Most commonly, laminectomy is performed to treat spinal stenosis - Best Spine Surgery Hospital in India

Laminectomy or Laminotomy (a partial laminectomy) is sometimes called a decompression procedure and is a spinal procedure to remove a portion of the vertebral bone called the lamina. The lamina is a posterior arch of the vertebral bone lying between the spinous process, which juts out in the midline and the more lateral of each vertebra. The pair of lamina, along with the spinous process, make up the posterior wall of the bony spinal canal.  Although the procedure indicates excision of the lamina, the operation called conventional laminectomy, removes the lamina, spinous process and overlying connective tissues and ligaments, cutting through the muscles that overlie these structures. Minimal surgery laminectomy is a tissue preserving surgery that leaves the muscles intact, spares the spinal process and takes only one or both lamina. Laminotomy is removal of a mid-portion of one lamina and may be done either with a conventional open technique, or in a minimal fashion with the use of tubular retractors and endoscopes.

BRIEF ABOUT THE PROCEDURE

There are many variations of laminectomy, in the most minimal form small skin incisions are made, back muscles are pushed aside rather than cut and the parts of the vertebra adjacent to the lamina are left intact. After an incision is made in the midline of the neck or back, the muscle is moved away to expose the lamina, which are the bony shingles that overlay the neural (nerve) elements. The lamina can be removed in whole or in part to expose a single nerve root or more of the neural elements as needed. In the case of a lumbar disc herniation, a laminotomy, or partial removal of the lamina is usually sufficient to gain access to the affected nerve root.  The nerve root will usually be visible just beneath the lamina, with a disc herniation underneath it. The nerve root is gently held out of the way with a retractor and the disc herniation can be accessed. The traditional form of laminectomy (conventional laminectomy) excises much more than just the lamina, the entire posterior backbone is removed, along with overlying ligaments and muscles. The usual recovery period is very different depending on which type of laminectomy has been performed: days in the minimal procedure and weeks to months with conventional open surgery. A lamina is removal is done to break the continuity of the rigid ring of the spinal canal to allow the soft tissues within the canal to expand or as one step in changing the contour of the vertebral column, or in order to allow the surgeon access to deeper tissues inside the spinal canal. Conventional open laminectomy often involves excision of the posterior spinal ligament and some or all of the spinous process and facet joint. Removal of these structures, in the open technique, requires cutting the many muscles of the back which attach to them. Laminectomy performed as a minimal spinal surgery procedure, however, allows the bellies of muscles to be pushed aside instead of transected and generally involves less bone removal than the open procedure. The recovery period after laminectomy depends on the specific operative technique; minimally invasive procedures having a significantly shorter recovery period than open surgery. Removal of substantial amounts of bone and tissue may require additional procedures to stabilize the spine, such as fusion procedures and spinal fusion generally requires a much longer recovery period than simple laminectomy. Most commonly, laminectomy is performed to treat spinal stenosis. Laminectomy for Spinal Stenosis Spinal stenosis is the single most common diagnosis leading to any type of spine surgery and laminectomy is a basic part of its surgical treatment. The lamina of the vertebra is removed or trimmed to widen the spinal canal and create more space for the spinal nerves and thecal sac. Surgical treatment that includes laminectomy is the most effective remedy for   severe spinal stenosis, however most cases of spinal stenosis are not severe and do not require surgery. When the disabling symptoms of spinal stenosis are primarily neurogenic claudication and the laminectomy is done without spinal fusion, there is generally a very rapid recovery with excellent long term relief. However, if the spinal column is unstable and fusion is required, there is a recovery period of months to more than a year and relief of symptoms is less likely.

Minimally Invasive, Endoscopic and Laser Spine Surgery - Best Spine Surgery in India

Laser therapy is the use of monochromatic light emission from a low intensity laser diode (250 milliwatts or less) or an array of high intensity super luminous diodes (providing total optical power in the 1000-2000 milliwatt range).

Conditions treated include musculoskeletal injuries, chronic and degenerative conditions and wounds. The light source is placed in contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellular biomolecules resulting in the restoration of normal cell morphology and function. This also enhances the body's natural healing processes. The following chart outlines some of the specific effects of Low Intensity Laser Therapy. 

