Spinal Disc Protrusions do not require Open Spine Surgery

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.

Benefit from Microsurgical Discectomy : Spine Surgery Hospital in india

A microsurgical discectomy, microdiscectomy or micro decompression spine surgery involves removal of a small portion of the bone/disc over or under nerve root to relieve nerve pinching and provide more room for the nerve to heal.

A microsurgical discectomy is typically performed for a herniated lumbar disc or spinal stenosis and is actually more effective for treating leg pain (commonly known as radiculopathy) than lower back pain.

Pressure on the nerve root (Neural impingement) can cause substantial leg pain. While it may months for the nerve root to heal completely and any numbness or weakness to get better, patients normally feel relief from leg pain almost immediately after a microdiscectomy lumbar spine surgery.

Microsurgical Discectomy is considered to be more reliable compared to the closed procedures like percutaneous procedures. Here the surgeon can directly view the disc fragments. After moving the muscles of the back and excising a bit of bone tissue, the surgeon can directly look into the spinal canal. The microsurgical discectomy involves the use of an operating microscope which allows magnification of the spinal disc material and further allows greater maneuverability to the operating surgeon. This allows quicker post operative healing of the wound and hastens recovery.

Who can benefit from Microsurgical Discectomy?

A microsurgical discectomy is typically recommended for patients who have:

•     Experienced leg pain for at least six weeks
•     Not found sufficient pain relief with conservative treatment (such as oral steroids, NSAID’s, and physical therapy).
•     In cases of severe disc herniation, causing weakness, pain, numbness and in cases of loss of control of bowel/bladder (Clauda Equina Syndrome) or worsening neurological symptoms. It is recommended to conduct the surgery immediately as conservative care is not expected to provide relief.

Prior to deciding the surgical intervention on the patient, it is crucial that conservative treatment is tried. Conservative care includes NSAIDS, physical therapy with exercises for pelvic stabilization. Occasionally traction may be required

Some patients may benefit from epidural steroid injections, directly into the spinal canal, to alleviate the irritation caused due to inflamed nerve roots.

Usually the conservative treatment is tried for about 2 months before considering surgery.

The Microsurgical Discectomy Surgery:

Before the disc material is removed, a small piece of bone (the lamina) from the affected vertebra may be removed. This is called a Laminotomy or Laminectomy It allows the surgeon to better see the herniated disc.

Microdiscectomy uses a special surgical microscope to view the disc and nerves. This surgical microscope is mounted on a flexible stand and lets the surgeon to view with both eyes. This larger well lit view allows the surgeon great flexibility and to operate using a smaller incision. Usually the incision is less than 2 inches. This causes less damage to surrounding tissue. Upon the initial incision the back muscles are stretched out rather than being cut to allow the surgery. This step aids greatly in post surgical recovery.

The surgeon then uses a special high speed surgical drill to remove a small portion of facet joint. The nerve is very carefully moved to the side. Then the surgeon removes the part of the disc that is herniated and is pushing into the spinal canal. Any loose fragments of disc are also removed. The nerve is then moved back and the incision is closed with sutures or surgical tape. This surgery is carried out under general anesthesia and in some cases might involve overnight stay in the hospital.

Minimal Invasive Spine surgery comes with more benefice than invasive spine surgery.

• Less scar tissue is created thereby not leaving the patient to recover with huge and ugly scar marks.
• Pain associated with this procedure is effectively less severe as small incisions are made. Also less soft tissues are damaged.
• Less blood is lost and therefore the patients don’t have to be at a medication for long periods of time
• Procedure is more accurate and leaves the patient with better results.
• The cost for such a surgery is quite lesser as compared to an Invasive Spinal surgery.

The Post Surgical care after Micro Surgical Discectomy:

The patient will be given antibiotics to prevent infection and pain relievers to help with post operative pain.

The patient will be mobilized within 24 hours. Some studies noted no extra risk of re herniation in the patients who resumed normal activities sooner.  Everyday activities can be resumed within few days while high intensity activities should wait 2-3 months.

