 Spine
Surgery
How
is the cause of back pain determined?
The first step in a complete diagnosis to determine the root cause of back pain are
X-rays and Computerized Tomography Scans (CT Scans).
More extensive imaging techniques may be used such as a multislice CT with myelogram,
which clearly shows both bony structure and nerve roots both through vertical and
horizontal slices building up a detailed picture of the spine and Magnetic Resonance
Imaging (MRI), which produces a similarly detailed picture of the entire anatomy of
the spine clearly showing the soft tissue detail.
It may also be necessary to assess the condition of nerves in the cervical (neck)
or thoracic (chest) areas. Somatosensory evoked potentials (SSEP) may be recorded
to assess the speed at which the nerves are conducting electrical signals across the
spinal cord. |
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If the cord is significantly pinched or adversely affected, the signals
will travel slower than normal. Electromyography (EMG) assesses the electrical activity
of the nerve root. EMGs can help to distinguish nerve degeneration from nerve root compression.
What are specific causes of back pain, when is surgery
indicated?
For patients with chronic lower back pain,
there are several possible causes. These may include disc herniation, degenerative
disc disease, and isthmic spondylolisthesis in younger adults. In older adults, osteoarthritis,
lumbar spinal stenosis and degenerative spondylolisthesis may be indicated.
For patients with upper back pain, causes may include disc herniation,
cervical stenosis, cervical degenerative disc disease and cervical osteoarthritis.
Spinal trauma and tumors of the spine may also cause pain at any age.
After consultation with a neurosurgeon, it may be determined that
the best course of treatment to correct these conditions is through surgical intervention.
Surgeons offer several surgical procedures to address each of these conditions.
In general, surgeons can relieve the pain through "decompression surgery",
in which the piece of the offending disc or bone is removed; and/or through "fusion
surgery", in which portions of the bony spine are fused together to decrease
or eliminate excessive movement of the disc, thereby eliminating the source of pain.
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Sciatica pain causes and treatments
The diagnosis of 'sciatica' means that there is inflammation of the sciatic nerve. The sciatic
nerve supplies information about movements to the leg, and sends information about sensations
back to the brain. The sciatic nerve is quite large; in fact, it is the largest peripheral
nerve in the body.
The sciatic nerve is formed from the lower segments of the spinal cord; it is made up from
the lumbar and sacral nerve roots from the spine. The sciatic nerve exits the lower part
of the spinal cord (lumbosacral region), passes behind the hip joint, and runs down the
back of the thigh.
How does this nerve normally function?
The sciatic nerve, like most other nerves, performs two basic functions: first, it sends
signals to your muscles from the brain; and second, it collects sensory information from
the legs and passes this back to your brain.
What happens to cause sciatica?
The most common cause of sciatica is a herniated disc. Other conditions, such as
spinal stenosis, spondylolisthesis, or piriformis syndrome can also cause sciatica symptoms
by irritating the nerve.
What are the signs and symptoms of sciatica?
Sciatica can cause both sensory and muscular abnormalities in the legs and thighs. Common
symptoms of sciatica include:
- A cramping sensation of the thigh
- Shooting pains from the buttock, down the leg
- Tingling, or pins-and-needles sensations in the legs and thighs
- A burning sensation in the thigh
In addition, patients with sciatica may notice a worsening of their symptoms
with manoeuvres such as squatting or coughing. These manoeuvres can increase pressure around
the nerve and magnify the symptoms of sciatica.
Who is prone to developing symptoms of sciatica?
Sciatica can affect just about anyone, but it is extremely uncommon in young patients. Sciatica
typically affects 30 to 50 year old patients. Often there is a sudden onset that may be
attributed to over-exertion or a back injury.
What should I do about sciatica?
Most importantly, you need to find out if sciatica is the cause of your symptoms. Your doctor
will take a thorough history, perform a physical exam, and test several specific functions
of the nerve. Several other conditions may cause hip and thigh pain, and need to be considered.
It is important to determine the correct cause of your symptoms prior to beginning treatment
of sciatica. Other tests, including X-Rays or possibly an MRI may be helpful, but they may
not needed.
What treatments are available?
Treatment is initially aimed at addressing the inflammation associated with sciatica.
Rest, anti-inflammatory medications, and muscle relaxers are often good places to start.
Some patients require a more powerful anti-inflammatory treatment and are given oral steroids.
These steroids do have potential side-effects, but the powerful anti-inflammatory effect
can be helpful in the treatment of sciatica.
