leading to pain, numbness or tingling in the part of the body that the nerve supplies. Lumbar decompression is a surgical procedure performed to relieve pressure over the compressed nerves in the lower spine (lumbar region). It is usually indicated in patients with herniated lumbar disc, spinal stenosis, spinal injury or spinal tumors, who have not found adequate pain relief with conservative treatment.

Lumber decompression is performed under general anesthesia. Your surgeon makes a small incision in the midline over your lower back. The layers of muscle are separated, and the affected nerve root is identified. The lamina (bony arch of your vertebra) may be removed (laminectomy) and the facet joints may be trimmed to reach the compressed nerve. Your surgeon removes any bone spurs or disc material that is pressing on the spinal nerve. The incisions are closed with absorbable sutures and covered with a dressing.

As with any procedure, lumbar decompression may involve certain risks and complications such as infection, bleeding, leakage of cerebrospinal fluid, bladder or bowel incontinence, weakness, numbness and pain.

Sympathetic nerves, located in the lower spine, control basic functions such as regulating blood flow. They also carry pain signals from tissues to the spinal cord. Lumbar sympathetic block is an injection containing a local anesthetic and steroid, which is injected into or around the sympathetic nerves to block the transmission of pain impulses from the legs or lower back, thereby relieving pain.

The lumbar sympathetic block is usually indicated as a treatment for conditions such as reflex sympathetic dystrophy (pain and dysfunction of an extremity), Herpes zoster infection, vascular insufficiency (impaired blood flow) and peripheral neuropathy (nerve damage). You are contraindicated for this procedure if you are allergic to the medications being injected, are taking blood thinning medications, have an active infection, or you have diabetes or heart disorders.

The lumbar sympathetic block is performed under local anesthesia and sedation, in an outpatient setting. You will lie flat on your stomach. Your doctor will numb the area of your lower back to be treated. With the help of live X-rays, your doctor will insert a needle into your back. A dye is then injected to check the correct path of the medication. When this is confirmed, the steroid medication and anesthetic is injected into the target site. The entire procedure usually takes less than 30 minutes. 

After the procedure you may feel warmth in your lower back and your legs may feel numb or weak. You may have pain relief immediately after the injection, but pain may return after a few hours as the anesthesia wears off. Relief from the medication is observed in 2 to 3 day, as the steroid begins to work. Most often you will need 2 to 10 injections at regular intervals to get continued pain relief.

As with most therapeutic procedures, lumbar sympathetic block may be associated with certain side effects such as temporary pain or soreness at the site of injection, bleeding and infection. This procedure is usually safe and the risks are rare.

Transforaminal lumbar interbody fusion (TLIF) is a type of spinal fusion procedure in which bone graft is placed between the affected vertebrae in the lower back (lumbar) region through an incision on the patient’s back.

Indications:

Based on the spinal condition, age, activity levels, and the medical history of the patient, the surgeon may recommend TLIF as a treatment option.

It is indicated in the following spinal instability conditions:

• Degenerative disc disease (damaged disc)
• Spondylolisthesis (slippage of one vertebra on another)
• Spinal stenosis

The common symptoms associated with lumbar spinal instability are pain, numbness, and muscle weakness in the lower back, hips and legs.

Procedure

The basic steps involved are as follows:

• A small incision is made in the skin on your back over the affected vertebrae
• Muscles encircling the affected spine are retracted to gain accessibility to the spine
• Lamina covering the vertebra is removed to view the nerve roots
• Facet joints (structures that connect the vertebrae to one another) may be undercut or trimmed to provide more space for the nerve roots
• Nerve roots are moved away to remove the disc material from the anterior region of the spine
• Bone graft is inserted between the vertebrae
• Screws and rods are fixed to stabilize the spine
• Soft tissues are re-approximated and the incision is closed

Recovery:

Patients who have undergone TLIF surgery are usually discharged on the same day, but in some cases, hospital stay may be extended. Most of the patients observe immediate improvement of some or all of their symptoms but sometimes the improvement of the symptoms may be gradual.

Your surgeon may recommend few specific post-operative instructions for a fast and better recovery. Generally, patients may return to their routine activities within weeks after surgery.

Risks and complications:

The possible complications associated with TLIF include:

• Infection
• Nerve damage
• Blood clots
• Blood loss
• Bowel or bladder problems

The primary risk of TLIF is failure of fusion of vertebral bone and bone graft which may require an additional surgery.

Please consult your physician for a complete list of indications, warnings, precautions, adverse effects, clinical results and other important medical information that pertains to TLIF procedure.

Spinal fusion, also called arthrodesis, is a surgical technique used to join two or more vertebrae (bones) within the spine. Lumbar fusion technique is the procedure of fusing the vertebrae in lumbar portion of the spine (lower back).

Lumbar fusion surgery may be used to treat spondylolisthesis (slipping of the spine bones), degenerated discs, scoliosis or kyphosis (abnormal curvature of the spine), spinal infections or tumors, traumatic injury of the spine, recurrent disc herniation, and unstable spine.

The surgery can be done as an open or laparoscopic (keyhole) surgery.

Posterior spinal fusion is a procedure where the surgeon makes an incision on the patient’s back part of the body exposing the spine; the soft tissues and blood vessels are kept apart.

In spinal fusion, a piece of bone, taken from other parts of the body or donated from a bone bank is transplanted between the adjacent vertebrae. Screws, plates, or cages may be used with the bone graft to help hold the spine.

Spinal fusion is a surgical technique used to join together two or more vertebrae in the spine and to minimize the pain caused by movement of these vertebrae. Fusion of vertebrae in lumbar portion of the spine is called as lumbar fusion and the surgery can be done as an open or minimally invasive procedure.

Several techniques are practiced for minimally invasive surgery and they include

• Anterior lumbar interbody fusion, ALIF – accessing the spine from the front
• Posterior lumbar interbody fusion, PLIF – approaching the spine from the back
• Transforaminal lumbar interbody fusion, TLIF – approaching from the side

In PLIF surgery, several 1-2 inch incisions are made on the back, a series of increasingly larger dilators are used to spread the muscles apart and to provide access to the spine. The rods and screws are placed through the dilator tubes. In some cases, an operating microscope may be used to provide a better view.

During the surgery, a piece of bone harvested from other parts of the body or collected from a bone bank is transplanted between the adjacent vertebrae. As the healing occurs, the bone fuses with the spine. This stimulates growth of solid mass of bone which helps in stabilizing the spine. In some cases, metal implants such as rods, hooks, wires, plates or screws are used to hold the vertebra firm until new bone grows between them.

A minimally invasive lumbar fusion technique is used to treat fractured vertebra, lumbar instability, spine deformities—scoliosis or kyphosis, cervical disc hernias, tumors, back pain and failed back syndrome. Spondylolisthesis, a painful condition of the spine caused by disc displacement or slipped disc, can be treated with minimally invasive lumbar fusion technique.

Minimally invasive technique of fusion carries many advantages and they include:

• Minimal damage to the adjacent tissues
• Reduced post-operative pain
• Reduced hospital stay
• Faster recovery
• Diminished blood loss

Posterolateral lumbar fusion is a surgical technique that involves correction of spinal problems from the back of the spine by placing bone graft between segments in the back and leaving the disc space intact.

Minimally invasive surgical techniques may be used to perform the procedure.

Indications

Patients with spinal instability in their lower back due to degenerative disc disease, spondylolisthesis or spinal stenosis that has not responded to other non-surgical treatment measures such as rest, physical therapy or medications may be recommended for Posterolateral Lumbar Fusion.

Procedure

In this procedure the patient lies on his or her stomach. The surgeon makes a small incision in the back over the vertebra (e) to be treated. The surgeon dilates the surrounding muscles of the spine to access the section of the spine to be stabilized. The lamina, roof of the vertebra, is removed to visualize the nerve roots and the facet joints that are directly over the nerve roots are trimmed to provide the nerve roots more space.

