Spine Surgery

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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.

CONDITIONS
Lumbar microdiscectomy is usually recommended only when specific conditions are met. In general, surgery is recommended when a ruptured disc is pinching a spinal nerve root(s) and you have:

Leg pain which limits your normal daily activities

Weakness in your leg(s) or feet

Numbness in your extremities

Impaired bowel and/or bladder function

PROCEDURE

A microdiscectomy is performed under general anesthesia. 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 home from 1 to 2 days. 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

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Lumbar fusions

Spinal fusion, also called arthrodesis, is a surgical technique used to join two or more vertebrae (bones) within the spine. Lumbar fusion technique is the procedure of fusing the vertebrae in lumbar portion of the spine (lower back).Lumbar fusion surgery may be used to treat, spondylolisthesis (slipping of the spine bones), degenerated discs, scoliosis or kyphosis (abnormal curvature of the spine), spinal infections or tumors, traumatic injury of the spine, recurrent disc herniation, and unstable spine.

The surgery can be done as an open or minimally invasive (keyhole). Your surgeon may approach your spine from the back or neck, depending on the area to be treated. In spinal fusion, a piece of bone, taken from other parts of the body or donated from a bone bank is transplanted between the adjacent vertebrae. Screws, plates, or cages may be used with the bone graft to help hold the spine. During the surgery, your surgeon performs a discectomy where a portion of the diseased or damaged disc material is removed. After the removal the roof of the vertebra will be trimmed or removed to relieve the pressure on the nerve and this procedure is called as laminectomy. Following laminectomy, the bone graft (small chips of bone) will be placed alongside of the vertebrae between the vertebrae to be fused. Screws are placed into the vertebrae to be fused. Rods are attached to connect the screws, to stabilize and hold the bones together while the fusion heals.

CONDITIONS
For patients with the following conditions, if abnormal and excessive motion at a vertebral segment results in severe pain and inability to function, a lumbar fusion may be considered:

Lumbar Degenerative Disc Disease

Lumbar Spondylolisthesis (isthmic, degenerative, or postlaminectomy spondylolisthesis)

fracture, infection

BENEFITS
For patients with the following conditions, if abnormal and excessive motion at a vertebral segment results in severe pain and inability to function, a lumbar fusion may be considered:

Reduction of pain.

Less or ceased use of pain medications.

Stronger structure

Better Walking ability.

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Anterior Cervical Discectomy with Fusion (ACDF)

Anterior cervical discectomy with fusion is an operative procedure to relieve compression or pressure on nerve roots and/or the spinal cord due to a herniated disc or bone spur in the neck. In anterior cervical discectomy with fusion, the surgeon approaches the cervical spine through a small incision in the front of the neck and removes the total disc or a part of the disc along with any bony material that is compressing or putting pressure on the nerves and producing pain. Spinal fusion implies placing a bone graft between the two affected vertebral bodies encouraging the bone growth between the vertebrae. The bone graft acts as a medium for binding the two vertebral bones, and grows as a single vertebra that stabilizes the spine. It also helps to maintain the normal disc height.

Spine surgery may be needed for a variety of reasons. Generally, surgery is be performed to treat degenerative disorders, trauma, instability of the spine, or tumours.

AN ACDF IS USUALLY PERFORMED FOR ONE OR MORE OF THE FOLLOWING REASONS

To treat pressure on the spinal cord (caused by a prolapsed or ruptured disc, or other causes of spinal canal narrowing)

To treat pressure on one or more spinal nerve roots (caused by a disc prolapse or rupture, or foraminal stenosis or narrowing)

To treat instability of the cervical spine (from degeneration, arthritis, or trauma)

Surgery is usually recommended when extensive conservative measures (pain medications, nerve sheath injections, physical therapies, neck collars etc.) have failed, or if the degree of spinal compression is severe. In cases of significant instability or neurological problems, surgery may be the most appropriate first treatment option.

PROCEDURE

Your surgeon makes a small incision in the front side of the neck and locates the source of neural compression (pressure zone). Then, the intervertebral disc that is compressing the nerve root will be removed. Afterwards, a bone graft will be placed between the two vertebral bodies. In certain instances, metal plates or pins may be used for providing enough support and stability, and to ease the fusion of the vertebrae.A specific post-operative recovery/exercise plan will be given by your physician to help you return to normal activity at the earliest possible.The duration of hospital stay depends on this treatment plan. You will be able to wake up and walk by the end of the first day after the surgery. You would be able to resume your work within 3-6 weeks, depending on your body’s healing status and the type of work/activity that you plan to resume. Discuss with your spinal surgeon and follow the instructions for optimized healing and appropriate recovery after the procedure.

