Procedure
Should I be considering surgery?
Surgery for Back PainMost episodes of back pain settle. If intrusive back pain persists, or if episodes recur frequently, surgery may be considered but fortunately this is only in a small proportion of cases. Many people manage moderate back ache, controlling their symptoms through exercise and with tablets. In the same way, occasional severe episodes are manageable although some advice on how to deal with these episodes can be helpful. At The Spine Clinic we can certainly look into the causes of these problems and offer good advice. It is when problems start to become unacceptable that many people wonder if surgery might be helpful. This point is usually when back pain becomes restrictive and intrudes into day to day activities, affecting your
quality of life. One or two bad episodes a year may be acceptable. Four or five bouts bad enough to keep you off work will generally not be.
Surgery has traditionally been regarded as the ‘last resort’. That remains the case to some extent, but with modern surgical techniques the prospect of surgery no longer needs to carry with it a sense of fear and avoidance . Improved diagnostic tests allow a better understanding of the true nature of the condition being treated, allowing the use of appropriate techniques (Looking into the Spine in Greater Detail). Those techniques are now far less invasive and often orientated towards the preservation of motion in the spine (What Sort of Surgery Should I Have?). All this means that surgery is now more readily considered in cases of troublesome and intrusive back pain.
Things to Think About before You Think About Surgery
Lifestyle Issues
Have you done all you can to give your back a chance? There is a lot of helpful advice available from many sources but areas to think about include:
1. Getting your weight down. Being overweight overloads the back and makes back pain more likely and more of a problem.
2. Lead a less sedentary life. Our backs are meant to be mobile. Sitting at a desk all day is not good for structures such as the intervertebral discs and leads to deconditioning of muscles and ligaments in the back.
3. Improve your level of activity. Regular exercise helps in so many ways. The discs and joints in the back generally respond well to movement and moderate exercise will help improve the muscles which are vital for support of the back. The increased activity will help get your weight down too if this is a problem.
4. Stop smoking. As if there weren’t enough reasons to kick the habit, smoking accelerates degeneration of the discs in the lower back and increases your susceptibility to back problems.
Strengthening Your Back1. Pilates Exercises. These include a number of exercises specific to the lower back and can be very helpful.
2. Physiotherapy. It is often useful to have guidance and advice on back exercises and physiotherapists with experience in dealing with low back problems have considerable expertise in this area. Hydrotherapy (a form of physiotherapy undertaken in water) may be particularly beneficial early on, especially in the acute phase of a back pain episode. Core stability work is vital and other techniques, after a careful and detailed assessment, can make a real difference.
Managing Pain1. Medication. Tablets may not be a solution in the long term but analgesics (such as paracetamol) and anti-inflammatories (such as ibuprofen or voltarol) can be very useful in helping to bring acute symptoms of back pain under control. The two in combination can be particularly useful, but ensure that you keep to recommended doses. Anti-inflammatories can cause certain adverse effects and may not be tolerated by some people. They should always be taken with food. Muscle relaxants can be helpful too in acute episodes of back pain but generally should not be continued for more than a few days.
2. Balancing rest and mobilisation. Long periods of bed rest tend to be counter-productive, adding to muscle deconditioning and vulnerability as well as leading to back stiffness. When hit by an acute episode try and get moving as soon as you can and certainly within a couple of days.
If back pain remains a significant and intrusive problem despite allowing a reasonable period for things to settle and attending to these issues as far as you can, then perhaps it is time to explore the possibility of surgical treatment.
3. Root Block and Epidural Injections: In some cases, of disc prolapse with radicular pain special medication can be given directly surrounding the nerve root and spinal cord to achieve immediate pain relief.
Surgery for Sciatica (leg pain)The majority of acute episodes of sciatica will settle on their own. If it does not do so within a reasonable period of time, or if the symptoms are unacceptable, it is reasonable to consider surgery. What constitutes a reasonable period of time, and what are unacceptably severe symptoms, are of course subjective matters and will vary from one person to another. If improvement is going to occur it will usually be evident within the first six weeks and the patient should be showing good signs of recovery by three months.
Not everybody can wait this length of time for symptoms to settle. If this is the case, or if symptoms have failed to show the expected improvement, discectomy may be appropriate.
There are other causes for leg pain, such as spinal stenosis. Disorders of the Lower Spinedescribes what causes this condition and the possible treatments , including surgery, are discussed in Discectomy
Discectomy aims to remove the protruding or bulging disc material that is pressing on the nerve root and causing sciatic pain. This will give the nerve root the best chance for recovery.