The bone graft is implemented between the transverse processes in the back of the spine. Screws and rods can also be used to stabilize the spine for better healing and fusion. At the end of the procedure, the incision is closed and usually it leaves behind a minimal scar.

This procedure includes a smaller incision and muscle dilation that allows the surgeon to gently separate the surrounding muscles of the spine rather than cutting them.

Post-operative Instruction

After the minimally invasive procedure, most patients are discharged the day after surgery, but a few patients may require prolonged hospitalization. Many patients observe immediate improvement of some or all of their symptoms but sometimes the improvement of the symptoms may be gradual.

Contribution of a positive approach, realistic expectations and compliance with your doctor’s post-surgical instructions helps bring a satisfactory outcome to the surgical procedure. Most patients can resume their regular activities within several weeks.

Risks or Complications

The complications include infection, nerve damage, blood clots, blood loss, bowel and bladder problems and any problem associated with anesthesia. The underlying risk of spinal fusion surgery is failure of fusion of vertebral bone and bone graft which usually requires an additional surgery.

Discuss with your spine surgeon if you have any questions regarding the procedure.

Low back pain is one of the most common health problems experienced by a majority of individuals, at different phases of their lives.

The most common causes of low back pain include:

• Lumbar spinal stenosis
• Herniated disc
• Adult degenerative spondylolisthesis
• Degenerative disc disease

Most patients with low back pain do not require surgery for the management of their condition. However, surgery may be beneficial in patients with persistent pain, spinal instability, weakness or numbness in legs or feet, and impaired bowel or bladder function. Lumbar spine surgery may also be considered if all the conservative methods have failed to provide pain relief. 

An open surgery or a minimally invasive technique can be used to relieve nerve compression and stabilize the lumbar spine. Your surgeon may choose a minimally invasive approach rather than open spine surgery, due to the lower incidence of complications with a minimally invasive surgery.

Spinal fusion with instrumentation has been used to treat many painful conditions of the lumbar spine. In spinal fusion surgery two or more vertebrae are joined together with the help of bone grafts to eliminate the movement between them. Spinal instrumentation is used to stabilize the spine, after the fusion, with the help of implants such as rods, plates, screws, and interbody devices.

There are several types of lumbar spine surgeries. If you require a surgery, your doctor will decide on the most appropriate type of surgery, based on your condition. Some of the different lumbar surgeries include:

• Anterior and posterior lumbar interbody fusion (ALIF or PLIF)
• Direct lateral lumbar interbody fusion (DLIF)
• Axial lumbar interbody fusion (AxiaLIF)
• Intradiscal Electrothermoplasty (IDET)
• Transforaminal lumbar interbody fusion (TLIF)
• Image Guided Spine Surgery
• Laminoplasty
• Laminotomy

Before surgery

Before the surgery, your doctor will explain the surgical procedure as well as its risks and complications to you. You should obtain a medical clearance, from your physician, before proceeding with the surgery. Your doctor may also order a few blood tests, X-rays, or other imaging tests to assess your medical condition.

After surgery

After the surgery, you will be shifted to the recovery room where your vital signs will be closely monitored by the medical staff. You may have mild discomfort following the surgery.

Post-operative care

You should keep your incision area clean and dry. You should not smoke, drive, lift heavy things, swim or use a hot tub. Start physical therapy as directed by your doctor. Take medications as recommended by your doctor as well as arrange a follow-up appointment with your doctor.

Risks

The possible risks associated with lumbar spine surgery may include infection, bleeding, problems with anesthesia, and nerve or spinal cord injury.

Call you doctor if you experience a fever over 101° F or if the incision site shows signs of infection such as pain, redness, swelling, or alteration in the quantity or smell of the drainage. Also contact your doctor if you experience difficulty with bowel or bladder function or numbness over the genital area.

Anterior Lumbar Corpectomy and Fusion

Anterior Lumbar Corpectomy and Fusion is a surgical technique performed to remove the vertebral bone or disc material between the vertebrae to alleviate pressure on the spinal cord and spinal nerves (decompression) in the lumbar (lower back) region.

The term corpectomy originates from the Latin word ‘corpus’ which means ‘body’ and the word ‘ectomy’ means ‘removal’. Spinal fusion is essential for spinal stability after the removal of vertebral bone and disc material to relieve the compression over the neural structure.

Indications:

Anterior lumbar corpectomy and fusion is recommended when non-surgical treatment options fail to reduce the symptoms.

Nerve compression in the lower back usually leads to back pain, numbness or weakness extending into the hips, buttocks and legs.

Common causes of spinal nerve compression are:

• Degenerative spinal conditions such as herniated discs
• Spinal fractures
• Tumors
• Infection

Before recommending surgery, the surgeon considers various factors such as age, condition to be treated, health, lifestyle, and the activity level of the patient.

Surgical procedure:

For the procedure, the surgeon makes an incision in the side of the abdomen and retracts the soft tissues such as muscles to gain visibility to the spine. A portion of vertebral body and intervertebral disc is removed to access the involved neural structure. The source of compression is removed, and the compressed nerves released. During the fusion of two adjacent vertebrae, bone graft or bone graft substitute is inserted between the vertebrae at the decompression site to promote healing and to preserve the normal disc height. Implant material such as rods, plates and screws are fixed to the treated vertebra (e) to deliver additional support and stability during the fusion and healing process. After the procedure, the surgeon realigns the soft tissues and closes the incision.

Recovery:

Following a Lumbar Corpectomy and Fusion, you may observe an immediate improvement of some or all symptoms or sometimes a gradual improvement of the symptoms ..

The duration of hospitalization depends on the treatment rendered. At the end of the first day of the surgery you are allowed to move and walk around the hospital. Returning back to your daily life or to work depends on how well you are healing and the type of work or activity level.

Follow your spinal surgeon’s instructions regarding the proper recovery program and instructions to augment the healing process for a successful recovery.

Risks or complications:

The complications of the surgery include infection, nerve damage, blood clots or blood loss or bowel and bladder problems and any problem associated with anesthesia. The underlying risk of spinal fusion surgery is failure of fusion of vertebral bone and bone graft which usually requires an additional surgery.

Talk to your spine surgeon if you have any concerns or queries regarding Anterior Lumbar Corpectomy and Fusion.

Intervertebral discs are fibrocartilagenous cushions between adjacent vertebrae in the spine. The normal intervertebral disc is composed of a semi-liquid substance (nucleus pulposus) at the center surrounded by a fibrous ring (annulus fibrosis). A herniated disc, also known as a bulging disc, is a condition in which the inner gelatinous substance of the disc is forced out through a tear in the outer, fibrous ring (annulus fibrosus). This may compress the spinal cord or the nerves around the spinal cord. Lumbar discectomy is a surgical procedure performed to remove a herniated or ruptured disc from the lumbar (lower) region and relieve pressure on the nerve, alleviating pain.

This procedure is performed under sterile conditions in an operating room with the patient under general or spinal anesthesia. You will lie face down. Your surgeon will make a small incision over the affected disc in the lumbar region. A small portion of bone may be removed along with the adjoining ligament to expose the herniated disc. Your surgeon visualizes the discs and the nerves through a surgical microscope. This enlarges the view of the surgical site, minimizing damage to the surrounding tissues. The spinal nerve root is then gently lifted with a special hook, to gain access to the injured disc, and the ruptured or herniated disc is removed. Any loose disc fragments are also removed. After the completion of the procedure, the surgical wound is irrigated with antibiotic solution and closed.

Following surgery, you are advised to limit activities for four weeks that involve bending and lifting, and sitting for long periods. Your recovery will involve physical therapy, where you will be taught certain exercises to improve flexibility and strength of your muscles around your spine. Depending on the level of activity, you will be able to resume work in two to six weeks.

As will all surgical procedures, lumbar discectomy may be associated with certain complications which include infection, nerve injury, spinal cord injury, ongoing pain and problems with anesthesia.