The underlying science behind cold laser therapy is sound. Studies have shown that light of certain wavelengths can reduce pain and inflammation. Lasers can offer very focused beams of light which can be used to target specific areas, which means that in theoretical use, a low intensity laser calibrated to emit light of a specific wavele ngth could potentially be used very effectively to treat areas of inflammation on the body. However, like all medical devices, cold lasers need to be carefully evaluated for safety and efficacy.

Doctors generally recommend cold laser therapy as part of an overall pain management program. For people dealing with chronic pain, cold laser therapy is an option which could be used to reduce the pain, while people with persistent inflammations may also benefit. However, this therapy should not be undertaken without medical supervision, and it is generally not recommended as a replacement for other forms of medical treatment, such as the use of physical therapy to manage chronic pain.

Some practitioners of acupuncture have suggested that cold laser therapy could be used much like acupuncture and acupressure, with the beams of the laser targeting specific points on the body. These practitioners of alternative medicine rely on their training and experience to support their beliefs about the use of cold laser therapy. Stimulation of pressure points can be used to treat a number of conditions treatable with acupuncture. 

A number of terms are used to refer to cold laser therapy, including low power laser therapy (LPLT), low level laser therapy (LLLT), biostimulation, soft laser, and laser acupuncture. In all cases, the technique involves exposing the skin to targeted laser beams for set periods of time and at set intervals. The light in the laser is supposed to stimulate damaged cells to promote healing and a reduction in inflammation and pain. The "cold" refers not the temperature of the laser, but to the fact that the laser is of low intensity, rather than high intensity lasers, which can burn the skin. 

Our network hospitals have the most advanced spine surgery facilities. The spine surgeons here use minimally invasive and computer guided techniques in spine surgery. In a Minimally Invasive spine surgery the surgeon makes a few small incisions unlike the open surgery where a single large incision is made. 

Minimally Invasive spine surgery has several important benefits for the patients. If you have been advised spine surgery your first choice should be the latest minimally invasive technique developed by our world best hospitals in India. Most advanced Technology like Intra Operative MRI, Brain Suite and Computer Assisted Navigation System are deployed by highly trained surgeons for accurate and safe Spine Surgeries through a small incision.

Why should you choose to get Indian hospitals offer the best spinal surgery treatment in India at affordable prices. MedWorld india associated best spine surgery hospitals in India have the latest technology and infrastructure to offer the most advanced spine surgery at low cost.

Salient features of these hospitals are:

• Comprehensive management of spine disorder from birth defects to degeneration of tumor and trauma.

• Dedicated team of International trained and vastly experienced Spine Surgeons, Rheumatologists, Neurologist, Physicians and Physiotherapist.

• Expert evaluation of spinal problems by dedicated team of experienced spine Surgeons, Rheumatologists, Neurologist, Physicians and Physiotherapist.

• Latest Generation Diagnostic and Imaging facilities including dynamic digital X rays, Spiral CT scanning , MRI and Electrophysiology unit all under one roof.

• Physiotherapy and Rehabilitation by experts after the surgery help you regain functional abilities quickly helping in vastly improved overall results.

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Most Advanced Minimally Invasive Lumbar Fusion Surgery in India

Lumbar spinal fusion is a common technique to help patients with back pain, who have failed non-operative treatment. Once you and your physician have decided that you need fusion of your lumbar spine, you should realize that there are many different ways this procedure can be done. The choice of which technique is best for you is dependent on what is wrong with your spine. Your surgeon may have more experience with fusion techniques from the front of the spine (anterior), the back of the spine (posterior), or some of the newer, less invasive approaches. These newer techniques are often called Minimally Invasive Spinal (MIS) surgery. The goals of all these techniques remain the same, to achieve a lumbar fusion, and lessen the patient's pain.

The most common method of spinal fusion involves the posterior approach, with an incision along the back of the patient's spine. Often, this procedure is used if bone spurs, thickened ligaments, or disc ruptures need to be removed to alleviate pressure on the nerves. The fusion procedure then involves placement of metal screws, rods and bone graft. Anterior spinal fusions require an incision through the abdomen. After removal of the degenerated disc, a metal cage with bone graft is usually placed between the spinal bones (vertebral bodies). Some patients will require both front and back procedures.

