Lumbar Microdiscectomy

Microdiscectomy is a surgical procedure employed to relieve the pressure over the spinal cord and/or nerve roots, caused by a ruptured (herniated) intervertebral disc. A herniated disc, common in the lower back (lumbar spine) occurs when the inner gelatinous substance of the disc escapes through a tear in the outer, fibrous ring (annulus fibrosis). This may compress the spinal cord or the surrounding nerves, resulting in pain, sensory changes, or weakness in the lower extremities.

It is usually indicated in patients with herniated lumbar disc, who have not found adequate pain relief with conservative treatment. This procedure involves the use of microsurgical techniques to gain access to the lumbar spine. Only a small portion of the herniated disc that compresses the spinal nerve is removed.

Procedure:

A microdiscectomy is performed under general anaesthesia. Your surgeon will make a small incision in the midline over your lower back. Through this incision, a series of progressively larger tubes are placed and positioned over the herniated disc. The affected nerve root is then identified. Your surgeon removes a small portion of the bony structure or disc material that is pressing on the spinal nerve using microsurgical techniques. The incisions are closed with absorbable sutures and covered with a dressing.

Postoperative Care:

Following the surgery, patients will be discharged on the same day or the next day. Post-operatively, patients are advised to gradually increase their activity levels. If required, physical therapy is started after four to six weeks of the surgery to improve strength and range of motion.
Benefits of microdiscectomy include:

• Less muscle and soft tissue disruption
• Shorter recovery time
• Minimal postoperative pain and discomfort
• Fewer risks of complications

lumbar Discectomy and Decompression surgery

Lumbar Discectomy

Lumbar discectomy is a surgical procedure performed for the removal of a herniated or ruptured disc from the lumbar (lower) region. Intervertebral discs are fibrocartilaginous cushions between adjacent vertebrae. The normal intervertebral disc is composed of a semi-liquid substance (nucleus pulposus) at the centre 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 material may compress the spinal cord or the nerves around the spinal cord. Lumbar discectomy is performed to remove the damaged disc and relieve the pressure on the nerve, alleviating the pain.

Procedure

This procedure is performed under sterile conditions in an operating room with the patient under general or spinal anaesthesia. The patient is placed in a face down position. During the procedure, the surgeon will make a small incision, in the midline, over the affected disc in the lumbar region. After accessing the vertebrae, a small portion of bone from the back of the vertebra is removed along with partial removal of the ligamentum flavum, a membrane over the nerve roots. The surgeon then 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 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.

Postoperative Care

Following the surgery, you will be discharged home on the same day or the next day after surgery. The surgery provides significant pain relief, however tingling or numbness, leg pain, pain at the incision site, and back muscle spasms may occur in a few patients. Your doctor will prescribe medications for the management of these complications which should improve within one to two weeks of the surgery.

Risk and Complications

Lumbar discectomy is comparatively safe with minimal complications. Some of the potential risks of this procedure include infection, nerve injury, spinal cord injury, ongoing pain and problems with anaesthesia.

Talk to your surgeon for any concerns you have about Lumbar Discectomy surgery.

Lumbar Decompression

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 tumours, who have not found adequate pain relief with conservative treatment.

Lumbar decompression is performed under general anaesthesia. 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.

lumbar Spinal Fusion

Spinal fusion, also known as arthrodesis, is a surgical technique which involves the union of two or more vertebrae in the spine. Lumbar fusion refers to the surgical union of the vertebrae in the lumbar region i.e. lower back. Lumbar fusion is performed to relieve pain, restore the neuronal functions and prevent abnormal movement in the spine.

Lumbar fusion surgery may be employed for the management of various conditions such as spondylolisthesis (gliding of the spine bones), scoliosis or kyphosis (anomalous curvature of the spine), degenerated discs, repeated disc herniation, spinal infections or tumours, traumatic injury to the spine, and spine instability.

Based on the location of the surgery and placement of the bone graft, spine fusion surgery can be categorized as:

• Posterolateral gutter fusion: this procedure is performed through the back
• Posterior lumbar interbody fusion (PLIF/TLIF): this procedure is also performed through the back and involves the removal of the intervertebral disc and insertion of a bone graft in the space created
• Anterior lumbar interbody fusion (ALIF): this procedure is performed from the front and involves the removal of the intervertebral disc and insertion of a bone graft in the space created
• Anterior/posterior spinal fusion: the procedure is also performed from the front as well as the back

Procedure

Lumbar fusion can be performed either from the front (anterior) or the back (posterior). In the anterior approach, the disc and surrounding arthritic area is removed by the surgeon. A bone graft is then placed between the vertebrae, which helps in the fusion of the adjoining vertebrae responsible for the abnormal motion of the spine. In the posterior approach, the bone graft is placed on the sides of the vertebrae to fuse them and prevent abnormal motion.