The vertebrae (spinal bones) have openings known as neuroforamen on either side for the passage of spinal nerves. The neuroforamen are surrounded by tiny joints known as facet joints, present in pairs at the back of the each vertebra, which connect and stabilize them together. Bone spurs, herniated intervertebral disc material, and thickened ligaments can obstruct the neuroforamen causing compression of the nerves and resulting in pain in the arms and legs.

Facetectomy and foraminotomy are the most common spinal surgical procedures recommended for patients suffering from chronic pain due to spinal nerve compression. Lumbar foraminotomy is a decompression surgery involving the removal of bone and tissue obstructing the neuroforamen to release the pressure on the spinal nerve roots.  In severe cases, the entire facet joint is removed which is referred to as lumbar facetectomy.

Procedure

The surgical steps involved in foraminotomy and facetectomy are:

• The patient is sedated before the procedure
• The patient lies on their abdomen, on the operation table
• An X-ray is used to identify the positioning of the incision
• An incision is made through the skin to approach the spine
• The muscles are retracted with the help of a retractor
• Specially designed cutting instruments are then used to remove bone spurs, thickened ligaments and segments of the herniated disc
• Micro-instruments are also employed to confirm whether the compressed nerves are completely free or not
• Removal of the bones and tissues around the neuroforamen releases the compression over the nerve roots
• Unlike foraminotomy, fusion of the spine is required in facetectomy for stabilizing the spine
• Finally, the incision is sutured

Post-operative care

Patients undergoing a foraminotomy are usually discharged on the same day of the surgery whereas the facetectomy patients have to stay in the hospital for a day or two after the procedure. Most patients experience pain relief immediately after the surgery.  However, some may experience pain, due to muscle spasms, for a few days after the surgery. The doctor will prescribe medications such as muscle relaxants and pain killers for the management of such pain. General post-operative instructions for the patient after a lumbar foraminotomy or facetectomy include:

• Keep the incision clean and dry
• Avoid movements such as bending and twisting, for at least 6 weeks
• Regular intake of the prescribed medications
• Avoid heavy lifting

Risks

Lumbar foraminotomy or facetectomy is comparatively safe with minimal complications. Some of the potential risks of these procedures include bleeding, infection, leakage of the spinal fluid, nerve injury and injury to the spinal cord.

Lumbar Interbody Fusion (LIF) surgery is a surgical technique involving the removal of the damaged intervertebral disc, and the insertion of a bone graft into the disc space created between the two adjoining vertebrae. Bone grafts promotes healing and facilitate the fusion. Screws and rods are used to stabilize the spine during the healing process.

Lumbar Interbody Fusion (LIF) surgery may be recommended in patients with degenerative disc disease, spondylolisthesis, and disc herniation. The aim of the surgery is to alleviate back or leg pain and stabilize the spine. An interbody fusion can be performed with different approaches which include:

Anterior Lumbar Interbody Fusion (ALIF): In this technique, the spine is approached from the front by making an incision over the abdomen.

Posterior Lumbar Interbody Fusion (PLIF): Your surgeon gains access to the spinal canal, disc, and nerve roots from the back. In this procedure, the lamina is removed, and the facet joints are trimmed to gain access to your spine.

Transforaminal Lumbar Interbody Fusion (TLIF): In this technique, the spine is approached from the side. This allows the surgeon to access the front as well as the back of your spine.

Direct Lateral Interbody Fusion (DLIF): In this approach, the spine is also approached from the side. Using minimally invasive technique, the underlying soft tissues and the psoas muscle are gently separated to reach the intervertebral disc. As the spine is approached through the psoas muscle, DLIF is also known as trans-psoas approach.

Anterior lumbar interbody fusion (ALIF), direct lateral lumbar interbody fusion (DLIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF) may all be performed using minimally invasive technique. All these procedures are performed under general anesthesia with the assistance of X-ray or fluoroscopic guidance.

Before surgery

Before surgery, your doctor will discuss the type of procedure as well as its associated risks and benefits, with you. You will need to obtain a medical clearance for the surgery from your physician. In addition, your doctor may also recommend a few blood tests, X-rays or other imaging tests to evaluate your medical condition.

After surgery

Following the surgery, you will be shifted to the recovery room and the medical staff will closely monitor your vital signs. Minor discomfort, pain at the incision site, muscle spasms in the neck or back, or other related symptoms may be present after the surgery. You may need to wear a lumbar brace to support the spine during the healing process.

Post-operative care

You will need to keep the incision area clean and dry. Do not swim or use hot tubs. Also avoid driving, smoking, and heavy lifting. You can begin physical therapy as directed by your surgeon. You should take the medications as recommended by your surgeon and also schedule a follow-up with him.

Risks

Infection, bleeding, nerve injury, and problems with anesthesia are the potential risks and complications associated with lumbar interbody fusion (LIF) surgery.

If you develop any signs of infection such as pain, redness, swelling, or alteration in the quantity or smell of the drainage, or fever over 101° F you should immediately call your doctor. Also inform your doctor if you develop bowel and bladder dysfunction or numbness over the genital area.

Minimally invasive lumbar surgery is an alternative to open lumbar surgery that allows the surgeon to access the spine through smaller incisions. Special techniques and instruments, used in this approach, minimize muscle and soft tissue damage and also offer several advantages over the traditional open approach which include smaller scars, less blood loss, lower postoperative pain, faster recovery and shorter hospital stay. Thus, after a minimally invasive surgery, patients return to their normal activities sooner when compared to that after an open surgery.

The minimally invasive approach is available for lumbar discectomy, lumbar fusion and lumbar laminectomy.  With advancements in technology and spinal instrumentation, more spinal surgeries are possible through a minimally invasive approach. However, certain conditions may still require an open approach for direct visualization and better access to the spine. Thus, the best approach for a patient depends on both the patient’s condition and the surgeon’s preference and is decided only after an evaluation of the patient’s condition and a discussion between the patient and the surgeon.

Procedure

Minimally invasive lumbar surgery is performed through a few small incisions on the back rather than one large incision. To allow for better visualization with the smaller incisions, the whole procedure is conducted under a C-arm; a device for intra-operative fluoroscopy. The C-arm provides real time X-ray images of the patient’s spinal anatomy to guide the surgeon during the procedure. To reach the patient’s spine, the back muscles are not cut but are instead split or retracted using special surgical instruments such as retraction blades and tubes resulting in less muscle damage and blood loss, reducing the need for blood transfusion. To facilitate surgery through the small incisions, special spinal instruments are used. For example, Sextant spinal system for spine fusions has been especially designed for spinal fusion surgeries through the minimally invasive approach. It allows the surgeon to attach the screws and rod to the vertebrae through small skin incisions with minimal damage to the muscles. The soft tissue and the muscles are then put back in their normal position and the incision is closed with glue rather than staples or sutures. The recovery is much faster than open approach and the patient is discharged within a few days of the surgery. 

After the surgery

The incisions should be kept clean and dry till they heal completely. Lifting, bending and twisting of the back should be avoided for a few weeks as advised by the surgeon.

Risk

With minimally invasive approach the same procedure is performed as in open approach, thus the risks associated with minimally invasive procedure are similar to that with open surgery and may include bleeding, infection and nerve injury.

Lumbar discectomy is a spinal surgery that involves removal of damaged intervertebral disc to relieve pressure on the spinal nerves (decompression) in the lumbar (lower back) region. Minimally invasive technique is implemented to perform the surgery.

The lumbar region forms the lower portion of the spine and comprises of five vertebrae (L1-L5).

Indications

It is indicated in cases of severe nerve root compression due to a ruptured disc. Symptoms of nerve impingement include back pain or radiating pain into the hips, buttocks or legs, numbness or tingling sensation and muscle weakness in the back and lower extremities.