There are many new surgical techniques that are being developed to improve the results of lumbar fusions. Minimally invasive spine surgery for lumbar fusion is one of these newer techniques. MIS procedures have smaller incisions, cause less trauma to the surrounding normal tissues, and hopefully results in a faster recovery for the patient. One of these MIS techniques is a procedure known as extreme-lateral lumbar interbody fusion (XLIF). During the XLIF procedure the lumbar spine is approached from the side through a small skin incision. The surgery is performed through a muscle that lies next to the lumbar spine known as the psoas muscle.

With the XLIF procedure, approximately 2/3 of the disc can be safely removed. After the disc is removed, an artificial graft is placed in between the vertebrae, to allow the bones to fuse together. For a single level XLIF procedure, the surgery can be usually be performed in about an hour. Most patients stay in the hospital for 24 hours following the procedure, and do not require a brace. Occasionally, weakness may be noticed while lifting your leg after surgery. This psoas muscle weakness should return to normal fairly soon after surgery.

Not everyone is a candidate for this surgery, once conservative (non-operative) treatments have failed, you should consult a surgeon to see if you are an appropriate candidate.

The major advantage of all of these  minimally invasive techniques is that there is less damage caused to the surrounding tissues. Unfortunately, in traditional spinal surgery it is necessary to cut through muscles and move them out of the way in order to reach the spine. This can cause a large amount of pain following surgery, and it can lengthen the recovery time. Instead of cutting and moving muscles, the minimally invasive techniques can more gently spread through the muscles to allow access to the spine. This is much less painful for the patient, and it does not require as long of a recovery period for the muscle to heal.

Another benefit of less muscle damage is less blood loss and thus a reduced need for blood transfusions using the minimally invasive techniques. There is often less need for narcotic pain medications following this form of surgery, and a shorter hospital stay.

 

Most Advanced Back Surgery in India - World Best Spine Surgery Hospitals in India

There are three basic types of back surgery

1. A laminectomy – removing the back part of the bone (called the lamina) over the spinal column. A laminectomy is performed to relieve nerve root compression (pinched nerve) on one or more nerve roots in the spinal column. The compressed nerve root often causes back and leg pain. A segment of the entire lamina can be removed to relieve pressure on a nerve..

2. A discectomy – removing a portion of a disc to relieve pressure on a nerve.

3. A spinal fusion – this involves the permanent fusion of two or more vertebrae for more stability, to correct a deformity or to relieve pain. The surgeon will harvest small pieces of bone from your hip or pelvic bone and place them between the vertebrae. In many cases they will use wires, rods, screws, metal cages or plates to provide immediate stability.

Laminectomy

How is a laminectomy performed?

Step 1: A laminectomy is performed with the patient lying on his stomach or side and under general anaesthesia. The surgeon (an orthopaedic or neurosurgeon) reaches the spinal column through a small incision in the back.
Step 2: He will use a retractor to spread the muscles of the back apart in order to expose the bony lamina.
Step 3: He cuts away part of the lamina to uncover the ligamentum flavum – a ligament supporting the spinal column.
Step 4: In the next step he will cut an opening in the ligamentum flavum to reach the delicate spinal canal containing the compressed nerve.
Step 5: The compressed nerve can now be seen as well as the bundle of nerve fibres (known as the cauda equina) to which it is attached. It is now possible to identify the cause of compression: a bulging, ruptured or herniated disc, or perhaps a bone spur.
Step 6: The source of the pressure can now be removed. This may involve removing the bulging portion of the disc or the bony spurs and scar tissue. The herniated disc is removed after the compressed nerve has been gently retracted to one side. The surgeon will remove as much of the disc as is necessary to take pressure off the nerve. Sometimes a fragment of disc has moved and presses on the nerve root as it leaves the spinal canal. This will often cause more severe symptoms.
Step 7: With the cause of compression removed, the nerve can now begin to heal. The space created by removal of the disc will gradually fill with connective tissue. The incision is closed in several layers, from the inside outwards.
Step 8: The skin layer will be closed with steri-strips, sutures or skin clips. A dressing will be placed over the incision to protect the wound.

