Lumbar Microdiscectomy

In a microdiscectomy a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and provide more room for the nerve to heal. A microdiscectomy is typically performed for lumbar herniated disc. Microdiscectomy helps leg pain

A microdiscectomy surgery typically helps treat leg pain. The impingement on the nerve root can cause substantial leg pain, and while it may take weeks or months for the nerve root to fully heal and any numbness or weakness get better, patients normally feel relief from leg pain almost immediately after a microdiscectomy surgery.

A microdiscectomy spine surgery is performed through a small (1 inch to 1 1/2 inch) incision in the midline of the low back. The back muscles are lifted off the bony arch of the spine. Since these back muscles run vertically, they can be moved out of the way rather than cut. The surgeon is then able to enter the spine by removing a membrane over the nerve roots, and uses either operating glasses or an operating microscope to visualize the nerve root. Often, a small portion of the inside facet joint is removed both to facilitate access to the nerve root and to relieve pressure over the nerve. The nerve root is then gently moved to the side and the disc material is removed from under the nerve root.


Lumbar Laminectomy

Lumbar laminectomy is a surgical procedure most often performed to treat leg pain related to herniated discs, spinal stenosis, and other related conditions. Stenosis occurs as people age and the ligaments of the spine thicken and harden, discs bulge, bones and joints enlarge, and bone spurs or osteophytes form. Spondylolisthesis (the slipping of one vertebra onto another) also can lead to compression.

The goal of a laminectomy is to relieve pressure on the spinal cord or spinal nerve by widening the spinal canal. This is done by removing or trimming the lamina (roof) of the vertebrae to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disc. Various devices (like screws or rods) may be used to enhance the ability to obtain a solid fusion and support unstable areas of the spine.

A small incision (usually about 3-4 inches, though it may be longer depending on how many levels of the spine are affected) is made in the lower back. The surgeon uses a retractor to spread apart the muscles and fatty tissue of the spine and exposes the lamina. A portion of the lamina is removed to uncover the ligamentum flavum - an elastic ligament that helps connect two vertebrae. Next an opening is cut in the ligamentum flavum in order to reach the spinal canal. Once the compressed nerve can be seen, the cause of compression can be identified. Most cases of spinal compression are caused by a herniated disc. The surgeon retracts the compressed nerve and the source of the compression is removed and pressure on the spinal nerve or nerve components is relieved.

If necessary, the surgeon will perform a spinal fusion with instrumentation to help stabilize the spine. This occurs when a lot of bone needs to be removed and/or when multiple levels are operated on. A spinal fusion involves grafting a small piece of bone (usually taken from the patient's own pelvis) onto the spine and using spinal hardware, such as screws and rods, to support the spine and provide stability.


Posterior Lumbar Fusion (PLF)

A posterior lumbar fusion is the most common type of fusion surgery for the low back. A fusion is a surgical procedure that joins two or more bones (in this case vertebrae) together into one solid bone. The procedure is called a posterior fusion because the surgeon works on the back, or posterior, of the spine.

Posterior fusion procedures in the lumbar spine are used to treat spine instability, severe degenerative disc disease, and fractures in the lumbar spine.

Other procedures are usually done along with the spinal fusion to take the pressure off nearby nerves. They may include removing bone spurs and injured portions of one or more discs in the low back. Most surgeons also apply metal screws and rods, called instrumentation, to hold the bones securely while they fuse.


Anterior Lumbar Fusion (ALF)

The anterior lumbar fusion is similar to the posterior lumbar fusion, except that the disc space is fused by approaching the spine through the abdomen instead of through the lower back.

A three-inch to five-inch incision is made on the left side of the abdomen and the abdominal muscles are retracted to the side. Since the anterior abdominal muscle in the midline (rectus abdominis) runs vertically, it does not need to be cut and easily retracts to the side. The abdominal contents lay inside a large sack (peritoneum) that can also be retracted, thus allowing the spine surgeon access to the front of the spine.

Some ALF procedures will be done using a minilaparotomy (one small incision) or with an endoscope (a scope that allows the surgery to be done through several one-inch incisions).

  • The minilaparotomy allows better visualization and can be done with a minimal amount of postoperative pain. Most spine surgeons use the open, minilaparotomy approach.
  • The endoscopic approach has more limited visualization, and it usually leads to larger surgical times and carries with it a much higher technical learning curve for the surgeon.

The results with either procedure are equivalent and the type of approach used should depend mostly on which procedure the spine surgeon is most comfortable using. The endoscopic approach has largely fallen out of favor because of the technical difficulties associated with it, and it has not been proven to generally lessen postoperative pain or hasten the healing process.

The large blood vessels that continue to the legs (aorta and vena cava) lay on top of the spine, so many spine surgeons will perform this surgery in conjunction with a vascular surgeon who mobilizes the large blood vessels. After the blood vessels have been moved aside, the disc material is removed and bone graft, or bone graft and anterior interbody cages, is inserted.

The ALF approach has the advantage that, unlike the PLF and posterolateral gutter approaches, both the back muscles and nerves remain undisturbed. Another advantage is that placing the bone graft in the front of the spine places it in compression, and bone in compression tends to fuse better.


Lumbar Prosthetic Disc Replacement

The newest technology in back surgery is the artificial disc replacement surgery, also known as disc implantation surgery. In this procedure, the biological injured or degenerated disc material is removed, and an artificial intervertebral disc is implanted in the spine.