Procedure

The procedure will be performed with the patients lying on their stomach. A small incision is made over the lower back and the surgeon gently separates the muscles to access the affected disc. A tubular retractor can be inserted to produce a portal through which the surgeon can perform the surgery. Through the tubular retractor, a portion of lamina, the bony vertebral component that covers the posterior wall of the spinal canal, is removed to expose the compressed area of the spinal cord or nerve roots. Removal of the lamina releases the source of compression from the herniated disc or bone spurs. The complete procedure is known as decompression. After the completion of the procedure, the incision is closed leaving behind a minimal scar.

Post-operative instructions

Recovery period depends on the body’s healing capacity. The post-surgical hospitalization includes the rehabilitation program. If required your surgeon may prescribe pain medications or a brace and follow-up physical therapy upon discharge.

The period of your rest or inactivity depends on a few factors such as the type of surgical procedure and the approach used to access your spine, the size of the incision and presence of any complications. Return to work or normal activity depends on the type of work or activity you plan to perform. Usually 3 to 6 weeks is the ideal time of healing.

Strictly adhere to the post-operative instructions suggested by your spine surgeon to promote healing and reduce the possibility of post-operative complications.

Advantages

Some of the benefits include:

• Very small incisions are placed
• Surgery can be performed in less time
• Minimal damage to the surrounding structures
• Shorter recovery time with less post-surgical complications
• Lower rate of infection
• Greater range of motion with less post-operative pain

Anterior lumbar interbody fusion (ALIF) is a surgery performed to correct the spinal problems in the lower back. The surgery can be implemented either as an open surgery or minimally invasive technique.

Indications:

The common indications of ALIF are:

• Severe lumbar (low back) or leg pain that is unresponsive to non-surgical treatment.
• Degenerative disc disorder of lumbar spine (pain due to damaged disc)
• Spondylolisthesis (slippage of one vertebra on another)
• Scoliosis (S-shaped curve of spine)
• Fractures of spine
• Tumors
• Spinal instability

Surgical procedure:

The ALIF surgery is usually performed under general anesthesia. The patient is positioned supine lying on the back. The surgeon makes an incision in the abdomen and retracts the muscles and various structures to enhance the clarity and accessibility to the anterior aspect of the vertebrae. The surgical approach is from the front of the vertebral body in the lower back region. Your surgeon removes whole or a part of the damaged disc between two adjacent vertebrae followed by fusion of the same with or without the use of bone grafts. External implant materials such as rods, screws, plates, and wires may be fixed to the treated vertebrae to deliver extra support and stability during the healing process. At the end of the procedure, the structures are re-approximated, and the skin is closed with sutures.

The success of surgery depends on various factors such as age, spinal condition, overall health status, and activity level of the individual.

Recovery:

The recovery period after ALIF surgery depends on the body’s healing capacity. The post-surgical hospitalization includes the rehabilitation program. If required your surgeon may prescribe pain medications or a brace and follow-up physical therapy upon discharge.

The period of your rest or inactivity depends on a few factors such as the type of surgical procedure and the approach used to access your spine, the size of the incision and presence of any complications. Return to work or normal activity depends on the type of work or activity you plan to perform. Usually 3 to 6 weeks is the ideal time of healing. With the advanced and innovative techniques, it is now possible to achieve improved fusion rates, short hospital stay with an active and rapid recovery period.

Strictly adhere to the post-operative instructions suggested by your spine surgeon to promote healing and reduce the possibility of post-operative complications.

Risks or complications of ALIF surgery:

The complications of the ALIF surgery include infection, nerve damage, blood clots or blood loss or bowel and bladder problem and any problem associated with anesthesia. The underlying risk of spinal fusion surgery is failure of fusion of vertebral bone and bone graft which usually requires an additional surgery.

Talk to your spine surgeon if you have any concerns or queries regarding ALIF.

Introduction

Our spine is made up of small bony segments called vertebrae. These vertebrae are categorized into cervical or neck vertebrae, thoracic (upper back) and lumbar (lower back). Cushioning discs present between each vertebrae act as shock absorbers. A cylindrical bundle of nerve fibers called the spinal cord passes through the entire vertebral column and branches out to the various parts of our body. Any damage or deformity to the bones of the vertebral column or to the disks present between the vertebrae can damage these nerves, leading to pain in the body part that the nerve supplies.

Transforaminal lumbar interbody fusion (TLIF) is a minimally invasive fusion of the vertebrae of the lumbar region (lower back). It is designed to provide stability to the spine and treat back and leg pain.

Indication

Transforaminal lumbar interbody fusion is indicated for:

• Degenerative Disc Disease: Wearing out of the intervertebral discs with age
• Scoliosis: Abnormally curved spine
• Spinal Stenosis: Narrowing of the spinal canal
• Spondylolisthesis: Forward dislocation of one vertebra over the other
• Fractures
• Infections
• Tumors

Surgical procedure

Your surgeon may recommend a TLIF when conservative measures (rest, physical therapy, and medications) fail to relieve your back and leg pain.

TLIF usually takes about 3 to 6 hours depending on the number of spinal segments treated. It is performed under general anesthesia, so you will be asleep throughout the procedure. You will be given preoperative antibiotics to prevent infection, and will be placed in the prone position (lying on your stomach).

X-ray is used to confirm the location of the diseased segment. Your surgeon will then create a small incision on your back. Your back muscles are separated and held in place with a tubular retractor in order to clearly expose the diseased part of your spine.

Your surgeon then removes the lamina (roof of the vertebrae) to allow better visualization of the nerve roots. Your surgeon will then trim or remove the facet joints providing more space to the nerve roots. The nerve roots are then protected and gently moved aside.  The diseased disk material is then removed. A disk implant known as a spacer made of bone, carbon-fiber, titanium, or a polymer is then inserted into the empty disc space. The implant provides proper disk height and acts as a scaffold for the new bone to grow. Your surgeon will then place small screws or rods in the upper and lower vertebral bodies to provide stability during the healing process. X-rays are then taken to document the correct location of the spacer. The retractor is removed, releasing the muscles to their normal position. The tissue layers are closed with sutures, the incision closed using stitches or surgical staples, and a sterile bandage is applied over the surgical site. In time, the bone graft will fuse to create a solid bone.

Post-Operative Care

Most patients are able to go home in 2 to 3 days after the TLIF procedure. Mild pain is normal, for which you will be prescribed pain medications. You will be advised to wear a brace for three months after your surgery to support you while standing and walking. Physical Therapy and Occupational Therapy will instruct you on how to get in and out of bed properly and walk independently. You should not bend or twist at your waist or lift more than 5 pounds for 4 to 6 weeks until your back muscles are stronger, and your pain subsides after your procedure. You may shower immediately after your procedure, but necessary precautions need to be taken to keep your surgical wound clean and dry. You may return to light duties 2 to 3 weeks after your surgery depending on your pain level. Moderate level work and light recreational activities are allowed 3 months after your surgery.

Advantages

One of the major advantages of TLIF is that it causes relatively less damage to the spinal structures which helps maximize the stability of the fusion. As TLIF is a minimally invasive procedure, the operative time, hospital stay, pain, blood loss, and risk of nerve and muscle injuries are reduced.

Risks and complications

As with any procedure, TLIF is associated with certain risks and complications including:

• Formation of blood clots or deep vein thrombosis
• Improper fusion of the implant
• Injury to adjacent tissues
• Nerve or spinal cord damage
• Infection

Posterior cervical fusion (PCF), a surgical procedure performed through the back of the neck, involves joining or fusing two or more damaged cervical vertebrae. The fusion of vertebrae is also known as arthrodesis. Sometimes metallic plates may be used for fixing the vertebrae, this is also known as instrumentation.

PCF may be employed for the management of cervical fractures, bone dislocations, and deformities due to abnormal curvature of the cervical vertebrae.