Based on the source of the bone graft, it can be categorized as either an autograft or an allograft. Autograft refers to a bone graft taken from a different bone of the same patient, whereas an allograft is obtained from a bone bank. Metal rods, plates and screws, referred to as instrumentation, are also used along with the bone graft to stabilize the spine.

Post-operative care

Patients may be discharged home after 1-4 days of the surgery. Some of the post-operative instructions after a lumbar fusion surgery include:

• Back braces
• Avoid uncomfortable movements such as twisting and bending
• Adequate rest
• Keep the incisions clean and dry
• Avoid heavy work

Risks and complications

The risks and complications associated with lumbar fusion surgery include infection, nerve damage, loss of sensation, bladder or bowel dysfunction, implant dislocation, pain at the site of bone graft, and pseudarthrosis.

Cervical Discectomy & Fusion

Anterior cervical discectomy with fusion (ACDF) is a surgical procedure to treat a herniated disc in the cervical or neck region. The goals of surgery are to remove the damaged spinal disc or bony overgrowths causing nerve compressing and to fuse the adjacent vertebrae by placing bone graft in the space created. This procedure is performed by approaching the spine anteriorly or from the front of your neck.

Disease Overview

There are seven vertebrae in the neck separated by intervertebral discs that act as shock absorbers. Each disc has a tough exterior called the annulus fibrosus and a gel-like centre called the nucleus pulposus. Conditions such as trauma or wear and tear can damage the disc causing the nucleus pulposus to herniate or protrude through its tough outer layer. This can put pressure on the spinal cord, ligaments or nerve roots entering and exiting the spine. Nerve compression may also be caused by bony overgrowths or spurs in the cervical spine that occur due to calcium accumulation. Cervical disc herniation causes neck pain as well as pain, numbness, weakness and lack of coordination in the arms and fingers.

Indications

ACDF surgery is indicated to treat symptoms that do not respond to non-surgical treatments and adversely affect your ability to perform your daily activities.

Surgical procedure

Anterior cervical discectomy with fusion is performed under general anaesthesia. You will lie on your back and your surgeon makes a transverse incision in the front of your neck. The muscles and other important structures in the neck are retracted to gain access to the surgical area.

• The affected cervical disc is identified by X-ray imaging.
• The disc material is surgically removed to decompress the areas of nerve root and spinal cord compression.
• Any bone spurs causing nerve or tissue compression are also removed.
• The space left after removing the disc is instrumented to receive the bone graft.
• The bone graft is prepared and placed in the intervertebral space. Alternatively, a fusion cage made of artificial material such as titanium or PEEK is packed with bone graft and inserted in the space.
• A metal plate may be screwed into the vertebrae to provide stability.
• The muscles are released and the incision is closed.
• With the help of the bone graft, the adjacent vertebrae will grow and fuse together to form a solid piece of bone.

Post-Operative Care

After surgery, you are placed in a neck brace for stability and comfort, which you may wear intermittently for 2 weeks. Your doctor will prescribe appropriate medication for pain. Smoking and using non-steroidal anti-inflammatory drugs or NSAIDs should be avoided as they interfere with bone healing. You will be instructed to avoid lifting heavy objects or bending forward or backward. Post-operative exercises are recommended to safely restore movement as early as possible. You may return to work in 3-6 weeks depending on your level of activity.

Advantages

The anterior approach to cervical spine surgery provides easier access to the cervical spine, minimal muscle division and less postoperative pain than the posterior approach.

Risks and complications

As with all surgical procedures, ACDF may be associated with certain risks and complications such as

• Infection
• Blood loss
• Blood clots
• Nerve damage
• Difficulty swallowing for a few days
• Bowel and bladder problems
• Fusion failure

Cervical Disc Replacement

Artificial Cervical Disc Replacement is a spine surgery involving the replacement of the degenerated disc, from the cervical region, with an artificial disc through an incision on the front of the neck. It is indicated in patients experiencing severe neck and arm pain along with numbness and weakness in the arm due to cervical radiculopathy (compression of the spinal nerves) and/or cervical myelopathy (compression of the spinal cord).

The degenerated disc is thinner than the normal disc resulting in loss of height, between the adjacent vertebrae. Moreover, the disc loses its ability to absorb shock which increases the pressure over the facet joints causing increased wear and tear and damage to the cartilage of the joint leading to formation of bone spurs and neck pain.