Once the pain subsides, exercises and physio therapy are helpful. Seing a sports physiotherapist
is a good idea. exorcises to streangthen the muscles surrounding the spine will help to
ensure that the symptoms dont return. Courses such as Pilates Core Strength exercises are
helpful. Many people find that heat packs applied to the neck and lumbar areas soothe the
muscles that are painful in sciatica. Some doctors may prescribe an epidural steroid injection
that can deliver anti-inflammatory medication directly to the inflamed area around the nerves.
If two injections havent improved the condition further injections should be avoided and
surgery may be necessary.
Surgical treatment of sciatica is not usually needed, but in individuals who undergo the
above treatments for a minimum of three months, and still have symptoms, surgery may be
considered. The surgical procedure is one that allows more room for the nerve in the area
being compressed. This may mean removing the ruptured disc, opening up the bone around the
nerve, or a combination of both.
Will I get better from sciatica?
Most people, 80-90% fully recover from sciatica without surgery. In most cases the
nerve is not permanently damaged, and individuals recover in the 3-week to 3-month time
frame.
Sciatica is not a medical emergency. However, if you experience difficulty with bowel or
bladder function, decreased sensation around the genitals, or progressive leg weakness,
this may be the sign of cauda equina syndrome, a medical emergency. If
you have these symptoms, contact your doctor or attend a hospital emergency department immediately.
Disc Herniation symptoms and
corrective treatments
A herniated disc is a rupture of the intervertebral disc of the spine.
When this occurs, the cushion that sits between the spinal vertebra is pushed outside
its normal position. A herniated disc bulges outwards putting pressure on the spinal
nerves that are very close to the edge of the intervertebral disc. The intervertebral
disc is a soft cushion that becomes more rigid with age. In a young individual, the
disc is soft and elastic, but like so many other structures in the body (such as tendons
and ligaments), as we age, the disc looses its elasticity and is more vulnerable to
injury. In fact, even in individuals as young as 30, a MRI shows evidence of disc
deterioration in about 30% of people. Hydration may be an important factor as dehydration
is thought to lead to earlier degeneration of discs.
When a herniated disc bulges out from between the vertebrae, the spinal nerves and
spinal cord can become pinched. There is normally a little extra space around the
spinal cord and spinal nerves, but if enough of the herniated disc is pushed out of
place, then these structures may be compressed. |
A
normal disc and surrounding structures.
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Symptoms of a herniated disc
When the herniated disc ruptures and pushes out, the nerves may become trapped. A
herniated disc may occur suddenly in an event such as a fall or an accident, or may occur
gradually with repetitive straining of the lumbar spine. Often people who experience a herniated
disc already have lumbar spinal stenosis, a problem that causes bone spurs and inflammatory
tissue to take up some of the precious space around the nerves. When a herniated disc occurs,
the space for the nerve is diminished and irritation of the nerve results.
Common symptoms include:
Leg Pain
Most commonly experienced over the outside of the thigh, the lower leg, or foot.
Shooting pain may be experienced coming all the way down the leg; patients often describe
an electric shock type of symptom.
Parasthesias
This is the medical word for abnormal sensations such as tingling, numbness, or pins
and needles. These symptoms may be experienced in the same region as painful sensations.
Muscle Weakness
Because of the nerve irritation, signals from the brain may be interrupted causing
muscle weakness, usually of the ankle. Nerve irritation can also be tested by examining
the reflexes of the knee and ankle.
Bowel or Bladder Problems
These symptoms are important because it may be a sign of cauda equina syndrome,
a possible condition resulting from a herniated disc. This is a medical emergency, and you
should see your doctor immediately if you have problems urinating, having bowel movements,
or if you have numbness around your genitals.
All of these symptoms are due to the irritation of the nerve from the herniated disc. By
interfering with the pathway by which signals are sent from your brain out to your extremities
and back to the brain, all of these symptoms can be caused by a herniated disc pressing
against the spinal nerves.
Corrective Treatments
Depending on the size of the herniated disc and the condition of the patient, treatments
of a herniated disc may be conservative or aggressive. The usual treatment for a herniated
disc is to proceed conservatively. After diagnosing the problem, usually a period of rest
is advised. It is important that rest take place initially, but that gradually you return
to activities. Often a two days on relative inactivity will help tremendously.
Initial treatments are aimed at minimizing inflammation around the nerve with anti-inflammatory
medications and possibly an epidural steroid injection, and stabilizing the lumbar spine
with physical therapy and strengthening exercises.