This operation is normally performed within one or two hours, depending on the number of levels that are decompressed.

After surgery
A plastic drain will run from inside the wound to remove any accumulating blood. In most cases, the drain can be removed on the second day after surgery.

An intravenous line to administer medication may remain connected through a vein in your hand or arm for two to three days.

Pain can and should be well controlled. Usually the acute pain subsides after a day or two. Pain may be most severe in the lower back. Leg pain may be caused by swelling of the previously compressed nerve and the trauma of the surgery. Muscle spasms across the back and down the legs are not uncommon and this can be relieved by muscle relaxants.

A physiotherapist will help you to begin standing and walking again, and show you how to get in and out of bed and how to sit, stand, and sleep.

 What about new and less invasive procedures?
The era of less invasive surgery has dawned – also in back surgery. Smaller keyhole incisions are replacing large surgical cuts. These less invasive techniques include:

• Endoscopic discectomy – this technique employs a disposable scope that the surgeon inserts through a small incision. The protruded disc that is compressing the nerve is then removed using specially designed instruments.
• Vertebroplasty – the injection of bone cement into a fractured vertebrae. The hardened cement will seal and stabilise the fracture and relieve pain. People suffering from severe pain because of a compression fracture will be considered for this procedure, especially if they have difficulty standing and walking.
• Kyphoplasty – the insertion of a “balloon” to expand a compressed vertebra and the injection of bone cement
  
  
  

Spinal Disc Protrusions do not require open spine surgery : Best Spine Surgery Hospital in India

Percutaneous Disc Nucleoplasty is minimally invasive surgery to reduce the volume of a bulging or herniated disc. In both cases the spinal disc puts pressure on a nerve root or the spinal cord and causes back pain or sciatic pain.

Spinal Disc Protrusions do not require open spine surgery

Many patients with back pain show no clear indication of a herniated disc. However with MRI investigation protrusion of the intervertebral discs can be diagnosed. This protrusion can put pressure on nerves or the spinal cord and can cause persistent, or stress-related chronic back pain. Normally this kind of back pain (lumbar or cervical), responds well to conservative treatment options.

When will your neurosurgeon consider Nucleoplasty?

If after six weeks, conservative treatment has not been successful, your spine specialist should consider an intradiscal procedure: The disc protrusion can be reduced by treating the liquid core of the spine simply by using an injection needle. This needle (cannula) allows a radiofrequency instrument to enter the core of the disc, thereby avoiding all the surgical risks associated with open back surgery. This is essentially the principle of the Nucleoplasty.

Nucleoplasty, as a minimally invasive treatment, covers only smaller disc herniations or disc bulges that have not yet broken through the solid fibre ring of the disc and are therefore are not accessible via an open surgical procedure (surgical removal of the disc material).

Endoscopic Nucleoplasty is safe for patients and is a minimally invasive procedure, which produces very good outcomes, without the risks and postsurgical complications associated with open back surgery.

Disc Nucleoplasty is performed on an outpatient basis, with minimal anesthesia requirements. Fluoroscopic guidance is employed as an introducer needle is placed at the nucleus/annulus junction. A SpineWand is introduced through the passage way, and advanced into the disc nucleus. Using Coblation, tissue is then removed by either creating channels (lumbar spine) or spheres (cervical spine). After sufficient tissue is removed, a bandage is placed on the skin and the patient is discharged home. Patients are then usually placed on a routine rehabilitation program.

Nucleoplasty is recommended for patients who have not responded to rest, medical intervention (including steroid injection), and/or physical therapy.

There are many people across the world who suffers from slipped disc problem. In 90 per cent of these cases, the disc prolapsed is contained or limited to the disc space and are not suitable for the traditional discectomy surgery involving the complete removal of the diseased disc. The open surgery is an overkill leading to unsatisfied results, more complications and costly procedure.

In such clinical circumstances, percutaneous treatment also known as disc nucleoplasty has emerged as the best alternative. Moreover the cost of Disc Nucleoplasty at Medworldindia affiliated hospitals in India is minimal. Conventionally the disc prolapse is treated with bed rest and analgesics but with limited relief.

Many successful Nucleoplasty procedures have been performed in India. This minimally invasive approach to treating contained disc herniations has helped most of the International patients return to active and productive lives with effective cost savings. 