Procedure

The basic steps of posterior cervical fusion include:

• The procedure is conducted in an operating room with the patient under general anesthesia.
• The patient lies face down, on the operation table.
• A small incision is made over the middle of the neck, at the back.
• The muscles and the soft tissues are then retracted to approach the spine.
• X-ray imaging is employed to identify the affected intervertebral disc.
• The surfaces of the lamina of the each vertebra to be fused are trimmed. This results in bleeding which aids in rapid healing of the fused bones.
• In addition, small strips of bone graft taken from the pelvis are placed over the spinal column, which aid in fusion of the bones.
• Confirmatory X-rays may be taken to confirm the proper placement of the bone graft.
• Finally, the retracted muscles and soft tissues are placed in their normal positions and the wound is sutured.

Postoperative care

Patients may be discharged from the hospital within a week of the surgery. A neck brace is recommended for several months, however this restriction may not be required if the vertebrae are fixed with a metal plate during the PCF surgery. Patients are initiated on a liquid diet which is gradually changed to solid food, depending on their recovery.

Physical therapy is recommended after 4-6 weeks of the surgery. Physical therapists help patients perform their routine activities without exerting any extra stress on the neck. Rest is advised as it helps in healing of the bone graft.

Risk and complications

Every major surgery is associated with complications. Some of the complications associated with posterior cervical fusion include:

• Complications related to anesthesia
• Conditions such as thrombophlebitis
• Non-union or pseudarthrosis
• Infection
• Damage to the spinal nerves
• Problem related to bone graft
• Persistent pain

Posterior cervical laminectomy and fusion is a surgical procedure performed to decompress the spinal cord and nerve roots in the cervical region of the spine. Some of the spinal conditions that may compress the spinal cord and nerve roots include disc degeneration, bulging or herniated disc, spinal stenosis, and spondylosis.  Nerve compression may result in neck pain and /or arm pain. The “lamina” is a bony plate or layer that covers and protects the spinal cord, and “ectomy” means to remove. The aim of this surgery is to alleviate neck and/or arm pain and stabilize the spine, by decompressing the spinal nerves and the spinal cord in the cervical region.

A cervical laminectomy may involve a partial or complete removal of the herniated disc that is exerting pressure over the spinal cord or the nerves surrounding the spinal cord.

During cervical laminectomy a portion of the ligamentum flavum, a yellow ligament that connects the laminae of the vertebrae, is also removed. As a part of the aging process, the ligamentum flavum can thicken, compressing the spinal cord and nerve roots, resulting in spinal stenosis. The removal of the ligamentum flavum relieves the pressure over the spinal cord and the nerve roots.

Before surgery

Your doctor will explain the surgical procedure, its risks and benefits, and answer all your other surgery related queries, before the procedure. A medical health clearance is required, from your physician, for the surgery. Blood tests, X-rays, or other imaging tests may also be ordered to assess your medical condition.

Procedure

The surgery is performed under general anesthesia. The patient is placed in a face down position, on the operating table. X-ray or fluoroscopic guidance is used to enhance the visualization of the operative field, during the procedure.  X-rays are taken to confirm the level of the affected cervical vertebra.  An incision is made at the back of your neck and the muscles and soft tissues are moved aside to expose the lamina.  The lamina and spinous process, projections of bone which can be felt as you rub your fingers along the back of your spine, are removed to access the spinal cord and nerve roots. Any disc fragments, and/or other tissue, causing nerve compression, may also be removed or trimmed. This releases the pressure over the spinal cord and the nerves. Fusion involves use of bone graft, inserted into the space between the affected vertebrae, to stimulate new bone growth. Screws and rods are used to hold the vertebrae together during the healing process.

Posterior cervical laminectomy and fusion utilizes a minimally invasive technique with small incisions and minimal damage to the muscles and soft tissues.

After surgery

After your surgery is completed, you will be moved to the recovery room where your vital signs will be closely monitored by the medical staff.  After the surgery you may experience slight discomfort, pain at the incision site, neck or back muscle spasms, or other related symptoms. Your surgeon may suggest a cervical brace to you, to provide stability and support during the healing process.

Post-operative care

You will need to take care of your incision, keeping it clean and dry. Avoid heavy lifting, smoking, driving, and using hot tubs and swimming pools. You can begin exercise or physical therapy as per the instructions given by your surgeon. You should take your medications as prescribed by your doctor. Also, arrange a follow-up appointment with your doctor to assess your recovery.

Risks

The potential risks and complications with posterior cervical laminectomy and fusion include infection, bleeding, problems with anesthesia, and nerve injury.

Warning signs of infection include pain, redness, swelling, or alteration in the quantity or smell of the drainage, or elevated temperature, usually above 101° F. if you experience any of these symptoms, you should contact your doctor. Also, inform your doctor if you experience bowel and bladder dysfunction or numbness over the genital area.

An anterior cervical corpectomy and fusion is an operative procedure to relieve pressure on the spinal cord and spinal nerves by removing the vertebral bone and intervertebral disc material (decompression) in the cervical spine, or neck.

Anterior cervical corpectomy involves removing the vertebral bone or disc material by approaching the cervical spine from the front side (anterior position) of the neck. Spinal fusion implies placing a bone graft between the two affected vertebral bodies, encouraging bone growth between the vertebrae. Spinal fusion helps in achieving adequate decompression of the neural structures. The bone graft acts as a medium for binding the two vertebral bones, and grows as a single vertebra which stabilizes the spine. It also helps to maintain the normal disc height.

Indications

Degenerative spinal conditions like herniated discs and bone spurs results in spinal nerve compression. In addition, spinal fractures, infection or tumors may also put pressure on the spinal nerve structures. Nerve compression in the neck region (cervical spine) can cause neck pain and/or pain, weakness or numbness that radiates down to the arms. Your surgeon recommends you for anterior cervical corpectomy and fusion surgery after examining your spine, medical history, and imaging results of cervical vertebrae such as X-ray, CT (computed tomography) scan or MRI (magnetic resonance imaging). Surgery is recommended only after non-surgical treatment approaches fail. Before recommending surgery, your surgeon considers several factors such as your health condition, age, lifestyle and anticipated level of activity following surgery. A thorough discussion with your surgeon regarding this treatment option is advised before scheduling the surgery.

Procedure

Your surgeon makes a small incision at the front of your neck to the side and locates the source of neural compression. Then, the vertebral body or intervertebral disc that is compressing the nerve root will be removed to relieve the compression. Afterwards, a bone graft will be placed at the site decompression. In addition, instruments such as plates and screws are used to provide additional support and stability and to ease healing and fusion of the vertebrae.

Recovery

A specific post-operative recovery/exercise plan will be designed by your physician to help you return to normal activity at the earliest possible. After surgery, your symptoms may improve immediately or gradually over the course of time. The duration of hospital stay depends on this treatment plan. You will be able to wake up and walk by the end of the first day after the surgery. You should be able to resume your work within 3-6 weeks, depending on your body’s healing status and the type of work/activity that you plan to resume. Discuss with your spinal surgeon and follow their instructions for optimized healing and appropriate recovery after the procedure.

Risks or complications

Treatment results and outcome are different for each patient. All surgeries carry risk and it is important to understand the risks of the procedure in order to make an informed decision to go ahead with the surgery. In addition to the anesthetic complications, spinal surgery is associated with some potential risks such as infection, blood loss, blood clots, nerve damage, and bowel and bladder problems. Failure to fuse the vertebral bones with the bone graft (fusion failure) is an important complication of spinal fusion which requires an additional surgery.

Please take your physician’s advice for a complete list of indications, clinical results, adverse effects, warnings and precautions, and other relevant medical information about the anterior cervical discectomy with fusion surgery.

A cervical discectomy is an operative procedure which relieves pressure on the spinal nerves and/or spinal cord by removing the total or a part of the damaged intervertebral disc. Cervical discectomy is performed using minimally invasive approach in selected patients, if appropriate.

Cervical discectomy is a surgical procedure which relieves compression on the nerve roots and/or the spinal cord because of a herniated disc or a bone spur. This procedure involves making an incision on the front side of the neck (anterior cervical spine), followed by the removal of disc material and/or a portion of the bone around the nerve roots and/or spinal cord to relieve the compression on neural structures and provide them with an additional space.

