Surgery and Invasive Procedures:

The health care provider should give patients solid information on the expected course of their low back pain and self-care options before discussing surgery. Patients should ask their health care provider about evidence favoring surgery or other (nonsurgical) treatments in their particular case. They should also ask about the long-term outcome of the recommended treatment. Would the improvements last and, if so, for how long? Another consideration when surgery is an option is the overall safety of the recommended procedure, weighed against its potential short-term benefits and its benefits in the long run.

Patients should generally try all possible non-surgical treatments before opting for surgery. The most common reasons for surgery for low back pain are disk herniation and spinal stenosis. The vast majority of back pain patients will not need aggressive medical or surgical treatments.

Nevertheless, when it is appropriate, surgery can provide great relief. Many approaches and procedures are available or being investigated. However, there have been few well-conducted studies to determine if any type of back pain surgery works better than others, or if a single procedure is better than no surgery at all.

It should be noted that surgery does not always improve outcome and, in some cases, can even make it worse. Surgery can be an extremely effective approach, however, for certain patients whose severe back pain does not respond to conservative measures.

Diskectomy

Diskectomy is the surgical removal of the diseased disk. The procedure relieves pressure on the spine. It has been performed for 40 years, and increasingly less invasive techniques developed over time. However, few studies have been conducted to determine the procedure's real effectiveness. In appropriate candidates it provides faster relief than medical treatment, but long-term benefits (over 5 years) are uncertain.

Diskectomy is recommended when a herniated disk causes one or more of the following:

• Leg pain or numbness that are severe or persistent, making it hard for the patient to perform daily tasks
• Weakness in the muscles of the lower leg or buttocks
• An inability to control bowel movements or urination

Most other people with low back or neck pain, numbness, or even mild weakness are often first treated without surgery. Often, many of the symptoms of low back pain caused by a herniated disc get better or disappear over time, without surgery.

When the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of a disk, it is called a slipped disk. Most slipped disks (herniated disks) take place in the lumbar area of the spine. Slipped disks are one of the most common causes of lower back pain. The mainstay of treatment is an initial period of rest with pain and anti-inflammatory medications followed by physical therapy. If pain and symptoms persist, surgery to remove the herniated portion of the intervertebral disk may be needed.

Microdiskectomy. Microdiskectomy is the current standard procedure. It is performed through a small incision (1 to 1-1/2 inch). The back muscles are lifted and moved away from the spine. After identifying and moving the nerve root, the surgeon removes the injured disk tissue under it. The procedure does not change any of the structural supports of the spine, including joints, ligaments, and muscles.

Other, less invasive procedures are available, including endoscopic diskectomy, percutaneous diskectomy (PAD), and laser diskectomy. The long-term benefits are of these procedures are unknown, however. There is currently no evidence that any of these less-invasive procedures are as effective as the standard microdiskectomy.

Complications and Outlook. Most people achieve pain relief and can move better after microdiskectomy. Numbness and tingling should get better or disappear. Your pain, numbness, or weakness may NOT get better or go away if the disk damaged your nerve before surgery.

Scar tissue is a potential problem, since it can cause persistent low back pain afterward Other complications of spinal surgery can include nerve and muscle damage, infection, and the need for another operation.

Patients are usually up and walking soon after disk surgery. It may take 4 - 6 weeks for full recovery, however. Gentle exercise may be recommended at first. Starting intensive exercise 4 - 6 weeks after a first-time disk surgery appears to be very helpful for speeding up recovery. Little or no physical therapy is usually needed.

Laminectomy

Laminectomy is surgery to remove either the lamina, two small bones that make up a vertebra, or bone spurs in your back. Laminectomy opens up your spinal canal so your spinal nerves or spinal cord have more room. It is often done along with a diskectomy, foraminotomy, and spinal fusion.

Laminectomy is frequently done to treat spinal stenosis. You and your doctor can decide when you need to have surgery for your condition. Spinal stenosis symptoms often become worse over time, but this may happen very slowly. When your symptoms become more severe and interfere with your daily life or your job, surgery may help.

Laminectomy for spinal stenosis will often provide full or partial relief of symptoms for many patients, but it is not always successful

Future spine problems are possible for all patients after spine surgery. If you had spinal fusion and laminectomy, the spinal column above and below the fusion are more likely to have problems in the future. If you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future problems.

