On the opposite end of the spectrum from various non-surgical therapies and minimally invasive surgical options are a host of conventional "open" surgical procedures. When a severe back or neck condition fails to respond to more conservative therapies and treatments, a more aggressive, and typically more invasive, surgical procedure may be recommended. Such procedures may, in fact, also require a hospital stay as well as several months to achieve a recovery.
An open discectomy is the most common surgical procedure used to treat a herniated or ruptured disc. The goal of this treatment is to achieve the partial or complete surgical removal of a damaged intervertebral disc. Removing the damaged disc eliminates the source of pressure and irritation on the nerve roots, which in turn removes the cause of the symptomatic back pain and weakness. Although this type of procedure may be done either as an open surgical procedure or via a minimally invasive method, a stay in the hospital or clinic of one to three days is typically required.
This surgery is performed to relieve sciatica due to disc herniation. Most of the lumbar disc herniations occur in the posterolateral position. In about 10% of cases disc herniations occur in the foraminal position. Foraminal disc herniations cause more pain and more severe neurological deficit and are more likely to require surgical intervention. Far lateral disc herniations are a type of foraminal disc herniations.
It is technically more difficult to surgically treat foraminal disc herniations than posterolateral disc herniations. L5 S1 foraminal disc herniations require removal of about one half of the L5 S1 facet joint. Surgeon stays on the opposite side of the disc herniation and look across into the foramen from the opposite side of the leg pain in order to remove the disc herniation. Foraminal disc herniations at other levels require paralateral approach staying lateral or outside of the facet joint. This is technically more difficult approach and many spine surgeons are not familiar with this approach.
Many of lumbar disc herniations resolve on their own. Surgery is usually indicated when the sciatica persists longer than 6 weeks interfering with activities of daily living. Exceptions are severe intolerable pain, profound neurological deficit, progressive neurological deficit, and cauda equina syndrome causing bowel and bladder dysfunction.
Success rate of lumbar microdiscectomy is quite high greater than 90 %. Surgery usually takes slightly more than one hour. Patients usually stay overnight. Office or light duty return to work is possible in a week or two. Heavy manual laborers such as carpenters are not released to full duty work for about a month to 6 weeks.
The most common complication of the procedure is recurrent disc herniation and this can occur in about 10% of cases. There is poor correlation with patient's activity level in my experience. It can occur any time after the surgery from a few days or many years later.
Other complications include dural tear( about 1 to 2%), nerve root injury( about 1 out of 1000 or less), wound infection( less than 1%), bleeding( very rare). Spinal cord injury or paraplegia is extremely rare as one is operating below the termination of the spinal cord. Very rarely epidural hematoma usually due to anticoagulation of patient's blood due to blood thinners can cause progressive blood clot formation tracking up to the spinal cord level resulting in paraplegia. Therefore it is essential that patients stop all types of anticoagulation including coumadin, persantin, aspirin, mortrin, naprosyn, Vioxx, Celebrex, advil, alleve, Relafen, fish oil, and all other types of blood thinners at least one week prior to surgery.
In less than 5 % of patients persistent low back pain, so called postlaminectomy low back pain, may remain despite complete clearance of their sciatica and some of these patients may require lumbar spinal fusion due to their chronic low back pain if it does not respond to physical therapy and other types of conservative care.
Cervical Laminoplasty is performed to take pressure off the spinal cord which is gradually paralyzing the patient. It is performed for myelopathy. Myelopathy is caused by arthritic spurs of the spinal canal. Occasionally condition called OPLL or calcification of posterior longitudinal ligament of spinal canal will also cause pressure on the spinal cord. This procedure can be performed only if the cervical spine is in neutral position or lordotic position and is contraindicated in patients who have cervical kyphosis.
The surgery takes about 3 to 4 hours. A complete cut is created on one side of the roof of the spinal canal and a hinge is created on the other side. The roof of the spine or lamina is gently pried open hinging on one side creating more room for the spinal cord. Usually multiple small plates are used to prevent the lamina collapsing back down on the spinal cord. One can usually see the dural sac containing the spinal cord reexpand during the procedure.
Mayfield head tongs or pins into the skulls are used to stabilize the head and neck area during the procedure. Electronic monitoring of the spinal cord or SSEP or somatosensory evoked potential is used during the surgery to monitor the spinal cord function.
Since the spinal cord is already in jeopardy there is risk of paralysis during the procedure.
The more severely the spinal cord is already compromised the higher the risk of paralysis. However without the surgery patient will gradually get paralyzed. Other risks of surgery include wound infection, up to 10% chance of usually temporary paralysis of shoulder muscle called deltoid as the nerve root supplying this muscle called C5 nerve root gets stretched as the spinal cord migrates backwards after the roof of the spinal canal is opened. Laminoplasty rather than conventional laminectomy stabilizes the cervical spine better after the spinal cord decompression making a condition called postlaminectomy kyphosis of cervical spine less likely even though it can occur. After the laminoplasty many patients also complain of severe shoulder pains which usually subside with time. This may be also related to stretching of the C5 nerve root. Soft neck collar is usually worn for about 6 weeks after the surgery.