The reduction in disc height constricts the cavity in the cervical spine (neural foramen) through which the spinal nerves pass. The compression of these spinal nerves results in pain, numbness, tingling and weakness in the arms. The bone spurs may also compress the spinal nerve or the spinal cord.

The degenerative changes in the disc may also lead to herniation of the disc wherein the soft gelatinous material (nucleus pulposus) may herniate through the outer fibrous ring (annulus fibrosis) and compress the nearby spinal cord and/or spinal nerves. Compression of the spinal cord can lead to pain and weakness even in the legs. In rare cases, it may also cause partial paralysis of the arms.

The initial treatment of degenerative disc disease and herniated disc comprises of non-surgical options which include medication and physical therapy. However, if the symptoms do not improve or radiculopathy or myelopathy occurs, the surgical removal of the herniated disc (discectomy) is recommended. Usually fusion of the adjacent vertebrae is performed along with discectomy. Artificial cervical disc replacement is an alternative to cervical fusion after discectomy in patients with degenerative disc disease or herniated disc. It involves the replacement of the damaged disc with an artificial disc. Artificial disc replacement cannot be performed in patients with cervical instability, significant facet joint damage or infection.

The artificial disc, used to replace the degenerated disc, is like the natural healthy disc. It restores the height between the two cervical vertebrae, enlarging the neural foramen and relieving the pressure on the spinal nerves. It is also capable of absorbing shock which relieves the pressure over the facet joints. Artificial cervical disc replacement not only stabilizes the cervical spine but also restores the normal mobility of the neck.

Procedure

Before the procedure, the patient is sedated and administered anaesthesia. The patient is placed on the operation table on the back. The cervical spine is approached through an incision on the front of the neck. The neck muscles, trachea and the oesophagus are retracted to access the cervical spine. The affected disc is identified, with the help of intra-operative fluoroscopy, and removed. Bone spurs or outgrowths compressing the nerves are also removed. The artificial disc is then placed precisely in the disc space between the vertebrae, with the help of intra-operative fluoroscopy. After checking the range of motion of the neck and confirming proper fit of the artificial disc, through fluoroscopy, the incision is sutured closed.

Patients are usually discharged a day after the surgery.

Risk and Complications

Every surgery has some risks associated with it. Although artificial cervical disc replacement is a safe procedure, some of the risks that can occur include infection, bleeding and nerve injury. Nerve injury in some patients may lead to hoarseness of the voice and difficulty in swallowing, but it usually resolves within a few weeks. Rarely, a spinal cord injury may also occur. This is a serious complication and can lead to paralysis and even death.

Artificial cervical disc replacement provides an alternative to cervical fusion for some patients with degenerative disc disease. Most patients, after undergoing artificial cervical disc replacement, have significantly less arm and neck pain and significant improvement in the mobility of the neck. It also relieves weakness and numbness in the arm.

Posterior cervical foraminotomy

Cervical Foraminotomy

Cervical foraminotomy is a decompression surgical procedure that involves the widening of the neural foramen, the space through which the spinal nerve roots pass. The widening of the foramen helps in relieving pressure over the spinal nerves due to compression at the foramen.

The compression of spinal nerves in the foramen may occur because of degenerative changes in the spine that causes development of bone spurs which may lead to foraminal stenosis. Nerve compression can also result from a disc collapse caused by excessive strain and stress in the neck area.

Procedure

The basic steps of cervical foraminotomy include:

• The procedure is conducted in an operating room with the patient under general anaesthesia.
• The patient lies face down, on the operating table.
• An X-ray is used to identify the location of the incision.
• A small incision is made over the middle of the neck, at the back.
• The muscles are retracted (moved aside) with the help of a retractor.
• A surgical microscope is employed to magnify the view of the area being operated.
• Specially designed cutting instruments are then used to remove bone spurs, thickened ligaments and segments of the herniated disc.
• Removal of the bones and tissues around the neural foramen also releases the compression over the nerve roots.
• Finally, all the muscles and the soft tissues are placed in their appropriate positions and the wound is sutured.

Post-operative care

Patients are usually discharged on the same day of the surgery and can resume driving within 1-2 weeks. General post-operative instructions for the patient after a cervical foraminotomy include:

• Use of soft neck brace

• Keep the incision clean and dry
• Move the neck with care and comfort
• Patient can return to work after 3-4 weeks
• Avoid heavy work or any sports for at least 2-3 months
• Physical therapy is recommended for the strengthening of the weak muscles

Risks and complications

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

• Complications related to anaesthesia
• Conditions such as thrombophlebitis
• Infection
• Spinal nerve damage
• Persistent pain

Kyphoplasty / Vertebroplasty

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

The mid to lower back area of the spine is mainly involved in weight bearing, making these regions of the spine more prone to collapse when bones weaken. This can lead to spinal (vertebral) compression fractures. Compression fractures are broken spinal bones that cause a part of or a complete vertebra to collapse. Many of these vertebral compression fractures occur by minimal trauma or no trauma at all. They can even occur during 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 aging, letting these vertebral compression fractures go undiagnosed.