The term microdiscectomy is often used, and refers to a procedure using a small incision, microsurgical instruments and an operating microscope or surgical ‘loops’ (magnifying glasses worn by the surgeon). These techniques are now normal practice with most spinal surgeons undertaking a discectomy. Spinal Decompression (Laminectomy)
In the lower back the spinal canal, which is a channel that runs down inside the spine, contains the nerve roots which pass down into the legs. These nerve roots, called the corda equine, normally have plenty of room. As an approximation the spinal canal is about the same in cross section as your little finger. Sometimes the spinal canal can become critically narrowed in one or more areas, a condition called spinal stenosis. This is usually due to age related wear and tear changes affecting the spine, although these changes won’t necessarily have caused much in the way of back pain previously. A worn disc may bulge backwards into the spinal canal, while the facet joints may enlarge and encroach on the canal from the back and the sides. As the discs narrow and lose height, ligaments within the canal, which are normally quite stretched out, buckle inwards and appear to thicken. As a result the nerve roots become more and more crowded and ‘strangled’ by the hour-glass narrowing of the canal. Symptoms become apparent.
The pattern of symptoms can vary considerably, but typically patients with spinal stenosis start to experience a sense of aching tiredness and heaviness in their legs when walking or standing upright. This is often accompanied by aching across the back which typically spreads into the buttocks. The problems in the back and the legs build up gradually with walking or standing and after a while may become bad enough that the individual feels unable to carry on and has to sit down. Sitting down, or even bending or leaning forwards, often brings relief within a few minutes, allowing the person to continue walking although the symptoms will return again after a similar period. The walking distance may be a guide to the severity of the narrowing and can become limited to 100m or less.
Decompression aims to open up the space for the nerve roots within the spinal canal. This may entail the removal of some bone from the back part of the vertebra called the lamina, hence the term laminectomy, which may be used for this operation.
Spinal Fusion
Rationale
Although there have been several advances in spinal surgery centred on the principles of motion preservation, the application of these techniques remains limited. F or many problems in the lower back requiring surgery, spinal fusion remains the best option.
Spinal fusion is effective for two reasons. Firstly, the main sources of pain, the worn out disc and facet joints, are removed. Secondly, any painful movement through the damaged part of the spine is completely eliminated. At The Spine Clinic MrBoeree may suggest one of three different spinal fusion techniques. Each of the techniques uses special instrumentation, such as specially designed cages, screws and rods, to correct any mal-alignment of the vertebrae and hold them still while the fusion develops. There are particular reasons and advantages for each, which we can explore. The techniques are:
1. Posterior Lumbar Interbody Fusion
2. Stand-Alone Anterior Lumbar Interbody Fusion
3. Combined Anterior and Posterior Fusion
Posterior Spinal Fusion
Posterior means from the back of the body. Posterior spinal fusion actually encompasses several different techniques but in all of them the operation takes place purely from the back, usually with pedicle screws being inserted into the sacrum and/or each of the vertebrae being fused together. These screws will be linked by rigid rods.
If the intervertebral disc is to be cleared away, which is very often the case, this will also be done entirely from the back, through the spinal canal. After clearing away the disc material special cages are inserted into the space left by the removed disc. This is called posterior interbody fusion and various possible techniques for positioning the cages and the bone graft can be used.
The cages and the rods help to maintain the proper alignment and spacing between the vertebrae and also stop all movement, allowing the bones to fuse together. The cages are filled with and surrounded by bone graft and additional bone graft will also be placed over the back of the vertebrae. It is this bone graft that forms the mass of fusion bone which joins the vertebrae together.
Rationale
Pedicle screws and rods provide a very strong and rigid form of fixation. Pedicle screws have to be put in from the back and this is why spinal fusion is most commonly done from the back. Although the prospect of inserting screws into the vertebrae of the spine sounds quite frightening it is now very routine in spinal surgery. The screws and rods allow the position of the vertebrae to be altered and controlled as well as held in place.
Another good reason for a posterior fusion is that the problems that have to be dealt with in the lower spine often need some work to be done inside the spinal canal, for example a decompression or removal of protruding disc material. These procedures can easily be undertaken at the same time. If they are needed it is a strong reason for choosing a posterior procedure.
Finally, it is quite common for the facet joints to be contributing to back pain problems since these joints can become quite worn. These joints form part of the back of the spine and a posterior spinal fusion will involve removing the facet joint surfaces and overlaying the joints with bone graft to encourage them to fuse. This should stop any pain coming from these joints.