Because the nerve root is irritated, anti-inflammatory medications will help reduce the
inflammation.
Non-steroidal anti-inflammatory medications are relatively safe, taken by mouth, and have
the benefit of also helping to alleviate pain. Injections of steroid medication (epidural
steroid injections) are sometimes administered. Patients also often use a muscle relaxant
to help control muscle spasms in the early treatment of a herniated disc. If pain is severe,
narcotic medications are prescribed. These medications have significant side-effects in
some patients, and can become addictive; care must be taken if using these medications.
Physical therapy and lumbar stabilization exercises do not directly affect the herniated
disc, but they can stabilize the lumbar spine muscles. This has an effect of decreasing
the load experienced by the disc and vertebrae. Stronger, well balanced muscles help control
the lumbar spine and minimize the risk or injury to the nerves and the disc.
If more conservative measures do not relieve your symptoms then surgical treatment may be
recommended. Surgery is performed to remove the herniated disc, and free up space around
the compressed nerve. Depending on the size and location of the herniated disc, and associated
problems (such as spinal stenosis, arthritis, etc.), the surgery can be done by several
techniques. In very straightforward cases, endoscopic or microscopic excision of the herniated
disc may be possible. However, this is not always recommended, and in some cases, a more
traditional surgery may need to be performed.
Spinal Microdiscectomy
A Microdiscectomy removes a herniated disc from the spinal canal. When a disc herniation
occurs, a fragment of the normal spinal disc is dislodged. This fragment may press against
the spinal cord or the nerves that surround the spinal cord. This pressure causes the symptoms
that are characteristic of herniated discs. During the surgery the surgeon removes the fragment
of spinal disc that is causing the pressure.
How is a Microdiscectomy performed?
A open Microdiscectomy is performed under general anaesthesia.
The procedure takes about an hour or so, depending on the extent of the disc herniation,
the size of the patient, and other factors. A Microdiscectomy is done with the patient lying
face down, and the back pointing upwards.
In order to remove the fragment of herniated disc, your surgeon will make an incision over
the centre of the spine. The incision is usually about 3 centimetres in length. Your surgeon
then carefully dissects the muscles away from the bone of your spine. Then using special
instruments, your surgeon removes a small amount of bone and ligament from the back of the
spine. This part of the procedure is called a laminectomy.
Once this bone and ligament is removed, your surgeon can see, and protect, the spinal nerves.
Once the disc herniation is found, the herniated disc fragment is removed. Depending on
the appearance and the condition of the remaining disc, more disc fragments may be removed
in hopes of avoiding another fragment of disc from herniating. Once the disc has been cleaned
out from the area around the nerves, the incision is closed and a bandage is applied.
What is the recovery from a Microdiscectomy?
Patients often awaken from surgery with complete resolution of their leg pain; however,
it is not unusual for these symptoms to take several weeks to slowly dissipate. Pain around
the incision is common, but usually well controlled with oral pain medications.
Gentle activities are encouraged after surgery, such as sitting upright and walking. Patient
must avoid lifting heavy objects, and should try not to bend or twist the back excessively.
Patients should avoid strenuous activity or exercise until cleared by their doctor.
What are the potential complications of Microdiscectomy?
The most common problem of a Microdiscectomy is that there is a chance that another fragment
of disc will herniate and cause similar symptoms down the road. This is a so-called recurrent
disc herniation, and the risk of this occurring is about 10-15%.
Most patients find relief of much, if not all, of their symptoms from a Microdiscectomy. However,
the success of the procedure is about 85-90%, 10% of patients will still have persistent
symptoms. Patients who have symptoms for long periods of time, or severe neurological deficits
(such as significant weakness) are at higher risk of incomplete recovery.
Other risks of surgery include spinal fluid leaks, bleeding, and infection. All of these
can usually be treated, but may require a longer hospitalization or additional surgery.
What is endoscopic micro-Microdiscectomy?
The endoscopic micro-Microdiscectomy is a procedure that accomplishes the same goal as
a traditional open Microdiscectomy, removing the herniated disc, but uses a smaller incision.
Instead of actually looking at the herniated disc fragment and removing it, your surgeon
uses a small camera to find the fragment and special instruments to remove it. The procedure
may not require general anaesthesia, and is done through a smaller incision with less tissue
dissection. Your surgeon uses x-ray and the camera to "see" where the disc herniation
is, and special instruments to remove the fragment.
Endoscopic micro-Microdiscectomy is appropriate in some specific situations, but not in all.