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 tumour, multiple myeloma, and vertebral hemangioma.

Until recently, treatment of compression fractures included bed rest, bracing, pain medications or invasive spinal surgery. Currently, two new therapeutic and preventive treatment options are available for compression fractures, called vertebroplasty and kyphoplasty.

Vertebroplasty

Vertebroplasty is a minimally invasive procedure performed under general or local anaesthesia. You will lie face down on the operating table. Using live X-ray imaging, your doctor will insert a large needle through the skin into the fractured vertebra and inject bone cement into it. The needle is then withdrawn before the cement hardens. The cement quickly hardens and provides strength and stability to the vertebra.

Kyphoplasty

Kyphoplasty is a minimally invasive procedure to relieve pain due to vertebral compression fracture. The procedure is like vertebroplasty and is performed under general or local anaesthesia. You will lie face down on the operating table. Using live X-ray imaging, your doctor will insert a large needle through the skin into the vertebra and insert a balloon through the needle. The balloon is then inflated until the desired vertebral height is obtained. The balloon is then removed and the empty space created between the vertebrae is injected with cement. The cement quickly hardens restoring height, and providing strength and stability to the vertebra.

Post-procedure Care

Following vertebroplasty and kyphoplasty you will be discharged most likely on the same day of the procedure. No bracing is required after the treatment procedure. You will be advised to stay in bed for the first 24 hours. After, you can start walking and quickly return to your normal daily activities. If there is a pain in the area where the needle was inserted, an ice pack can be applied. Driving should be avoided till the surgeon feels it is okay. Heavy lifting and any strenuous activities should also be avoided for at least 6 weeks after the surgery.

Risks and complications

Vertebroplasty and kyphoplasty are generally safe. As with any surgery, some risks can occur. Complications of surgery may include

• Bleeding
• Infection
• Blood clots
• Reaction to anaesthesia
• Leakage of the bone cement into surrounding area

After vertebroplasty and kyphoplasty, you should experience considerable relief from pain and improved quality of life.

Balloon Kyphoplasty

Balloon kyphoplasty is a minimally invasive surgical procedure that relieves the back pain caused by a vertebral compression fracture. It stabilizes the fracture and restores the vertebral body height.

Vertebral compression fractures occur because of trauma such as a fall, motor vehicle accident or bone diseases such as osteoporosis, and certain cancers. These fractures occur most commonly in the middle to lower back region because of the weight bearing load on the spine that causes the vertebrae to become crushed. There may be severe pain or sometimes no symptoms at all. Compression fractures can also result in a progressive spinal deformity and when multiple fractures occur, it causes a condition known as kyphosis or dowager’s hump.

Your surgeon will evaluate the cause for back pain by a detailed medical history and physical examination. Other diagnostic tests such as X-rays, MRI scan, CT scan and bone density test may be ordered to confirm a vertebral fracture.

Balloon kyphoplasty surgery is recommended in patients having severe pain and deformity that is not relieved by conservative treatment methods such as rest, pain medications, and bracing.

Surgical Procedure

Balloon kyphoplasty is an elective procedure and is performed with the patient lying in a face down position on the operating table. Your surgeon will make a small incision in the back through which a narrow tube is placed. With the help of fluoroscopy as guidance, the tube is advanced into the fractured area of the vertebra. Then a special balloon is inserted through this tube and carefully inflated. This elevates the fracture and restores the vertebra to its pre-fracture height. The balloon is then deflated and removed leaving behind an open cavity. Then your surgeon fills the cavity with a material called polymethylmethacrylate (PMMA) with the help of specially designed instruments. The material hardens in few minutes and stabilizes the bone.

Post-operative Care

Most patients experience immediate pain relief after balloon kyphoplasty surgery. You will be allowed to get up and walk once you regain consciousness. Pain medications will be prescribed to make you comfortable during the first few days. You can return to normal activities but lifting heavy weights and strenuous activities should be avoided for 6 weeks. After 2 weeks, your doctor will prescribe a postoperative rehabilitation program to strengthen the spinal muscles.