Cervical discectomy is also referred to as decompressive spinal procedure as the surgeon removes compression on nerve roots by removing the total or a part of the disc and/or bony material that is causing pain. Your surgeon may choose a minimally invasive approach based on your condition and the specific surgical goals.

Minimally invasive cervical discectomy involves a small incision(s) and muscle dilation to separate the muscle fibers surrounding the spine, unlike conventional open spine surgery which requires muscles to be cut or stripped.

Indications

Herniated disc is a condition in which the soft, gel-like center of the disc (nucleus pulposus) has pushed out through the disc’s tough, outer ring (annulus fibrosus). Besides, bony out growths also known as bone spurs or bone osteophytes are formed due to the accumulation of calcium in the spine joints. The pressure induced by a herniated disc or bone spur on nerve roots, ligaments or the spinal cord may cause pain in the neck and/or arms, numbness or weakness in the arms, forearms or fingers, and lack of coordination.

As most nerves to the body (e.g., arms, chest, abdomen and legs) pass through the neck region from the brain, pressure on the spinal cord in the neck region (cervical spine) can be very problematic. Patients with these symptoms are candidates for cervical discectomy procedure only after non-surgical treatment methods fail. Cervical discectomy can reduce the pressure on the nerve roots leading to pain relief.

Your surgeon recommends you for minimally invasive cervical discectomy procedure after examining your spine, medical history, and imaging results of cervical vertebrae such as X-ray, CT (computed tomography) scan or MRI (magnetic resonance imaging). Surgery is recommended only after non-surgical treatment approaches fail. Before recommending surgery, your surgeon considers several factors such as your health condition, age, lifestyle and anticipated level of activity following surgery. A thorough discussion with your surgeon regarding this treatment option is advised before scheduling the surgery.

Procedure

The procedure is performed with you resting on your back after injecting the sleep inducing medication (general anesthesia). Your physician makes a very small incision at the center of your neck on the front side, and gently separates the muscles and soft structures apart. Then a series of small tubes called dilators are inserted through the incision towards the spine. The sources of compression such as bone spurs and/or disc material are removed. Finally, after the procedure, your surgeon removes the tubes, brings back the soft tissues and muscles to their normal place, and closes the incision.

Sometimes, spinal fusion may also be done along with cervical discectomy which involves placing bone graft or bone graft substitute between two affected vertebrae to allow bone to grow between the vertebral bodies. The bone graft acts as a platform or a medium for binding the two vertebral bones, and grows as a single vertebra which stabilizes the spine. Spinal fusion also may be performed through the minimal invasive approach using “tubes”.

In some instances, your surgeon performs the surgery using a posterior approach that requires the incision to be made on the back of your neck. Posterior cervical discectomy may also be done using minimally invasive surgical technique.

Post-operative Instructions

A specific post-operative recovery/exercise plan will be given by your physician to help you return to normal activity at the earliest.  After surgery, your symptoms may improve immediately or gradually over the course of time. The duration of hospital stay depends on the treatment plan. In a few instances, surgery may also be performed on an outpatient basis. You will be able to wake up and walk by the end of the first day after the surgery. Your return to work will depend on your body’s healing status and the type of work/activity that you plan to resume. Discuss with your spinal surgeon and follow his instructions for optimized healing and appropriate recovery after the procedure.

Risks or Complications

All surgeries carry risk and it is important to understand the risks of the procedure in order to make an informed decision to go ahead with the surgery. In addition to the anesthetic complications, spinal surgery is associated with some potential risks such as infection, blood loss, blood clots, nerve damage, and bowel and bladder problems. Failure to fuse the vertebral bones with the bone graft (fusion failure) is an important complication of spinal fusion which requires an additional surgery.

Before scheduling the surgery, discuss the benefits, risks and complications related to minimally invasive cervical discectomy procedure with your surgeon.

Anterior cervical discectomy with fusion is an operative procedure to relieve compression or pressure on nerve roots and/or the spinal cord due to a herniated disc or bone spur in the neck.

In anterior cervical discectomy with fusion, the surgeon approaches the cervical spine through a small incision in the front of the neck and removes the total disc or a part of the disc along with any bony material that is compressing or putting pressure on the nerves and producing pain. Spinal fusion implies placing a bone graft between the two affected vertebral bodies encouraging the bone growth between the vertebrae. The bone graft acts as a medium for binding the two vertebral bones, and grows as a single vertebra that stabilizes the spine. It also helps to maintain the normal disc height.

Indications

Herniated disc is a condition in which the soft, gel-like center of the disc (nucleus pulposus) bulges out through the damaged or broken disc’s tough, outer ring (annulus fibrosus). Besides, bony out growths also known as bone spurs or bone osteophytes are formed due to the accumulation of calcium in the spine joints. The pressure induced by a herniated disc or bone spur on nerve roots, ligaments or the spinal cord may cause pain in the neck and/or arms, numbness or weakness in the arms, forearms or fingers, and lack of coordination.

As most nerves to the body (e.g., arms, chest, abdomen, and legs) pass through the neck region from the brain, pressure on the spinal cord in the neck region (cervical spine) can be very problematic. Patients with these symptoms are potential candidates for anterior cervical discectomy procedure but only after non-surgical treatment methods fail. Cervical discectomy can reduce the pressure on the nerve roots and provides pain relief.

Before recommending surgery, your surgeon considers several factors such as your health condition, age, lifestyle and anticipated level of activity following surgery. A thorough discussion with your surgeon regarding this treatment option is advised before scheduling the surgery.

Procedure

Your surgeon makes a small incision in the front side of the neck and locates the source of neural compression (pressure zone). Then, the intervertebral disc that is compressing the nerve root will be removed. Afterwards, a bone graft will be placed between the two vertebral bodies. In certain instances, metal plates or pins may be used for providing enough support and stability, and to ease the fusion of the vertebrae.

Post-operative Instructions

A specific post-operative recovery/exercise plan will be given by your physician to help you return to normal activity at the earliest possible. The duration of hospital stay depends on this treatment plan. You will be able to wake up and walk by the end of the first day after the surgery. You would be able to resume your work within 3-6 weeks, depending on your body’s healing status and the type of work/activity that you plan to resume. Discuss with your spinal surgeon and follow the instructions for optimized healing and appropriate recovery after the procedure.

Risks or Complications

Treatment results are different for each patient. In addition to the anesthetic complications, spinal surgery is associated with some potential risks such as infection, blood loss, blood clots, nerve damage, and bowel and bladder problems. Failure to fuse the vertebral bones with the bone graft (fusion failure) is an important complication of spinal fusion which requires an additional surgery.

Please take your physician’s advice for a complete list of indications, clinical results, adverse effects, warnings and precautions, and other relevant medical information about the anterior cervical discectomy with fusion surgery.

Anterior cervical discectomy is an operative procedure to relieve pressure or compression on the nerve roots and/or the spinal cord because of a herniated disc (damaged disc) or a bone spur.

Pain in the neck and extremities is a common symptom of intervertebral disc damage or herniation. During herniation the tough, outer ring (annulus fibrosus) of the intervertebral disc breaks due to which the soft jelly-like center (nucleus pulposus) bulges out and puts pressure on the neural structures, such as nerve roots and/or the spinal cord. Bone spurs or osteophytes, bony outgrowths, which occur due to the accumulation of calcium in spine joints, may also contribute to these problems.

Discectomy refers to the removal of total or a part of an intervertebral disc. This anterior cervical discectomy involves making an incision in the front side of the neck (anterior cervical spine), followed by the removal of disc material and/or a part of the bone around the nerve roots and/or spinal cord to relieve the pressure on neural structures and provide them with additional space.