Some recurrence of back pain and sciatica occurs in half to two-thirds of postoperative patients. Minimally invasive variations are under investigation. For spinal stenosis, the traditional approach is a laminectomy and partial removal of the facet joint. There is controversy whether performing a fusion procedure along with these procedures is needed. Only a few randomized trials have compared this procedure with nonoperative treatment. Their results suggest that surgical treatment is better, at least over the first 2 years after surgery.

Spinal Fusion

Spinal fusion is surgery to fuse spine bones (vertebrae) that cause you to have back problems. Fusing means two bones are permanently placed together so there is no longer movement between them.

Spinal fusion is usually done along with other surgical procedures of the spine, such as a diskectomy, laminectomy, or a foraminotomy. It is done to prevent any movement in a certain area of the spine.

Conditions fusion may be done for include:

• Spinal stenosis
• Injury or fractures to the bones in the spine
• Weak or unstable spine caused by infections or tumors
• Spondylolisthesis, a condition in which one vertebrae slips forward on top of another
• Abnormal curvatures, such as those from scoliosis or kyphosis

The surgeon will use a graft (such as bone) to hold (or fuse) the bones together permanently. There are several different ways of fusing vertebrae together:

• Strips of bone graft material may be placed over the back part of the spine.
• Bone graft material may be placed between the vertebrae
• Special cages may be placed between the vertebrae. These cages are packed with bone graft material.

The surgeon may get the graft from different places:

• From another part of your body (usually around your pelvic bone). This is called an autograft. Your surgeon will make a small cut over your hip and remove some bone from the back of the rim of the pelvis.
• From a bone bank, in a procedure called an allograft.
• A synthetic bone substitute can also be used, but this is not common yet.

The vertebrae are often also fixed together with screws, plates, or cages. These are used to keep the vertebrae from moving until the bone grafts fully heal.

Future spine problems are possible for all patients after spine surgery. After spinal fusion, the area that was fused together can no longer move. Therefore, the spinal column above and below the fusion is more likely to be stressed when the spine moves, and develop problems later on. Also, if you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future back problems.

There are currently a number of video-assisted fusion techniques. These new techniques are less invasive than standard "open" surgical approaches, which use wide incisions. To date, however, the newer procedures have higher complication rates than the open approaches, and some medical centers have abandoned them.

Other Surgical Procedures

Percutaneous Vertebroplasty. Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into vertebrae with compression fractures. It is done under endoscopic and x-ray guidance. The technique is proving useful for stabilizing the spine and relieving pain in patients with spinal compression fractures due to osteoporosis or cancer.

Warning: The Food and Drug Administration (FDA) has warned consumers that polymethylmethacrylate bone cement, used during vertebroplasty, could leak. Such leakage could cause damage to soft tissues and nerves. It is extremely important that the patient is sure that the health care provider has had significant experience performing the vertebroplasty procedure.

Percutaneous kyphoplasty. The health care provider injects bone cement into the space surrounding a fractured vertebra. (Vertebroplasty injects the cement directly into the vertebra.) Kyphoplasty is used to stabilize the spine and return spinal height to as normal as possible. Kyphoplasty should only be done if bed rest, medicines, and physical therapy do not relieve back pain. Those with severe fractures or spinal infections should not have kyphoplasty.

Artificial Disk Replacement. Total disk replacement is an investigative procedure for some patients with severely damaged disks. It is done instead of spinal fusion surgery, but has not yet been shown to be superior to it. The technique implants artificial disks (ProDisc, Link, SB Charite) consisting of two metal plates and a soft core. The surgery can be performed using a minimally invasive laparoscopic procedure, which is performed through tiny cuts using miniature tools and viewing devices. An artificial cushioning device called the prosthetic disk nucleus (PDN) replaces only the inner gel-like core (nucleus pulposus) within the intervertebral space, rather than the entire disk. . A possible benefit of these artificial disks is that they would allow more movement of the spine, and therefore prevent disk degeneration below and above the site of surgery (a frequent complication of spinal fusion). This benefit has not been yet been proven in large studies.

Intradiscal Electrothermal Treatment (IDET). Intradiscal electrothermal treatment (IDET) uses electricity to heat a painful disk. Heat is applied for about 15 minutes. Pain may temporarily feel worse, but after healing, the disk shrinks and becomes desensitized to pain. However, healing takes several weeks. While some studies have reported benefit, many consider the evidence to support the use of this procedure weak.