A laminectomy is a surgical procedure that removes a portion of the vertebral bone called the lamina in order to relieve pressure on the spinal cord and nerve roots. At its most minimally invasive, the procedure requires only small skin incisions. The back muscles are pushed aside rather than cut and the parts of the vertebra adjacent to the lamina are left intact. Recovery occurs within a few days.
Lumbar Laminectomy or Lumbar Decompression
This surgery is performed to take pressure off the pinched nerve roots causing sciatica. Spinal stenosis is the medical term. Spinal stenosis can be further classified into two types: central or subarticular stenosis and foraminal or lateral stenosis. Central or subarticular stenosis usually cause so called neurogenic claudication in which patients complain of low back and bilateral buttock pain with pain radiation into both lower extremities. In severe cases neurological deficit such as foot drop may be present. Pain is usually relieved by sitting and aggravated by standing and walking. In foraminal or lateral stenosis only one leg is affected and the sciatica may persist regardless of patient's position even though usually standing and walking are worse positions than sitting.
Surgery takes about two to three hours depending on number of levels to be "decompressed." CT scan or MRI scan and at times CT Myelogram are necessary to make the diagnosis. Nerve root injection may be necessary in lateral or foraminal stenosis to confirm the fact that radiographically pinched nerve root is indeed the cause of patient's leg pain. Lumbar epidural steroid injections or therapeutic nerve root injections may be tried up to three times a year to try to prevent the surgery. Success rate of these procedures are less than 50%. The surgery usually carries about 80 to 90% success rate in relieving patient's symptoms long term.
Complications include about 3 to 5 % chance of dural tear, 1% or less chance of nerve root injury, wound infection, and postoperative instability requiring subsequent fusion surgery. In order to prevent postoperative instability and recurrent stenosis lumbar spine fusion is carried out at the same time when spinal stenosis is accompanied by degenerative spondylolisthesis, isthmic sypondylolisthesis, and degenerative scoliosis.
Please refer to "Postoperative Recovery after Lumbar Decompression" for further information regarding recovery after this surgery.
To prevent postoperative epidural hematoma causing possible paralysis patients should avoid taking all types of blood thinners such as coumadin, persantin, and anti-inflmmatory medications including even Vioxx and Celebrex.
Posterior Cervical Microforaminotomy
This surgery is commonly performed to relieve chronic arm pain due to pinched nerves in the neck either due to bone spur or disc herniation.
Surgery takes about 2 hours. Patient's head is held in a Mayfield head holder that holds the head with 3 pins going into the skull bone during the surgery. Incision is made in the back of the neck and muscles are pushed apart exposing the bony structures of back of the neck. High speed drill is used to make opening into the area where nerve roots come out from the spinal cord. The nerve root may be gently manipulated so that a bone spur or disc fragment pinching the nerve root may be safely removed thus "decompressing" the nerve root.
Success rate is usually greater than 80%. Risks of the surgery include nerve root injury, spinal cord injury, wound infection, and persistent pain despite the surgery. Hospitalization is 2 to 3 days. After surgery patient's neck may be placed into a soft neck collar for comfort.
Recovery is rapid since fusion is not performed and patients may return to normal unrestricted activities in about a month. For the right indication this is an excellent operation in my experience.
Anterior Thoracic Decompression and Fusion
This procedure is performed to take pressure off the anterior or front aspect of the spinal cord in the thoracic spine. Usually disc herniation, tumor, infected abscess, or fracture fragments are pressing on the spinal cord compromising spinal cord function.
Adequate decompression cannot be performed in the back side of the spinal cord as spinal cord cannot be retracted or manipulated as the offending agent is directly in front of the spinal cord.
Resection of a rib is necessary to enter the chest cavity. Occasionally patient can develop pain in the area of the rib resection so called post thoracotomy pain which can persist and that can be usually treated with a procedure called intercostals nerve block or ablation.
Chest tubes are required to drain the chest cavity after the surgery and they are usually removed several days after the surgery if there is less than 50 cc to 100cc of drainage in 24 hour interval.
Instrumentation such as screws and rods and plates may be used in addition to bone graft or cages to stabilize the spine. Additional posterior surgery using pedicle screws and rods may be necessary to further stabilize the spine.
Potential complications of the procedure includes risk of neurological injury including paralysis, wound infection, lung injury, accumulation of lymph fluid called chyle in the chest cavity, hardware failure, failure of fusion to occur, and thoracotomy pain as mentioned above. The surgery is performed in conjunction with a general surgeon.