Many patients are better served with a traditional open Microdiscectomy. While the idea of a
faster recovery is nice, it is more important that the surgery is properly performed. Therefore,
if open Microdiscectomy is more appropriate in your situation, then the endoscopic procedure
should not be done. Discuss with your surgeon if endoscopic micro-Microdiscectomy may be appropriate
for you.
Degenerative Disc Disease
Over time, discs naturally degenerate but they may not necessarily cause back pain.
This degenaration over time weakens the disc space in the region allowing excessive movement
around the disc, causing inflammation and irritation of the local area. The patient can
then experience chronic back pain.
Corrective Surgery: If surgery is indicated, a spinal fusion can be performed
to stabilise the area. First, bone is transplanted from the patient's pelvis. This bone
graft provides streangthening to promote new bone growth. In some cases titanium implants
can be used.
The surgeon can fuse the disc area together by placing replacement bone
either in front of the spine (anterior interbody fusion) in the disc space, or along the
back of the spine (posterior interbody fusion), or both in front and in back, depending
on the affected area. The fusion of the spinal segment limits the motion around the affected
area, thereby decreasing or eliminating pain.
In some cases, the surgeon may insert screws and rods into the pedicle
region of the spine around the affected disc. These pedicle screws and rods help to stabilize
the area and restrict movement so that the bone graft can heal. In the cervical area, surgeons
may apply a small plate to add stability to the area.
Isthmic or degenerative spondylolisthesis
Spondylolisthesis means "slipped vertebral body". In patients with this condition,
a stress fracture or generalized degeneration in one of the lower lumbar vertebra (L4 or
L5) causes it to slip forward and press onto, or dislocate over, another vertebra. Pain
can result from disc degeneration as the disc tries to stabilize itself, or from the fracture
itself, if present.
Corrective Surgery: Surgeons may treat spondylolisthesis by performing a
laminectomy (bone removal) and spinal fusion (see degenerative disc disease, above).
Spinal stenosis
The most common cause of spinal stenosis is degenerative changes of the spine (aging),
and it is uncommon to find this condition in individuals younger than 30 years old. Spinal
stenosis affects men and women equally, and most often is seen in individuals over the age
of 50.
When spinal stenosis does occur in younger patients it is often related to traumatic injury
to the vertebrae.
What is spinal stenosis?
Spinal stenosis is a condition that is caused by a narrowing in the vertebral canal
or vertebral foramina of the spine. The narrowing causes compression of either the spinal
cord (if the compression is within the vertebral canal), or the nerve roots that exit the
spinal cord (if the compression is within the vertebral foramina). Compression of these
structures leads to the common symptoms experienced by patients who have spinal stenosis,
most often pain and numbness in the extremities, and back pain. When the narrowing, or spinal
stenosis, is in the cervical (neck) region of the spine, symptoms are experienced in the
arm and hands. When the spinal stenosis is in the lumbar (low back) region, the most common
symptoms are in the legs and feet.
Causes of spinal stenosis.
Spinal stenosis may be caused by a wide variety of conditions, all of which lead
to a narrowing of the spinal canal. These conditions may be either inherited or acquired.
Spinal stenosis is most often caused from degenerative arthritis, a process that causes
changes in the spine that leads to narrowing of the spaces in the vertebral canal. Common
changes include the formation of bone spurs, calcification of spinal ligaments, thickening
of joint tissue due to chronic inflammation, and degeneration of the intervertebral disc.
Inherited conditions include congenital spinal stenosis (narrow canal), scoliosis, and achondroplasia.
As stated previously, the most common acquired condition that causes spinal stenosis is
degenerative arthritis. Other acquired conditions that may lead to spinal stenosis include
rheumatoid arthritis, tumors, Paget's disease, and traumatic damage to the vertebral column.
Symptoms of spinal stenosis.
Spinal stenosis can cause a wide variety of symptoms throughout the body. The most
common symptoms are generalized pain, weakness, and numbness in the affected region. If
the area of narrowing of the spine is in the cervical (neck) region the symptoms are experienced
in the arms, and if the area of narrowing is in the lumbar (low back) the symptoms are experienced
in the legs.
Other symptoms may occur as a result of spinal stenosis, and a few are treated specifically.
If you experience bowel or bladder dysfunction (inability to control your bowel or bladder
function) this should be treated as a medical emergency. This may be a sign of so-called
'cauda equina syndrome,' a serious condition of compression of the nerve
roots in the lower end of the spinal canal. This may require immediate surgery to decompress
an area of the spine that is seriously affected by the stenosis.