The patient will receive physical therapy to regain the spine strength and encouraged to walk on a regular scheduled regimen. The brisk walking is shown to improve the post surgical outcome and lower back stabilization.

Most Advanced Minimally Invasive Spine Surgery in India

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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Minimally Invasive Surgery for Spine Tumors : Vertebral Fracture Treatments , Vertebroplasty and Kyphoplasty (Vertebral Augmentation)

Minimally Invasive Spine Tumor Surgery

Tumor is abnormal mass of rapidly growing cells without any physiological function. That means it does not perform any function for the body but derives its nutrition from the body.  It can occur anywhere in the body. The cause is unknown. Those tumors that are found in and around the spinal cord are known as spinal tumors. They may be primary tumors whose cells of origin is the spinal tissue, or they may be secondary tumors which have spread (metastasize) via blood stream from some other focus in the body.
 

The Spinal cord is covered by a layer of protective tissue called as meninges. The entire spinal cord is encased within the vertebral column.
 

The Spinal tumor are of three types depending on their location:

• Intramedullary – within the substance of the spinal cord.
• Intradural-Extramedullary- within the layers (meninges) covering the spinal cord
• Extradural- between the meninges an the vertebral body. Most of the spinal tumors are extradural.  

Tumors are also classified as benign and malignant. Tumors that are confined to a particular area in the body are known as benign tumors. Those tumors that spread rapidly to various parts of the body are known as malignant tumor. A tumor can initially start as a benign one and can convert to a malignant one in a few cases. The benign tumors are easier to treat as they are localized in their extent and their complete removal is possible. Whereas incase of metastatic or malignant tumor, the earlier they are detected, the better the chances of their removal. But in the malignant tumor the chances of recurrence are also there as they are rapidly growing tumors.
 

What are the Symptoms of Spinal Tumor?

Tumor may cause generalized symptoms in the body (like persistent low energy levels, unexplainable weight loss, lump formation, enlargement of lymph nodes, malaise, irregularities of menstruation in females etc) as well as symptoms pertaining to the affected organ in the body. In case of spinal tumor the patient may present with any of the following:

• Back pain, often radiating to other parts of the body and worse at night
  
• Loss of sensation or muscle weakness, especially in the legs
• Difficulty walking, sometimes leading to falls
• Decreased sensitivity to pain, heat and cold
• Loss of bowel or bladder function
• Paralysis may occur in varying degrees and in different parts of the body, depending on which nerves are compressed.
• Scoliosis or other spinal deformity resulting from a large, but non cancerous tumor
• Erosion and Destruction of vertebral body

Minimally Invasive Surgery for Spine Tumors

Surgery is considered minimally invasive when it involves small incisions (e.g. ½ inch) and minimal tissue disruption. Most minimally invasive procedures are done on an outpatient basis, meaning that the patient can go home the same day, and have relatively short recovery times.

Vertebral Fracture Treatments
Vertebroplasty and Kyphoplasty, also referred to as vertebral augmentation, are typically reliable procedures designed to provide pain relief for patients who have a vertebral fracture associated with a spinal tumor.

Vertebroplasty
This procedure involves inserting a needle through a small incision in the back so that a medical-grade bone cement can be inserted into a fractured vertebra to fill in the empty spaces and act as an internal cast to stabilize the bone. The treatment is designed to reduce pain, prevent further collapse of the vertebra, and restore the patient's mobility.

Kyphoplasty (Vertebral Augmentation)
Kyphoplasty also involves injecting bone cement into a vertebra, and involves the additional step of first inserting a balloon into the bone and inflating the balloon to create a cavity. This treatment is designed to stop the pain caused by a spinal fracture, and to stabilize the bone via an internal cast.

Transarterial Chemoembolization
This procedure involves a small incision in the thigh for access to the femoral artery. A catheter guided by a wire is directed through the vascular system to the tumor with the aid of imaging. Once the tumor is located, a chemotherapeutic agent is injected directly into the tumor to shrink or destroy the tumor to remove pressure on individual nerve roots or the spinal cord.