Expert Neuro and Spine Surgeons in India who have ample experience in performing this procedure said that, “Spinal Surgery is fast becoming a major sub-speciality in neurosurgery”. Disc nucleoplasty is an innovative percutaneous method of healing disc disease. Disc prolapse can occur in lumbar as well cervical region causing low back pain, radiating pain and neck pain respectively. Related symptoms are excruciating pain, numbness, tingling sensation in hands and legs, burning and weakness of the limbs. The patient will have restricted movement, walking, bending and doing normal day to day activities becomes very difficult. The severe pain results in incapacitation leading to loss of man hours.

Treatment and Surgery for Back Pain in India

There are many ways to prevent low back pain problems from developing. Commonly people have created problems in their back themselves. What that means is that problems are self-inflicted, such as poor posture or poor moving and handling techniques.

Poor posture usually involves excessive flattening of the low back (slouching), and is associated with a forward slippage of the head resulting in a flattening of the neck curves. This puts extra stress on the muscles and ligaments in the neck and shoulders. Commonly this causes tension in the muscles which is felt as pain, and an increased likelihood of trapping nerves in the neck. Slouching in the low back results in the neck ligaments taking more strain on a daily basis. This results in the extra strain ultimately causing an misalignment of the spine and resultant nerve entrapment. Effects of this include low back pain pins and needles, sciatica, referred leg pains, and low back spasms and aches.

Although back pain is fairly common these days, there are times when the pain becomes unbearable. Here are the top 5 modes of treatment your doctor is likely to prescribe in case of severe back pain. 

Main Modes of Treatment

 Rest: The first step in the treatment of low back pain is to rest the spine. Because most cases of back pain are due to muscle strain, it is important to avoid further irritation to the spine and the muscles that surround the spinal column. Bed rest is fine, so long as this only lasts two to three days. Prolonged bed rest can actually lead to more persistent back pain. Once the acute back pain eases, avoid lifting, twisting, and physical exertion.

Oral Medication: Anti-inflammatory medications (NSAIDs) are helpful in treatment of both back pain and the associated inflammation. There are both over-the-counter and prescription NSAIDs, and both work well in the treatment of back pain. Side-effects of NSAIDs include problems of gastro-intestinal bleeding, and these medications should be avoided in patients with stomach ulcers. Sometimes, muscle relaxing medications are prescribed. They help to relieve muscle spasm, but may also make patients quite drowsy.

Physiotherapy and Exercises: Strengthening of back muscles is probably the most important step in treatment of most causes of back pain. By increasing strength and flexibility of back muscles, weight is better distributed, and less force is placed on the spine. Other modalities that can be used in the treatment of back pain if the exercises alone do not help include aquatherapy, ultrasound, electrical stimulation, short-wave diathermy and others.

Epidural steroid injections: They are an option for back pain treatment and inflammation around the spinal nerves. An epidural steroid injection is performed using an x-ray to guide the medication to the area adjacent to the inflamed spinal nerve.

Spine Operation: Spine surgery is rarely an initial treatment for back pain; there are a few emergencies, however, that may require surgical treatment. In the vast majority of patients, spine surgery is only considered after a long course of conservative therapy. Back pain often takes quite some time to resolve. Rushing into spine surgery, therefore, may not be the most sensible idea. Most commonly, doctors will advise at least 3 to 6 months of conservative treatment before considering spine surgery.

5 Operations commonly carried out for back pain are:

1. A Discectomy is a procedure to remove a portion of the disc that rests between each two vertebrae. A herniated disc is the most common reason for spine surgery. In this type of spine surgery, the protruding, herniated disc is removed and this relieves the pressure on the nerves.
2. A Foramenotomy is also a procedure used to relieve pressure on a nerve, but in this case, the nerve is being pinched by more than just a protruding disc. The surgery removes a portion of bone and other tissue that may be compressing the nerve as it exits the spinal column.
3. A Laminectomy is performed to relieve pressure on the spinal cord itself.  It is most commonly used to treat conditions such as spinal stenosis and spondylolisthesis, where the spinal column is seen slipping forwards. Depending on the amount of bone removed, this procedure may be done with a spinal fusion to prevent instability.
4. A spine fusion is surgery that is done to eliminate motion between adjacent vertebrae to treat a problem such as spondylolisthesis (an unstable spine), or it may be done because of the extent of other surgeries such as a Laminectomy.
5. Spinal disc replacement is a new surgery that is still quite uncommon. It is done to treat specific types of back pain, while avoiding the problems associated with spine fusion surgery.
   