Indications

Compression or pressure on the neural structures- nerve roots or spinal cord- due to herniated disc or bone spur may irritate the neural structures and cause pain in the neck and/or arms, numbness or weakness in the arms, forearms or fingers, and lack of coordination. As most of the nerves of the body pass through the neck region from the brain, pressure on the spinal cord in the neck region (cervical spine) can be problematic. Patients with these symptoms are potential candidates for this surgical procedure.

The procedure

An overview of what happens during anterior cervical discectomy is as follows:

Incision

The surgical procedure will be performed with you lying flat on a table on your back. A minor incision is made at the front of your neck to the side.

Exposure

Your surgeon exposes the region of compression (pressure zone) by spreading apart the soft tissues- fat and muscle, in the neck region.

Removal

The disc material or a portion of the bone compressing the nerve roots and/or spinal cord will be removed, to relieve the pressure on nerve structures and provide them enough space.

Closure

After the removal, your surgeon closes and dresses the incision.

Recovery

A specific post-operative recovery/exercise plan will be given by your physician to help you return to normal activity at the earliest. The duration of hospital stay depends on this treatment plan. You will be able to wake up and walk by the end of the first day after the surgery.

Risks and Complications

All surgeries carry risk and it is important to understand the risks of the procedure in order to make an informed decision to go ahead with the surgery. In addition to the anesthetic complications, spinal surgery is associated with some potential risks such as infection, blood loss, blood clots, nerve damage, and bowel and bladder problems.

Talk to your surgeon about any concerns you have about Anterior Cervical Discectomy surgery.

The cervical spine comprises the first 7 vertebrae of the spinal column. The vertebrae are separated from one another by shock absorbing pads called intervertebral discs. Over time, the discs can become worn out resulting in neck pain. Most patients with neck pain can be managed conservatively. However, surgery needs to be considered when the degenerative changes of the cervical spine exert excessive pressure on the spinal cord.

A cervical corpectomy and strut graft is a surgical procedure aimed at relieving the spinal cord compression by removal of the degenerated vertebrae and replacement with a bone graft. A corpectomy is indicated in compression of the spinal cord leading to spinal stenosis or cervical myelopathy.

Procedure

Your surgeon will make an incision in the front of your neck to reach the cervical spine. An X-ray is taken to ensure the affected vertebrae and discs are located. Once confirmed, the affected vertebrae and discs are removed along with any bone spurs around the vertebrae.

A cervical fusion is performed after a corpectomy. In cervical fusion, the space left after removal of the vertebral body is reconstructed with a bone graft to provide stability to the spine. The graft may be taken either from the patient or another individual and is usually taken from the small bone in the leg. The graft holds the vertebrae apart while the healing occurs and the vertebrae fuse. A metal plate and screws are used to hold the vertebrae and the bone graft in place.  Some patients are placed in a halo jacket to restrict the movement of the head during the healing process.

Some of the complications associated with corpectomy include subsequent pain, impaired healing, and a possible need for additional surgery.

Following surgery, patients will need to limit their activities to avoid strain on the healing vertebrae. Physical therapy may be initiated to improve neck strength and flexibility.  The intensity of physical therapy may be increased after the cervical fusion has healed sufficiently.

Your spine consists of a spinal cord supported by a series of interlocking bones called vertebrae. The cervical spine is the upper part of the spine situated in the neck region. It has seven vertebrae, separated and cushioned by spongy intervertebral discs. The vertebrae and discs may get damaged by injury, disease or wear-and-tear, compromising the cervical spine. Cervical spine fusion is a surgery performed to fuse weak cervical vertebrae with adjacent vertebrae to provide stability and prevent injury to the spinal cord.

A cervical spine fusion may be indicated to stabilize injuries and prevent fracture and spinal cord damage, and to treat misalignment of the vertebrae, herniated discs, arthritis, tumor, deformities and infection.

Different techniques may be used to fuse cervical vertebrae. The surgery is performed under general anesthesia. An incision may be made on the front or back of your neck, and muscles and tissues separated to expose the damaged vertebrae. The entire vertebrae or the spinal disc may be removed, and the adjacent bones fused. Your surgeon may take bone graft from another part of your body or use an artificial bone material and place it in between the vertebrae to form a bridge and stimulate new bone growth. The vertebrae may be stabilized by metal implants or plates and screws while new bone grows.

You may experience slight stiffness of the neck as a result of cervical fusion, but it doesn’t compromise the flexibility of the neck. As with all surgical procedures cervical spinal fusion may be associated with certain risks such as graft rejection, failure to fuse, nerve injury, bleeding and infection. Overall, however, the procedure has good results and can often treat pain, prevent paralysis and provide stability to the neck.

Thoracic spine decompression is a procedure to relieve pressure on the spinal nerves in the middle portion of the back. Spine decompression surgery is indicated in treating spinal stenosis. Spinal stenosis is the narrowing of the spinal canal caused by degeneration of the facet joints and the thickening of the ligaments. These thickened ligaments narrow the spinal canal and compress the nerves causing chronic pain, numbness and tingling sensation or weakness in your arms or legs. Thoracic decompressive surgery is recommended when your pain is not relieved with conservative treatments such as physical therapy or medications.

The following are common techniques for decompression:

• Laminectomy: During a laminectomy the entire lamina, a part of the enlarged facet joints and the thickened ligaments are removed to relieve pressure.
• Laminotomy: During a laminotomy, just a section of the lamina and ligament is removed.
• Foraminotomy: A foraminotomy is increasing the space where the spinal nerve roots leave your spinal canal to avoid compression.
• Laminoplasty: Laminoplasty is a surgical procedure indicated in conditions such as cervical spinal stenosis to relieve the pressure off the spinal canal by increasing the space within the spinal canal. This is achieved by creating a hinge on one side of vertebrae and cutting a portion of vertebrae on another side. This forms the swinging vertebrae and the portions or vertebrae are held in place using small wedges. These spacers are then held in place using tiny plates and secured with screws. This widens the space of the spinal canal and relieves the pressure off the spinal cord.

These surgeries are performed under general anesthesia and your surgeon makes an incision down the middle of your back and the muscles overlying the vertebrae are spilt and moved to the side exposing the lamina of the vertebra. The lamina is the bone that makes the back of the spinal canal and forms a protective roof over the back of the spinal cord. Then the entire bony lamina and ligament is removed (laminectomy). In some cases, only a small opening of the lamina is made by removing bone of the lamina above and below the spinal nerves to relieve compression (laminotomy). Next, to remove the bone spurs and the thickened ligament the protective sac of the spinal cord and the nerve root are retracted. Then the facet joints are trimmed to create more space for the nerve roots. If compression is caused from a slipped disc, your surgeon will perform a discectomy- the removal of a portion of a slipped disc.

This surgery makes the spine unstable and therefore another procedure, spinal fusion, is performed to stabilize the spine. Spinal fusion uses bone grafts, rods, plates or screws to join together two separate vertebrae in the spine.

Thoracic corpectomy is a procedure performed to relieve pressure on a nerve at the thoracic region (upper and middle back) by removing the source of the compression. It is indicated for conditions such as degenerative disc disease, spinal stenosis, bone spurs, tumor, fracture and infection leading to spinal compression, which cause pain, weakness and numbness in various parts of the body.

Thoracic corpectomy is carried out under general anesthesia. You will lie on your side during the procedure. An oblique incision is made. Important organs are moved aside to protect them during the surgery. The surgery involves two stages – decompression and fusion. To decompress the nerve, the presence of bone spurs, tumors or fractures causing the compression are removed. This is followed by fusion, where deformed or diseased vertebrae are removed along with the intervertebral discs, and the adjacent vertebrae are then fused. A bone graft is placed in this region to provide stability and a metal plate with screws may be used to provide added support. The procedure typically takes 3-4 hours to complete. Following surgery, you will remain in the hospital for 2-3 days.

You may notice immediate improvements in symptoms and may be able to walk the same day. Further improvement takes place over time. Your doctor will advise you when it is safe to return to work.

Risks and complications may be associated with this procedure, which is common to all spine surgeries. These include bleeding, infection and nerve damage.

