Surgical Options

Most people with spine problems do not require surgery. Individuals who fail conservative methods, or continue to have nerve compression pain or a neurological deficit (i.e. weakness in muscle, loss of a reflex) and have ongoing disability may be candidates for surgery.

As deep bruising within the spinal wound may be a sesrious problem after surgery, it is of the greatest importance that any medications which thin the blood (eg. Astrix, Cartia, Ecotrin, Aspirin, Persantin, Asasantin, Plavix,) be stopped for at least 2 weeks prior to surgery. Warfarin is also noteworthy. If you take any of the above medications please inform Assoc. Professor Richard Williams' team well in advance of surgery.

Lumbar Discectomy

An operation performed on patients with a herniated (ruptured) disc in the lower back. Of the many patients who suffer leg pain due to this problem, only a small number will need to consider surgery as an option for treatment. At least 80% of the time the symptoms resolve regardless of the treatment. In this surgery, the herniated part of the disc is removed which relieves leg pain. It is important to realize that the surgery is performed only for persisting leg pain. Pain in the middle of the lower back is rarely an indication for surgery of this type. Leg muscle weakness or skin numbness is a sign of nerve damage which has occurred due to the compression of the nerve. These problems will not be improved specifically by surgery to take the pressure off the nerve and after the operation in all likelihood these problems will persist for many months as the nerve regenerates very slowly. In the operation only the small piece of disc causing compression will be removed (not the entire disc). The disc prolapse has occurred due to internal wearing within the disc and this will not be repaired by the surgery. This means that, in the future, back pain due to this disc wear may occur from time to time. This pain is not related to the discectomy operation and is rarely disabling. Complications of surgery are uncommon however a full discussion of the risks and benefits of surgery will be undertaken by Assoc. Professor Richard Williams prior to the procedure.

Laminectomy

An operation performed on patients with spinal stenosis. Spinal stenosis is a narrowing of the canal through which the spinal nerves pass. This operation is a removal of the "roof" of the spinal canal to allow more space for the underlying spinal nerves.Part or all of the back surface (lamina) of a back bone is removed (-ectomy) to enlarge the opening through which the spinal cord and spinal nerves run. This permits removal of any protruding disc material or bony spurs and the spinal nerves at the affected level of the back are dissected free of compression individually.

Spinal Fusion

An operation performed to prevent or limit abnormal motion in the spine by fusing two or more vertebrae. A spinal fusion may be performed as treatment for lower back pain due to "wear and tear" or for numerous other reasons including infection, tumours or broken bones as well as in deformity of the spine such as in scoliosis. The actual fusion (joining together) is done by surgically applying bone graft and/or spinal instrumentation to the level to be fused. A decompressive procedure, such as a laminectomy, may also be performed if required. Any problematic protruding disc material as well as arthritic areas of the spine may also be addressed at the same time.
Generally spinal fusion surgery for back pain is reserved for patients with very specific and disabling pain. Few patients with back pain are considered likely to benefit from the surgery, and for those considered appropriate the likelihood of improvement in the pain following the surgery is around 70%. It should also be remembered that it may take many months for the pain to improve even if the surgery is successful. This relates to the long healing process which follows the surgery.

The bone graft used for a spinal fusion may be autograft (bone taken from your own body) or allograft (bone from a bone bank). As the harvesting of bone (usually from the hip) may be painful, alternatives to using the patient's own bone are being sought very enthusiastically. Some alternative methods include using specific blood cells taken from the patient at the time of surgery which contain bone growth proteins and combining them with allograft, artificially produced bone substitutes and proteins and electronic implants which generate an electric current around the bone graft and encourage its growth and maturation.

It is generally held that success of a fusion operation is improved by holding the bones in the desired position with screws and rods. There are many different types available although all are similar and there is very little to favour one type over another. If metal is used, it cannot be felt through the skin, mostly does not need to be removed and will not set off the metal detectors at airports!

There are several different ways in which vertebrae may be fused together and the particular technique depends largely of the characteristics of each individual case.

Anterior/Posterior fusion

In this operation, the disc is removed by approaching the front of the spine (through the abdomen). In place of the disc a ring of bone is inserted (usually thigh bone) from the bone bank. This is then held at the front with a screw. On occasions, a metal cage made of titanium may be used instead of bone bank bone. Because this insert in the disc space is a relatively weak construction, screws and rods are also required at the back of the spine to hold the implants in place while the bone heals into its new environment.
Posterior fusion - For situations where there is no clear advantage to removing the intervertebral disc, a fusion may be achieved by joining the bones together from behind only. This would usually also involve metal screws and rods.

Posterior Interbody fusion

it is possible to fuse two back bones across a disc space by placement of a special cage made of carbon fibre from the back of the spine without surgery through the abdomen (TLIF). This surgery may be employed to provide a weight bearing strut at the from between two adjacent bones and particularly to allow free passage of individual nerves out of the narrowed apertures at the site of the spine where the nerves may be "pinched".

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