Lumbar disc replacement allows for motion preservation at the operative level which is desireable, especially in younger patients to avoid the stiffness of fusion and with that the junctional stress transfer which can lead to adjacent segment disease and the need for additional surgery adjacent to fused segments.


Anterior Cervical Fusion

For patients who have a cervical herniated disc or spinal stenosis causing spinal cord or nerve root compression or a post traumatic or generative instability anterior cervical fusion is the recommended surgery in most cases. It generally involves disc and/or bone spur removal from an anterior approach. Fusion (stabilization) is accomplished with structural bone graft inserted into the disc base with anterior plating(instrumentation) to provide stability.


Cervical Disc Replacement

Many cervical pathologies can be treated with the newest technology which still allows motion preservation (physiologic neck motion) cervical disc replacement is performed from the anterior approach just like cervical anterior fusion, but instead of placing bone and plate to stabilize (fuse) the segment, an artificial disk is inserted which instead allows retention of physiologic motion at that spinal segment.

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Cervical Laminectomy

Generally cervical decrompression surgery is directed to whichever side of the spinal cord (front or back) the compressive lesion is most notable. Cervical laminectomy is partial or complete removal of the lamina bone from the back to decompress the spinal cord and/or nerve roots from the posterior approach. The majority of cervical decompression surgery is still performed from an anterior (front) approach.


Permanent Implant of Spinal Cord Stimulator

Spinal Cord Stimulation is a treatment option for patients suffering from Complex Regional Pain Syndromes (CRPS) also know as Reflex Sympathetic Dystrophy (RSD), nerve damage (neuropathic pain), failed back surgery pain, spinal cord damage, phantom limb pain, and pain caused by blood vessel disease. It is not a "first line" treatment and is performed after more conservative therapies have failed. The Spinal cord stimulator electrically stimulates the spinal cord with a low voltage impulse that blocks the sensation of pain. Electrical stimulation is delivered through an implanted lead near the spinal cord in the epidural space. The lead is connected to an implanted long life battery or a receiver that receives energy from an external battery.

The procedure is done in two stages at different times. In the trial stage, temporary wires are placed and an external device is used by the patients to generate electrical stimulation. This is really a test to determine if a permanent spinal cord stimulator should be used. If this trial is successful in relieving your pain, then the permanent device is placed under the skin, usually about two weeks later.


Deformity Correction Surgery (Scoliosis, Kyphosis, Spondylolisthesis)

If deformity progresses such that it becomes markedly painful, disabling or results in either neurologic deficit or pulmonary compromise, modern spine surgery allows for very powerful corrective surgeries.

These procedures are generally performed with titanium and/or stainless steel screws and rods, allowing excellent bony fixation and very powerful deformity correction capability. For large deformity surgery intraoperative spinal cord and neurologic monitoring is performed to mininmize the risk of neurologic injury or deficit.


X-Stop IPD

The X-Stop Spacer is a titanium metal implant that is placed between two bones, called spinous processes, in your lower back. The X-Stop Spacer procedure is minimally invasive. When implanted, the X-Stop Spacer is not positioned close to nerves or the spinal cord, but rather behind the spinal cord, between the spinous processes.

The procedure is done in the operating room at the hospital. With the help of x-ray guidance, the X-Stop Spacer is implanted through a small incision in your back. Depending upon your anatomy and specific medical conditions, your doctor may elect to use local or general anesthesia.

The procedure to implant the X-Stop Spacer may last anywhere from 45 to 90 minutes. The procedure can be done under local or general anesthesia, depending on your medical health.


Kyphoplasty

Kyphoplasty is a minimally invasive spinal surgery procedure used to treat painful, progressive vertebral compression fractures (VCFs). A VCF is a fracture in the body of a vertebra, which causes it to collapse. In turn, this causes the spinal column above it to develop an abnormal forward curve. VCFs may be caused by osteoporosis (an age-related softening of the bones) or by the spread of tumor to the vertebral body. Certain forms of cancer can also weaken bone and cause the same problems.

Kyphoplasty is not appropriate for:

  • Patients with young, healthy bones or those who sustained a vertebral body fracture or collapse in a major accident
  • Patients with spinal curvature such as scoliosis or kyphosis that results from causes other than osteoporosis
  • Patients who suffer from spinal stenosis or a herniated disk with nerve or spinal cord compression and loss of neurologic function not associated with a VCF

Kyphoplasty involves the use of a device called a balloon tamp to restore the height and shape of the vertebral body. This is followed by application of bone cement to strengthen the vertebra. The procedure is performed with the patient lying face down on the operating room table and under intravenous sedation. Two x-ray machines are used to show the collapsed bones.

To begin, the surgeon makes two small (less than 3 mm) incisions in the back. A tube is inserted into the center of the vertebral body to the site of the fractured bone. The balloon tamp is then inserted down the tube and inflated. This pushes the bone back to its normal height and shape.

The balloon tamp is inflated, and the collapsed vertebral bone is restored back to its normal height and shape. Inflation of the balloon creates a cavity in the vertebral body, which the surgeon fills with bone cement. When the cement hardens, the tubes are removed. The incisions are closed with a single stitch, and patients usually go home the same day. Patients can go back to all normal activities of daily living as soon as possible with no restrictions.

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