Recovery

Recovery after tumor surgery is a relatively slow process as the patient is weakened by the tumor and all the medications, chemotherapy and radiotherapy, he has been subjected to. Regular follow ups are required to detect any recurrence of tumor. Positive mindset combined with a strong support system can work wonders for the patient’s recovery. The patient should take nutritious diet to replenish his body reserves. 

Tumor or cancer as it is referred to in common man’s language, is a much feared disease. Many of those who are affected feel their world go crumbling around them with the mere mention of such a diagnosis. They go through a variety of emotional phases from denial to acceptance to defeat against the killer. Not only the patient but also the caretaker or the family member is totally drained out while attending to the patient. The picture may seem very dismal, but tumor patients still have a hope to live a normal life, provided the condition is detected early and the remedial measures are begun in time. We provide these patients with a world class diagnostic setup to detect tumors as early as possible and also advanced surgical techniques to treat them. We provide a multidisciplinary approach towards handling of such patients as they require medical, surgical, emotional and psychological support. We make the stay of the patient as well as that of the caretaker as comfortable as possible and try our best to allay their fears and anxieties. All this is offered at our hospitals at very affordable costs.

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
  
  
  

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 : Transforaminal and Posterior Lumbar Interbody Fusion in India

As with all spinal fusion surgeries, the PLIF and TLIF procedures involve adding bone graft or bone graft substitute to an area of the spine to set up a biological response that causes the bone to grow between the two vertebral elements and thereby stop the motion at that segment.

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.

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 posterior approach. 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 PLIF procedure (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 instrumentation in the form of a cage can be placed through this approach.

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).

Post-Operative Care

Most patients are usually able to go home 1-3 days after surgery. Patients will typically stay longer, approximately 2-5 days, if an anterior spinal surgery is also performed. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury. Patients can gradually begin to bend, twist, and lift after 4-6 weeks as the pain subsides and the back muscles get stronger.

Brace

Patients are generally not required to wear a back brace after surgery. Occasionally, some patients may be issued a soft or rigid lumbar corset that can provide additional lumbar support in the postoperative period, if necessary.

Wound Care

The wound area can be left open to air. No bandages are required. The area should be kept clean and dry.

Shower/Bath

Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should remove the bandage, and dry off the surgical area. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Driving

Patients may begin driving when the pain has decreased to a mild level, which usually is between 7-14 days after surgery. Patients should not drive while taking pain medicines (narcotics). When driving for the first time after surgery, patients should make it a short drive only and have someone come with them, in case the pain flares up and they need help driving back home. After patients feel comfortable with a short drive, they can begin driving longer distances alone.

Return to Work and Sports

Patients may return to light work duties as early as 1-2 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to moderate level work and light recreational sports as early as 1-2 months after surgery, if the surgical pain has subsided and the back strength has returned appropriately with physical therapy. Patients who have undergone a fusion at only one level may return to heavy lifting and sports activities when the surgical pain has subsided and the back strength has returned appropriately with physical therapy. Patients who have undergone a fusion at two or more levels are generally recommended to avoid heavy lifting, laborious work, and impact sports.

Benefits of Arthroscopic techniques in minimally invasive spine surgery

This type of minimally invasive surgery is performed on an outpatient basis using a local anesthetic. Since general anesthesia is not used, surgical risks are less. Arthroscopic surgery and use of endoscopic tubes minimizes muscle and other soft tissue damage. Patient benefits include less bleeding during surgery, reduced postoperative discomfort, fewer and smaller incisions, minimal scar tissue formation, and a speedier recovery. In addition, patients can avoid hospitalization and spinal fusion.

Arthroscopic Spine Procedures

Depending on the patient's diagnosis and surgical needs, sometimes more than one procedure is performed during a single surgery.

There are 4 primary arthroscopic spine procedures : -

1. Foraminotomy : - A foraminotomy helps to relieve symptoms caused by nerve root compression. The foramen are passageways between the vertebrae through which nerve roots exit the spinal canal. A foraminotomy may be performed to treat foraminal stenosis, bulging or herniated discs, pinched nerves, scar tissue formation, bone spurs (osteophytes), spinal arthritis, or sciatica.
   