BENEFITS

Relief of neural compression

Pain alleviation

Medication reduction

Prevention of deterioration

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Posterior Cervical Microforaminotomy

Posterior cervical microforaminotomy/discectomy is an operative procedure that relieves pressure or compression on the nerve roots at the cervical spine. The cervical region (neck area) forms the upper portion of the spine. A series of cervical vertebrae, C1-C7 connects the cervical spine to the skull. The massive nerve supply to the head, neck, and upper portions of the shoulders and arms is by the spinal nerve roots that branch out from the cervical spine. Nerves exit spinal cord through an opening called foramen- a tunnel or space through which a spinal nerve exits the spine. Herniation of disc (disc damage) or spinal stenosis (narrowing of spinal canal) can narrow the foramen, and pinches or compresses the nerve structures in the neck region leading to pain, weakness and limited movement in the hands and arms.

Posterior cervical microforaminotomy/discectomy involves making an incision in the back side of the neck (posterior cervical spine) followed by the removal of disc material and/or a part of the bone that compresses nerve roots.

Conditions

Neck, shoulder or lower arm pain due to compression in the cervical region

Swollen or bulging discs

Bone damage caused by trauma, or conditions like arthritis or osteoporosis.

Throbbing pain that radiates to the fingers, hands, and lower portion of the arm

Weakness and restricted range of motion or movement of the neck.

Various spinal disorders that cause foraminal narrowing include degenerative disc diseases, spinal stenosis, and spondylosis.

METHOD OF SURGERY

Posterior cervical microforaminotomy/discectomy surgery is done from the back side (posterior side) of the neck. In this technique, the patient lies face down on the operating table. A small incision is done along the back of the neck. The muscle which lies behind the spine is cut and the affected part of the spine bone is exposed. Miniature surgical instruments are inserted through the incision and expose the compressed nerve or herniated disc. A small amount of bone surrounding the nerve root is carefully removed. This is called microforaminotomy. Any bulging or herniated portion of the disc will be removed, if it continues to bulge against the nerve root, which is known as microdiscectomy. Once after the nerve root is decompressed the muscles are re-approximated and the incision is closed with sutures.

Some of the benefits of posterior cervical microforaminotomy/discectomy include

Very small incisions

Total surgery time is very less

Minimal damage to the surrounding structures

Shorter recovery time with less post-surgical complications

Lower rate of infection

Greater range of motion with less post-operative pain

Following are the post-surgical guidelines to be followed after the surgery

Make sure you get plenty of rest

Take medications and antibiotics to help alleviate pain and inflammation as prescribed by your doctor

Avoid neck bending or straining activities

Absolutely no driving for about 2 weeks or while taking pain medicines

Braces such a soft cervical collar may be advised to wear after surgery to reduce the pain and stress on the neck

Start rehabilitation (physiotherapy) as recommended by your spine surgeon

Return to work and sports once the neck has regained normal strength and function

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Cervical Laminoplasty

A cervical laminoplasty is an operative procedure that involves reshaping/repositioning the bone at the neck region (cervical spine) to relieve excess pressure on the spinal nerves. It can also be performed to relieve the symptoms of narrowed spinal canal known as spinal stenosis.Laminoplasty involves repositioning or reshaping of the lamina (roof), unlike laminectomy which involves removal of the lamina.

Conditions:

Degeneration of the facet joints and intervertebral discs that connect vertebrae to one another results in narrowing of the spinal canal, known as spinal stenosis

The arthritic facet joints become bulkier and consume the space existing for the nerve roots. Besides, thickened ligaments and bony out growths also known as bone osteophytes or bone spurs can also narrow the spinal canal. The condition of spinal stenosis, narrowing of the spinal canal, puts pressure on the spinal nerves and spinal cord, causing symptoms such as neck pain, tingling sensation, numbness or weakness that extends to the shoulders, arms and/or hands and bowel or bladder impairment.

PROCEDURE

The procedure is performed with you resting on your stomach and injected with sleep inducing medication (general anesthesia). Your surgeon makes a small incision near the center of your neck on the back side, and approaches the neck bones (cervical vertebrae) by moving the soft tissues and muscles apart. The spinal processes of the vertebra are removed. Then, a side of the cervical vertebra is cut making a “hinge” and later the other side is also cut allowing the bones to open like a “door”. The back of each vertebra is bent back to remove pressure on the spinal structures such as spinal cord and spinal nerves. Other compression sources such as bone spurs, excess ligaments and/or disc fragments (discectomy) are also removed. Small wedges are placed in the “open” space of the door and sealed with proper instrumentation. After the procedure, your surgeon brings back the soft tissues and muscles to their normal place and closes the incision.

BENEFITS

Good relief of neck pain

Spine is stabilized without fusion

Restores alignment of the spine

Direct removal of problem structures

The objective of cervical laminoplasty is to relieve pressure on the spinal nerves by removing the source of pressure without disturbing the stability of the posterior elements of the vertebrae. This procedure is also called an “open door laminoplasty” because it involves “hinging” one side of the vertebrae and cutting the other side forming a “door”, which is opened and placed with wedges made up of bone and instrumentation..

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Cervical Disc Replacement

Cervical disc replacement is a surgical procedure of replacing the diseased or damaged intervertebral discs in the neck region with an artificial disc to restore the motion of spine. It is considered as an alternative to anterior cervical discectomy and fusion. Artificial disc replacement is indicated in patients with degenerative disc disease, a condition referred to as a gradual degeneration of the disc between the vertebrae caused by a natural process of aging.