The human spine provides support to the body allowing you to stand upright, bend, and twist. The spine can be broadly divided into cervical, thoracic and lumbar spine. Thoracic spine lies in the mid back region between the neck and lower back and is protected by the rib cage.

24 spinal bones called vertebrae are stacked on top of one another to form a spinal column. Between two vertebrae there is a disc of cartilaginous tissue called intervertebral disc. Intervertebral disc acts as a shock absorber and protects the spine from the strong forces of movement during activities such as jumping, running and lifting.

Wear and tear can occur in the disc with age and may cause the soft spongy tissue in the center of the disc to squeeze (herniate) from a tear on the side of the disc. Disc herniation may also occur due to an injury such as during a car accident or a fall; a sudden and forceful twist of the mid-back or disease of the thoracic spine such as Scheuermann's disease.

The herniated disc protrudes into the hollow tube of the spinal column called the spinal canal and directly pushes against the spinal cord passing through the spinal column. This can injure the spinal cord. Herniated discs can also block blood flow from the one and only blood vessel going to the front of the spinal cord in the thoracic region of the spine, causing nerve tissues in the spinal cord to die.

Symptoms of thoracic disc herniation vary depending on the position and size of the disc herniation, nerve irritation or nerve injury, and damage to the spinal cord. Symptoms may include mid-back pain, pain around the front of the chest that may mimic heart problems, groin pain or pain, numbness and weakness in the legs and arms. It may even affect bowel and bladder function.

Usually thoracic disc herniation is treated conservatively with rest, back brace, medication and physical therapy. Surgery is considered when long term conservative treatment does not relieve pain, or the condition is rapidly getting worse or is affecting the spinal cord.

The goal of the surgery is to remove all or part of the herniated disc pressing on the nerve root or spinal cord and is called discectomy. Thoracic discectomy can be performed either through the anterior approach (front side) or posterolateral approach (behind and to the side).

Anterior approach: This approach usually involves open thoracotomy in which the herniated disc is accessed through the chest cavity. An alternative to open thoracotomy is Video Assisted Thoracic Surgery (VATS). VATS is a minimally invasive surgery that is done through several small incisions and involves the use of a thoracoscope, a surgical tool with a tiny camera. Thoracoscope is inserted into the side of the thorax through a small incision to provide real images of the surgical area on a TV screen. These images guide the surgeon to remove the herniated disc using instruments inserted through other small incisions. VATS is minimally invasive and results in quicker recovery than open thoracotomy.

Posterolateral approach: This approach is also called as costotransversectomy. The herniated disc is accessed through an incision on the back of the spine. A window through the bones that cover the herniated disc is created by removing a small part of rib where it connects to the spine (costo means rib) and transverse process (a small bone attached to the spine). The discectomy is then performed with the small instruments.

Thoracic spine fusion is a surgical procedure in which two or more bones (vertebrae) of the thoracic spine are joined together so as to eliminate the movement between them. The thoracic spine is the center part of the spine and is formed of 12 vertebrae. Thoracic spine fusion is done by placing bone grafts or bone graft substitutes in between the affected vertebrae. This promotes bone growth and eventually fuses the vertebrae into a single, solid bone.

Spinal fusion surgery is recommended in certain conditions that cause persistent back pain even after conservative treatment. The surgery is indicated in the following conditions:

• Injury or fracture of the vertebra
• Instability of the spine caused by infections or tumors
• Spondylolisthesis
• Abnormal spinal curvature (kyphosis)
• Degenerative disc disease
• Spinal stenosis (combined with foraminotomy or laminotomy)

To perform a spinal fusion the spine may be approached and graft can be placed either from posterior approach (back), anterior approach (front) or a combination of both (anterior and posterior). Thoracic fusion is usually performed by posterior approach. The aim of the surgery is to fuse the two vertebrae into a single solid bone.

Posterior approach – The approach is made through the back while the patient lies on his or her stomach. The incision is made down the middle of the back.

Bone Grafting

Usually, small pieces of bone graft material are filled into the space between the vertebrae to promote bony fusion. A bone graft stimulates bone healing by increasing bone production.

Bone grafts can be taken from the patient’s own hip bone. This is called as autograft. It can also be obtained from a donor (allograft). Several artificial bone grafts such as demineralized bone matrices (DBMs), bone morphogenetic proteins (BMPs), and ceramics may also be used.

Immobilization of the vertebrae after the surgery helps in the fusion process. Your surgeon may suggest a brace to be worn or internal fixation with plates, screws and rods may be done to hold the spine still.

Risks and Complications

It is important to be aware of the potential risks and complications before undergoing the surgery. As with any surgery, there are some possible complications after thoracic spinal surgery which includes:

• Infection: Antibiotics will be prescribed before, during, and often after surgery to decrease the risk of infections.
• Bleeding at the site of surgery
• Persistent pain at bone graft site
• Pseudarthrosis: This is a condition in which there is no enough amount of bone formed and this is more likely in patients who smoke
• Nerve damage
• Formation of blood clots in the legs

The recovery period for spinal fusion varies among individuals and also depending on the procedure. You may need to stay in the hospital for 3 to 4 days after surgery. You will be given pain medicines in the hospital and will be taught about the right way of mobilization, postures while sitting, standing, and walking. You may have to wear a brace or a cast when you leave the hospital.

You can resume normal daily activities only after 2-3 weeks of rest period during which the spine heals. Follow your doctor’s instructions and maintain a healthy lifestyle to achieve better outcomes.

Osteoporosis is a “silent” disease characterized by weakening of bones, making them more susceptible to fractures, typically in the hip and spine. Elderly people and especially post-menopausal women are at greater risk of developing osteoporosis.

The mid to lower back area of the spine is mainly involved in weight- bearing, making these regions of spine more prone to collapse when bone weakness is present. This can lead to spinal (vertebral) compression fractures in these patients. Many of these vertebral compression fractures occur by minimal trauma or by no trauma at all. They can even occur while doing simple activities, like bending or twisting. Symptoms range from severe pain in the back, arms and legs to no pain at all. Most patients suffering from such a fracture may believe that their back pain is just a part of ageing, letting these vertebral compression fractures go undiagnosed. However, a single vertebral fracture significantly increases a person’s risk of further fractures. When multiple fractures occur, it causes the spine to become rounded and bent forward resulting in loss of height and a hunchback appearance. This forward curvature of the spine negatively affects the quality of life of the patient and makes it more difficult for them to breathe, eat, walk, or sleep. Vertebral compression fractures can also occur in patients suffering from conditions such as metastatic tumor, multiple myeloma, and vertebral hemangioma.

Vertebroplasty is a minimally invasive procedure which is performed to reduce or eliminate pain caused by vertebral compression fracture. It stabilizes the fracture and prevents further collapse of the vertebra averting deformity. The vertebroplasty procedure involves injection of bone cement into the fractured vertebra under high pressure. The procedure is done under general or local anesthesia. You will be lying face down on the operating table. Your doctor will make a very small 1/2 inch incision in the skin over the fracture site. Under live X-ray guidance, a hollow needle called a trocar is introduced through the back and is positioned within the fractured vertebrae. Next, bone cement is injected into the area through the trocar under high pressure. After the vertebral body is filled completely with the bone cement, the needle is withdrawn before the cement hardens. X-rays or CT scans may be done to confirm the effective spread of the bone cement into the fractured vertebra. The skin incision is closed using steri-strips.

Contraindications

The procedure cannot be performed under the following situations:

• Compression fracture is stable and does not cause any pain
• A fractured fragment or tumor is present in the spinal canal
• Presence of a bone infection or bleeding disorder

Risks and complications

As with any surgery, some risks can occur. General complications include bleeding, infection, blood clots and reactions to anesthesia. The specific complications following a thoracic vertebroplasty include leakage of the bone cement into surrounding soft tissues or veins and damage to the spinal cord or spinal nerves leading to numbness or paralysis.