When is Spine Surgery the Next Right Step?: NeuroCare Partners: Board Certified Neurosurgeons

When is Spine Surgery the Next Right Step?

Spinal problems are one of the most frequent diseases that affect people all over the

world. For example, back pain occurs at least once in approximately 85% of people.

Although most of these diseases are treated conservatively, in some cases we may

use the surgical option. In this article, we will discuss the indications for surgical

intervention, as well as the available surgical techniques that have been used.

When Does One Need Surgery for Spinal Problems?

There is a number of reasons why someone may need spine surgery. In general,

Spinal surgery can essentially accomplish three tasks:

1. Decompress a nerve root or spinal cord.

2. Stabilize an unstable or painful segment with fusion surgery of the spine.

3. Reduce deformity (e.g. scoliosis surgery in the thoracic spine).

There are another less common indications for surgery such as trauma, spondylosis

and spondylolisthesis, spinal infections, and spinal tumors. In all cases, spine surgery is not done for exploration because the patient's pain is not easily apparent

with the opening and exploration of the spine without a precise preoperative

diagnosis.

In the following paragraphs, the commonest reasons for surgical interventions in

spinal diseases are discussed in more details:

Disc herniation:

We know that the pain of a herniated disc can, in most cases, be relieved with

painkillers and exercises to stretch the spine, but when cartilage presses on the

nerves, there is a risk of paralysis and here surgery is inevitable. The intervertebral disc can be repa

ired by surgery in two ways:

1. Fusion of spinal vertebrae:

This method is one of the surgical interventions that doctors use in the case of a

herniated disc. In this surgery the surgeon combines two adjacent vertebrae to form

one, especially when the vertebra are slippery. The intervention may involve

addition of screws and metal bars to stabilize the spine. The fusion of an unstable

joint is supposed to prevent movement that causes pain, but it is an important

process that sometimes does not provide a permanent solution, so people with a

weak column should be cautious about the fusion and its false promises.

2. Implantation of an artificial vertebra:

The second means is to implant an artificial vertebra to stabilize the spine while

keeping the affected parts flexible. However, the implementation of a mobile disk is

possible only in certain cases, when all other structures are intact.

Degenerative disc disease :

Degenerative disc disease has been defined as a clinical syndrome characterized

by manifestations of disc degeneration and symptoms associated with these

changes. As the spine discs stiffen and start to wear out, external bumps may

appear and exert pressure on nearby nerves. Sometimes walls are torn apart,

allowing the soft gelatinous substance inside to escape.

In the past, discectomy has been performed for treatment of patients with

incapacitating lumbar pain due to a painful degenerative disease of the disc.

Currently, there is no accepted indication to treat degenerative disc disease with

isolated discectomy. Discectomy is indicated in a patient with incapacitating root

symptoms leading to compressive neuropathy from a herniated nucleus pulposus

which is progressive or which has failed a 6-week trial of nonoperative treatment.

Symptoms may include incapacitating sciatica (extremity pain) with or without

neurological deficit. However, studies show that one year of conservative

treatment is equivalent to performing an effective discectomy. Therefore, the decision to undergo this intervention depends on your preference for immediate pain relief.

Operative role in management of axial back pain:

Although most cases of axial back pain are resolved over time with conservative

care, and there is a spontaneous improvement of 70% after 5 years in a study of a

group suffering from chronic back pain, surgical intervention can be used for the

management of persistent pain or when the presence of pathology was approved

such as degenerative changes secondary to an internal disc disorder. Other reported

indications for surgery include translational instability, segmental instability, post-

laminectomy syndrome, persistent lumbar pain after lumbar discectomy, annular

tear, failed back syndrome, and recurrent disc herniation.

Surgery for spinal canal narrowing:

Spinal stenosis is more common in the elderly, which is a compression of the

nerves or spinal cord in the cervical or lumbar spine. When the nerves are

compressed, the patient may have symptoms in the arm or leg, such as numbness,

tingling, pain, or weakness. Fortunately, most treatment options for spinal stenosis

are non-surgical, such as modification of activity, physiotherapy, anti-

inflammatory drugs, and modalities of interventional pain management which are

basically epidural injections for fixed injections to help decrease the inflammation

associated with spinal stenosis.

For patients who fail to responds to maximum non-operative management, we can

consider a surgery for the spine. Surgeries for spinal stenosis can be divided into

two categories; conventional spinal surgical techniques and minimally invasive

surgical techniques. The conventional technique is done by cutting the muscle of

the spine, getting the pressure off the nerves, and possibly restoring the spinal

column. Other patients may benefit from a minimally invasive technique, where

incisions are smaller.

Kyphosis and Scoliosis:

In patients with Scheuermann kyphosis, physiotherapy and guided exercise may be

sufficient for those with less than 60 degrees of curvature. A bracing may be added

for patients with curvature below 70 degrees. Surgical correction may be indicated

for patients with greater than 75 degrees, especially if conservative measures have

failed and are skeletally mature. Scoliosis of 20 degrees or more during peak

growth, significant scoliosis, progressive curvature, and atypical scoliosis are all

indications for surgical referral.

Traditional spinal surgery vs. minimally invasive spinal surgery?

The traditional surgery of the open spine involves complete exposure of the

anatomy. In minimally invasive spine surgery, we surgically expose less of the

anatomy, which means in many cases an earlier recovery in the first weeks after

surgery. In the case of minimally invasive spine surgery, we often use additional

surgical aids, such as intraoperative spinal navigation. This provides the surgeon

greater visibility into surgical areas with limited exposure. Whether minimally

invasive or traditional, the goals are the same for the long-term. We want to

accomplish overall improvement in symptoms or stop the degeneration. Ultimately,

we want our procedures to result in less blood loss, shorter hospital stay, lower

infection rates, and faster recovery in the weeks following surgery. Minimally

invasive surgery typically results in an easier recovery process for patients,

however, not every patient or surgical condition is appropriate for minimally

invasive surgery.

To sum up, modern spinal column surgery has made significant advances in both the

technique and the instrumentation/implantation of the spine in the last two decades.

Whereas surgical treatment may be attractive to patients with debilitating symptoms

of pain who seek rapid relief, there is a risk of complications that can be very

serious.