Procedure:

During the surgery, an incision is made on the front side of the neck, at the level of the damaged cervical disc. The muscles and soft tissues are gently moved apart for better view of the cervical spine. The disc space is opened and the damaged disc is removed and replaced with the artificial disc. The proper position of the implanted disc is confirmed by fluoroscopy. Then the incision is closed.

DISK DESIGN

Artificial disk designs are of two types- disc nucleus replacement and total disc replacement. In disc nucleus replacement only the central portion of the disc (nucleus) is removed and replaced with mechanical device, while the outer ring of the disc (annulus) is not removed. However disc nucleus replacement procedure is not commonly practiced and is in investigative stage. But in total artificial disc replacement, both the annulus and nucleus are replaced with a mechanical device to restore normal spinal function. Artificial discs are usually made up of metal, plastic or a combination of metal and plastic. Medical grade plastic (polyethylene) and medical grade cobalt chromium or titanium alloy are used for disk design.

As bone healing is not required following an artificial disk implantation, early movement is encouraged. Early motion can lead to quicker rehabilitation and recovery. Hospital stay of about 2 to 4 days may be required. Basic exercises like regular walking and stretching can be performed during the first few weeks after surgery.

BENEFITS

Disc replacement improves function after surgery.

Motion preservation reduces stress on the spine.

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Scoliosis

Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown. Most cases of scoliosis are mild, but some children develop spine deformities that continue to get more severe as they grow. Severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly.

Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse. In many cases, no treatment is necessary. Some children will need to wear a brace to stop the curve from worsening. Others may need surgery to keep the scoliosis from worsening and to straighten severe cases of scoliosis.

Symptoms:

Uneven shoulders

One shoulder blade that appears more prominent than the other

Uneven waist

One hip higher than the other

If a scoliosis curve gets worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side.

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Kyphosis

Kyphosis is an exaggerated, forward rounding of the back. It can occur at any age but is most common in older women.Age-related kyphosis is often due to weakness in the spinal bones that causes them to compress or crack. Other types of kyphosis can appear in infants or teens due to malformation of the spine or wedging of the spinal bones over time.

Mild kyphosis causes few problems. Severe kyphosis can cause pain and be disfiguring. Treatment for kyphosis depends on your age, and the cause and effects of the curvature.

Symptoms:

Mild kyphosis may produce no noticeable signs or symptoms. But some people experience back pain and stiffness in addition to an abnormally curved spine.

Causes:

Fractures

OsteoporosisDisk

DegenerationScheuermann's disease

Birth defects

Syndromes

Cancer and cancer treatments

The goals of a kyphoplasty surgical procedure are designed to stop the pain caused by a spinal fracture, to stabilize the bone, and to restore some or all of the lost vertebral body height due to the compression fracture. Kyphoplasty is a type of Vertebral Augmentation for Compression Fractures

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Osteoporosis

Osteoporosis literally means "porous bones." The bones become weaker, increasing the risk of fractures, especially in the hip, spinal vertebrae, and wrist.

Bone tissue is constantly being renewed, and new bone replaces old, damaged bone. In this way, the body maintains bone density and the integrity of its crystals and structure.Bone density peaks when a person is in their late 20s. After the age of around 35 years, bone starts to become weaker. As we age, bone breaks down faster than it builds. If this happens excessively, osteoporosis results.

Treatment :

Slow or prevent the development of osteoporosis

Maintain healthy bone mineral density and bone mass

Prevent fractures

Reduce pain

Maximize the person's ability to continue with their daily life

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Selective Nerve Root Block (SNRB)

A selective nerve root block (SNRB), is primarily used to diagnose the specific source of nerve root pain and, secondarily, for therapeutic relief of low back pain and/or leg pain.When a nerve root becomes compressed and inflamed, it can produce back and/or leg pain. Occasionally, an imaging study (e.g. MRI) may not clearly show which nerve is causing the pain and an SNRB injection is performed to assist in isolating the source of pain. In addition to its diagnostic function, this type of injection for pain management can also be used as a treatment for a far lateral disc herniation (a disc that ruptures outside the spinal canal).

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Transforaminal Percutaneous Endoscopic Discectomy

TPED is a minimally invasive technique mainly used for the treatment of lumbar disc herniation from a lateral approach. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss, trauma, and scar tissue compared to conventional procedures. However, the procedure should be performed by a spine surgeon experienced in the specific technique and capable of recognizing or avoiding various challenging conditions. In this review, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Procedure:

Generally, the indication for TPED, in compliance with clinical findings, is usually found to be persistent sciatica caused by LDH. There are several inclusion criteria such as radiculopathy, positive nerve root tension sign, sensory or motor neurological lesion on clinical examination, cauda equine syndrome, hernia confirmed by magnetic resonance imaging (MRI) of the lumbar spine. Failure of 12-wk conservative treatment is also a strong indication