   During a foraminotomy, the surgeon arthroscopically removes bone and tissue compressing the spinal nerve root. The endoscope is slowly removed to allow muscles and other soft tissues to move back into place. Occasionally, a stitch or two is needed to close the small incision.

2. Laminotomy : - A laminotomy is performed to increase the space around nerve roots and the spinal cord. The procedure helps to remove (decompress) pressure from these neural tissues. The lamina is the bony plate covering each vertebra's posterior arch, or entryway to the spinal canal and nerve structures.
   
   A laminotomy may also be performed to remove the ligamentum flavum. This is the spine's largest ligament. Sometimes the ligamentum flavum becomes thick and compresses the spinal cord contributing to spinal stenosis. When the surgeon removes part of the lamina, he can access the ligamentum flavum for removal.
   
   A laminectomy is similar to a laminotomy. The difference between the procedures is a laminectomy is usually performed during a traditional open back surgery to remove the entire lamina. A laminotomy does not remove the entire lamina, but only a portion of the bony plate
   
   A laminotomy is performed to treat bone spurs (osteophytes), bulging and herniated discs, pinched nerves, scar tissue, spinal arthritis, and spinal stenosis.

3. Percutaneous Arthroscopic Discectomy : - Percutaneous means through the skin. A percutaneous arthroscopic discectomy is the surgical removal of bulging or herniated disc material. Bulging and herniated discs are a common cause of nerve root and spinal cord compression.
   
   During this minimally invasive procedure, the surgeon uses a laser to vaporize disc material to reduce pressure on the spinal cord and nerve roots. When the procedure is completed, the endoscopic tube is slowly removed to allow muscles and soft tissues to move back into place. A percutaneous arthroscopic discectomy is a short procedure only taking 30 to 45 minutes.

4. Facet Thermal Ablation : - A facet thermal ablation is performed to treat facet disease, facet joint syndrome, facet hypertrophy (enlargement), facet arthritis, or facet joints affected by degeneration. The facet joints are the spine's joints. Found at the back of the spine, 2 vertebrae share 1 facet joint.
   
   Thermal ablation refers to disabling or destroying a nerve using a laser. During the procedure, the surgeon uses a laser to clean the facet joint and deaden the nerve that innervates the joint and causes pain.
   
   After a local anesthetic is administered, a small incision is made and the endoscope is inserted. The endoscope (about the size of a straw) helps protect surrounding anatomical structures from damage during thermal ablation. The procedure only takes about 40-minutes.

Laser Spine Surgery : -

The most commonly performed spinal operation in the United States is the lumbar discectomy. Lumbar discectomy is the cornerstone of surgical treatment of disc herniations. A disc herniation is a protrusion of the inner core of disc material beyond the confines of the disc space to compress on the lumbar nerve root(s). This nerve root compression causes a variety of symptoms, but most notable is that of sciatica. Sciatica is a radiating pain from the low back around the hip joint into the leg and down the leg to the foot. Fortunately, 80% of symptomatic disc herniations respond to non-surgical treatment. For the remaining 20%, lumbar discectomy is the treatment of choice 

How long does surgery typically last?

The average spine procedure lasts about an hour. When the procedure is complete, the surgeon removes the tube to let the tissue and muscle go back to their natural position. The last tube is gently removed and absorbable sutures are used to close the incision. The patient is wheeled into the post-anesthesia care area where their vital signs are monitored, medications are given as needed and some light refreshments can be enjoyed. That same day, patients are encouraged to walk around. Soon after, they are discharged home or to their hotel.

What's the recovery process like?

After a day of rest and recovery, the patient returns for a postoperative appointment. An epidural injection may be given to reduce swelling and increase range of motion. Physical therapy may be prescribed. Physical therapy consists of a series of stretching exercises, walking, ice or heat, gentle electronic stimulation and a nice relaxing massage. Each patient is given instructions for postoperative activity and limitations. Over the weeks and months to come, gradual and continuous improvement will be seen, as the nerves and tissues heal. With time and exercise, the body can repair any damage, gain strength, and a gradual increase in daily activities can occur.