Risks and complications

As with any major surgery there may be certain potential risks and complications involved with balloon kyphoplasty surgery which include:

• Injury to the nerves or spinal cord caused from placement of mispositioned instruments in the back
• Spinal cord compression or nerve injury caused from leakage of PMMA material into the veins or epidural space
• Deep or superficial wound infection

Benefits of Balloon Kyphoplasty

Apart from stabilization of vertebral fracture and reduction of back pain, balloon kyphoplasty procedure helps to restore vertebral height and thus reduces the kyphosis which may develop in most patients with spinal fracture. Other advantages of the procedure include:

• Improved quality of life
• Improved mobility
• Lesser complications
• Reduced hospital stay

Spinal Fracture Fixation

The backbone is made of small bones arranged from the neck region down to the buttocks, one above the other. The region at the chest and lower back are called the thoracic and lumbar spine, respectively. These are the two regions commonly affected by a fracture and frequently occur due to high-velocity accidents, falls from a height or a violent blow. They may also occur in cases of osteoporosis or a tumour where the bone is weakened.

A thoracic or lumbar fracture is associated with moderate to severe back pain. Fractures of the vertebral column may be associated with injury to the underlying spinal cord, causing pain, tingling sensation, numbness, weakness, and bowel and bladder dysfunction.

Injury to the thoracic and lumbar spine may be assessed by a physical examination, neurological tests, and imaging studies that help identify the nature and extent of the fracture.

Thoracic and lumbar spine fractures are usually treated with bracing for 6 to 12 weeks with a gradual increase in activity. Surgery is performed in cases of displacement of fractures, and significant injury to the adjoining ligaments, intervertebral discs or nerves. Your doctor makes an incision in your front, side or back, realigns your bones with screws, rods or cages, and releases the compressed spinal cord or nerves. This is followed by stabilization of the fracture. Surgery is followed by rehabilitation to alleviate pain and regain mobility.

Spinal Decompression

Spinal decompression is a surgical procedure that relieves pain caused from pressure exerted through the compression of the spinal cord or related spinal nerves. The pressure may be induced due to impaction of the bone or disc material. Spinal decompression can be performed through advanced techniques such as minimally invasive spine surgery.

Indications

A tear of an intervertebral disc with herniation may induce pressure on the neural tissues such as spinal cord, spinal nerves and nerve roots. This can cause pain, numbness and muscle weakness in the back, neck, arms, and legs. Impaction of the neural tissues may occur due to conditions such as spinal stenosis, spondylolisthesis, and occasionally spinal tumour.

In such cases, your spinal surgeon may recommend different procedures depending upon your pathological and neurological condition, degree of spine alteration and your medical history.

Extensively used spinal decompression procedures include minimally invasive lumbar discectomy, lumbar laminectomy, and cervical foraminotomy.

Procedure

Each spinal decompression procedure has its specific steps, but the common steps involved are as follows:

• An incision is made over the affected vertebra (e)
• Soft tissues such as skin, muscles and fat are smoothly pulled apart to expose the vertebra (e)
• Different sources such as vertebral elements, bone spurs, disc material or any other source causing compression are safely removed
• Soft tissues are gently placed back to their respective positions and finally the incision is closed

In some cases, spinal decompression procedure may be combined with a spinal fusion procedure. This involves additional placement of bone grafts between the affected vertebrae to stimulate the growth of bone to fuse the two vertebral bodies. The placed graft material act as binding agent and helps to retain the normal height of disc. With time, the bone graft ultimately grows to join and stabilize the affected vertebrae.

Due to advancements in technology, spinal decompression can also be performed through a minimally invasive procedure. The minimally invasive spinal decompression surgery has several advantages as compared to the traditional open method. Advantages include:

• Muscles can be easily separated from the affected spine area instead of cut
• Small incision is required that yields a smaller scar
• Less surgical discomfort to the patient
• Patient may go home on the same day of the surgery

Discuss with your surgeon to determine whether you are a candidate for minimally invasive spinal decompression surgery.

Post-operative care and recovery time

Patients may find correction in some symptoms soon after the surgery, whereas other symptoms may gradually recover with time. Your surgeon may recommend specific post-operative instructions for a fast and successful recovery.

The recovery time depends upon the treatment plan of the individuals. Usually spinal decompression procedure is performed on an outpatient basis. Patients must follow different rehabilitation protocols based on their condition and the type of activity they want to participate in after surgery.

Risks and complications

Although spinal decompression surgery is a safe procedure, as with any surgery complications may arise under certain circumstances. The possible complications associated with spinal decompression surgery are as follows:

• Infection
• Nerve damage
• Blood clots
• Blood loss
• Bowel or bladder problems
• Incomplete fusion of the bone graft (spinal fusion)

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