Treatment for spinal stenosis.
The most common first step in treatment is aggressive physical therapy. Emphasis
is on strengthening of the muscles of the back, stretching these muscles, and improving
posture. Anti-inflammatory medications often help relieve the pain. Problems associated
with lumbar (low back) spinal stenosis may benefit from wearing a brace to support their
spine.
Some treatments, including epidural steroid injections and transcutaneous electrical nerve
stimulation, are being investigated to determine their efficacy. The study of treatment
of chronic pain has been a hot topic in the medical field in recent years.
Surgery is indicated when the conservative treatment fails to improve the situation, usually
after a period of several months of unsuccessful physical therapy.
The exception to this is if the patient experiences symptoms of cauda equina
syndrome, such as inability to control bowel or bladder function. In this case an immediate
operation to decompress the stenotic region of the spine may be necessary.
The goal of surgery is to decrease pressure on the spinal cord or its nerve roots in an
effort to relieve the symptoms of spinal stenosis. The procedure performed is called a decompressive
laminectomy. In this procedure parts of the vertebral column are removed and more space
for the spinal cord and nerves is created. A fusion may or may not be performed to stabilize
the affected area of the spine.
Surgery usually benefits patients by relieving pain, weakness and numbness. Depending on
the extent of involvement and the severity of damage, not all of the symptoms may resolve.
However, there is usually an improvement. Complications of a decompressive laminectomy include
tears in the sac that surround the spinal cord and instability of the spine. Furthermore,
because degenerative changes are the most common cause of spinal stenosis, the problems
may reappear years after surgical treatment is performed.
Cauda Equina Syndrome
The cauda equina area is not the true spinal cord. The true spinal cord ends at L1/2.
The area below the true spinal cord is called the conus medullaris. Immediately below that
is the cauda equina area. The cauda equina are the nerves that leave the lower spinal cord
and travel inside the spinal canal below where the true spinal cord stops (at about L1/2)
before leaving the canal and going to the legs, bowel, bladder and genitals.
A cauda equina syndrome is what you get when you impair the function of many or all of the
nerve roots in the cauda equina area. Since these nerve roots serve sphincter and sexual
function, sensation around the perineum (anus, genitalia) sensation in the legs, muscles
throughout the legs, etc., it is possible to get pain and numbness as well as bladder and
bowel dysfunction, sexual dysfunction and muscle weakness in the legs. Simply put, CES is
damage to these nerve roots.
When a herniated disc requires corrective surgery and the surgery does not take place then
the patient can end up with CES usually from a herniation at L4/5 S1. CES may be permanent
nerve damage. The time before surgery, when it may still be possible to relieve this compression
and avoid permanent nerve damage is the acute stage of cauda equina syndrome. Once the candidate
has had the surgery and is left with the nerve damage they are then in the chronic stage
of cauda equina syndrome.
The one thing CES sufferers have in common is that they had a huge, centrally herniated
disc at L4/5 S1.. With these candidates the rupture is very large crushing the nerves.
Symptoms of cauda equina Syndrome
- Severe pain in radicular (nerve root) pattern: back, buttocks, perineum
(saddle area), genitalia, thighs, leg.
- Loss of sensation: often tingling or numbness in the saddle area.
- Weakness: in legs, often asymmetric.
- Bladder/bowel/sexual dysfunction: incontinence/retention of urine;
incontinence of faeces; impotence/loss of ejaculation or orgasm.
- Loss of reflexes: knee/ankle reflexes may be diminished, as may anal
and bulbocavernosus.
If you have the above symptoms you should immediately be investigated by
an orthopaedic surgeon.
Will the nerves Regenerate?
Nerve regeneration will depend on how long those nerves were crushed and how much
damage has been done. The only way to know is to wait, if the nerves are going to regenerate
it can take as long as two years.
When a nerve is crushed there are three possible outcomes. The nerve may be asleep when
there is enough pressure to cause it to completely shut down. It will come back if the pressure
is removed soon enough.
The second possibility is when there is a little more pressure and the nerve branch, called
an axon, is destroyed, but the insulation, called the myelin is still intact. The nerve
can re-grow its axon if the myelin sheath is still there to give it a guide back to where
it is supposed to go. The rate of growth under the best conditions is 1mm per day. That
is about one inch per month.
The third condition occurs when the axon is crushed and the myelin sheath is disrupted.
The nerve will try to grow its axon, but doesn’t have a guide to find it’s way
back to where it belongs. In this case nerve regeneration is not possible, at least not
at this time. |