   
   
   
   
   

Advanced Minimally Invasive Lumbar Spine Fusion Surgery in India at Low Cost

If the spinal arthritis has progressed to spinal instability, the patient may require a combination of lumbar decompression (laminectomy) and lumbar fusion to stabilize the spine and alleviate chronic back pain. Lumbar fusion, also called spinal fusion. Fusion may also involve supplemental hardware, such as plates, cages, and screws to hold the spine in place. Once the union between the vertebrae has solidified, the hardware is no longer needed, but few patients are eager to undergo another surgery for their removal.

Lumbar fusion can be performed using the traditional open technique or minimally invasive methods. In traditional open spinal fusion surgery, the surgeon must make a large incision and cut through thick spinal muscles. 

Spinal fusion procedures involve removing the disc from between the vertebrae (in the disc space) and then filling the gap with a metal, plastic, or bone spacer. These spacers, also called cages, contain bone graft material that facilitates bone healing and fusion. After the spacer is implanted, the surgeon may use metal screws, plates, and rods to further stabilize the spine.

About 80 percent of all fusion surgeries involve one or two levels of vertebrae of the spine. Patients undergoing this type of fusion are very likely to be able to return to their normal activities after the surgery.

The experienced physicians at Midwest Orthopaedics at Rush Minimally Invasive Spine Institute may recommend spinal fusion to alleviate symptoms for many back conditions, including:

• Tumor
• Spinal stenosis
• Spondylolisthesis
• Fracture
• Scoliosis
• Degenerative Back Disease

Lumbar fusion can be performed from the front (anterior approach), from the back (posterior approach) or from the side (lateral approach). The surgeons at Midwest Orthopaedic at Rush Minimally Invasive Spine Institute choose which approach is most appropriate based upon many factors, including the need for bone spur removal, the degree of instability, the medical condition, and body habitus of the patient. Usually the decision as to which approach makes the most sense involves a discussion of the pros and cons of each approach in a particular situation. The following are spinal fusion approaches that may be considered:

• Anterior Lumbar Interbody Fusion (ALIF) with Instrumentation
• Posterior Lumbar Interbody Fusion (PLIF)
• Transforaminal Lumbar Interbody Fusion (TLIF)
• Lateral Fusion Interbody Fusion (XLIF, DLIF)

Anterior Lumbar Interbody Fusion (ALIF) with Instrumentation: ALIF is used in the treatment of a disc problem that causes pain and instability in the lower back (lumbar spine). In ALIF, the procedure is performed from the front allowing to access the spine without moving nerves and disturbing the back muscles.

Posterior Lumbar Interbody Fusion (PLIF): In PLIF, the surgeon approaches from the back by making one or two 2.5 cm incisions that provide access to the spine once the lamina (bone) is removed and nerves are retracted. In addition to spinal stenosis, PLIF is common in treating patients with:

• Spondylolisthesis
• Degenerative Disc Disease
• Recurring Herniated Disc

Transforaminal Lumbar Interbody Fusion (TLIF): In TLIF,  use the posterior (back) approach or the lateral (side) approach. The surgery is performed on one side only and the bone graft is inserted into the disc space laterally. The facet joints may be trimmed or removed to give nerve roots room. This approach requires less movement of nerves and opening of back muscles. The incision is 2 cm in length. In addition to spinal stenosis, TLIF is common in treating patients with:

• Spondylolisthesis
• Degenerative Disc Disease
• Recurring Herniated Disc

Lateral Interbody Fusion (XLIF/DLIF): These procedures, which  helped to develop, are being used to treat patients with spinal instability caused by degenerative discs, loss of height of disc space that causes pinching of a spinal nerve, change in normal curvature to the spine (scoliosis), and slippage of one vertebra over another. These procedures make use of the side (lateral) approach avoiding the spinal muscles and may take about one to one and a half hours to complete.