AdvantagesCompared to other fusion techniques, the particular advantages of a posterior spinal fusion are:
1. A single surgical procedure for providing fixation and inserting cages in the disc space. This is an advantage when compared with the combined anterior and posterior technique, which requires two operation sites.
2. Spinal decompression can easily be undertaken at the same time.
3. At L5/S1 (the lowest level of the spine) anterior surgery (an operation from the front) has a very small risk in male patients of causing retrograde ejaculation. If this problem occurred it could affect your ability to have children. The risk is avoided with posterior surgery.
Possible drawbacks
1. Posterior surgery does cause some damage to the functionally important muscles of the back. This can have a negative effect on the outcome from surgery. At The Spine Clinic this problem is dramatically reduced through the use of minimally invasive image guided pedicle screw techniques, but these can not be applied in all situations.
2. Clearing out the disc and inserting cages through the spinal canal does require that the nerve roots are moved well out of the way. They can be damaged by this or during the cage insertion. This can cause long term sciatic pain or loss of feeling and weakness in certain parts of one leg. This risk is largely avoided with other fusion techniques.
3. Although a good proportion of the disc can be cleared away, more complete clearance is obtained, and more importantly a bigger cage with more bone graft inserted, with anterior surgery.
4. The fusion rates, which are an important factor in success, are good in both posterior and anterior fusion techniques, but the highest fusion rates are achieved with combined anterior and posterior surgery.
5. The use of pedicle screws does have some specific risks, such as the very small risk of injuring a nerve root.
6. Minimally Invasive spine fusion
7. Fusion means joining together with bone and here it involves the front parts of two or more vertebrae. The front parts of the vertebrae are the vertebral bodies and each intervertebral disc separates one vertebral body from another. 8. People often find it surprising that one would even consider getting to the spine from the front. After all, the spine is part of the back so this doesn’t seem very logical. However, in a slim person the front part of the spine can actually be felt very easily through the abdomen. It is much closer than you think. 9. Although ‘anterior’ refers to the front and anterior surgical approach to the spine may be from the side. This is determined by specific anatomical considerations but the surgery still involves a fusion of the front part of the spine.
Circumferential Spinal Fusion
Circumferential fusion, sometimes called 360 degree fusion, combines a posterior spinal fusion of the problematical part of the spine with fusion of the front of the spine over the same area. The posterior fusion is essentially the same as with a posterior lumbar interbody fusion except that clearance of the disc and the insertion of cages through the spinal canal is not undertaken from the back, through the spinal canal. Instead, the fusion of the front of the spine is performed as a separate minimally invasive operation through the abdomen.
Pedicle screws and rods are used to help to restore the proper alignment and spacing between the vertebrae and also stop all movement, allowing the bones to fuse together. A cage is inserted into the cleared disc space. This is filled with bone graft and additional bone graft will also be placed over the back of the vertebrae. It is this bone graft that forms the mass of fusion bone which joins the vertebrae together.
Rationale
Since this involves two operations it may be seen, in some ways, as more major surgery but it does have certain particular advantages in certain situations. It is a procedure which may be considered for some of the more major spinal problems or where previous techniques have failed for some reason. It may also be appropriate where a posterior fusion is needed but the risks of clearing the disc and inserting cages through the spinal canal are considered too high.
Pedicle screws and rods are used since these provide a very strong and rigid form of fixation and can be used to restore alignment in the spine. These are put in from the back. Although the prospect of inserting screws into the vertebrae of the spine sounds quite frightening it is now very routine in spinal surgery. It is quite common for the facet joints to be contributing to back pain problems since these joints can become quite worn. These joints form part of the back of the spine and a posterior spinal fusion will involve removing the facet joint surfaces and overlaying the joints with bone graft to encourage them to fuse. This should stop any pain coming from these joints.
If the disc is very damaged, or the affected part of the spine quite unstable, it can be particularly important to recreate a strong anterior column of the spine, that is to say the front, load bearing section of the spine. In this situation combining the posterior fusion with the insertion of a strong cage, filled with plenty of bone graft and securely fixed into the spine really provides the strongest construct and offers the best chance of achieving a sound fusion.
Advantages:
Compared to other fusion techniques, the particular advantages of a circumferential spinal fusion are:
1. The best chances overall of achieving a fusion.
2. This is the strongest method of fixing and holding the affected part of the spine. This is especially important where the spine is quite unstable.
3. The disc is cleared more completely than with a single posterior operation and a greater area for bone graft is possible between the vertebral bodies.
4. The risks to the nerve roots from clearing the disc and inserting cages through the spinal canal are avoided. If the nerve roots are damaged this can cause long term leg pain. This can be an important consideration.