The PLIF and TLIF approach has an advantage over the posterolateral gutter fusion surgery

Minimally Invasive Posterior Lumbar Interbody Fusion (PLIF)

The success rate for posterior fusion in the treatment of refractory discogenic back pain is only 60-70%. The selection of the appropriate patient for this surgery has been blamed for the relatively poor results. Other possible causes of poor results are that the actual pain-causer, the disc, is not addressed. Studies have shown continued significant movement of the disc despite solid posterior fusion. One study showed that patients with continued back pain after solid posterior fusion were improved after anterior fusion of the disc space.This image shows a side view of an instrumented spine. The arrow shows the force of gravity which is diverted from the disc to the posterior instrumentation. One can imagine how the disc space could continue to have motion despite solid posterior fusion.

In an attempt to improve the results of fusion surgery, fusion of the disc has been performed to directly address the most common source of pain. Unlike the posterolateral gutter fusion, the PLIF achieves spinal fusion by inserting bone graft and possibly instrumentation directly into the disc space. The disc excision and fusion can be performed anteriorly, or through a posteriorapproach. When the posterior approach is used to remove and fuse the disc, this is called a PLIF,Posterior Lumbar Interbody Fusion.

An alternative approach is used to minimize retraction of the dura. By resecting the facet joint, a farther lateral approach can be used to remove the disc. This approach, with removal of the facet, is called a TLIF - Transforaminal Lumbar Interbody Fusion.

THE GENERAL PROCEDURE:

 

1. First, the spine is approached through a three-inch to six-inch long incision in the midline of the back and the left and right back muscles (erector spinae) are stripped off the lamina on both sides and at multiple levels.
2. After the spine is approached, to perform the PLIFprocedure (shown below), the lamina is removed (laminectomy) which allows visualization of the nerve roots. The facet joints, which are directly over the nerve roots, are usually undercut to give the nerve roots more room and more room for performing the fusion and/or instrumentation. For the TLIF procedure (shwon below), the entire facet joint is removed.
3. The nerve roots are then retracted to one side and the disc space is cleaned of the disc material. Bone graft is then inserted into the disc space with or without interbody cages. For a standard PLIF procedure, the bone graft and/or instrumentation is performed on both sides. For the TLIF procedure, the disc space is accessed from one side, reaching over to remove and replace the disc on the other side. The TLIF approach is shown below, with removal of the disc. Bone graft, bone from the bone bank, or instrumentationin the form of a cage can be placed through this approach.                                  

AFTER SURGERY

Risks include:

• Nerve Injury
• Adjacent disc disease
• Infection
• Bleeding
• Non-union

The PLIF and TLIF approach has an advantage over the posterolateral gutter fusion in that the large spinal muscles do not need to be dissected off the transverse processes, so there is less scarring of the muscle and associated pain for the patient. The major advantage of PLIF and TLIF is that there is significantly more surface area for fusion in the disc space as compared to the posterolateral gutter.

However, the PLIF requires substantial retraction of the nerve roots to gain access to the disc space. Significant traction can injure the nerve root and has the potential to result in chronic leg pain and back pain. The pain associated with this type of nerve root injury can be severe, and there are no effective options for treatment. The TLIF requires less retraction of the dural sac, but nerve injury can occur at the level of the nerve cell bodies (dorsal root ganglion). Pain associated with manipulation of the DRG can also be very severe and debilitating. Fortunately, these complications are rare with meticulous care of the nerves.

There are numerous veins (epidural veins) over the disc space, and surgery in this area creates the potential for excessive blood loss during the surgery. Recurrent pain after a successful spinal fusion procedure is more likely due to a “transfer” lesion at the motion segment above or below the fusion, because stress is transferred to the next level and may cause that vertebral segment to degenerate and breakdown.

Nonunion rates of between 0% and 20% have been quoted in the medical literature. Nonunion rates are higher for patients who have had prior surgery, patients who smoke or are obese, patients who have multiple level fusion surgery, and for patients who have been treated with radiation for cancer. Other than nonunion, the risks of a spinal fusion surgery include infection or bleeding. These complications are fairly uncommon (approximately 1% to 3% occurrence).

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