The purpose of this blog post is to provide an overview about the basics of spine surgery. We will describe who potentially is a candidate for spine surgery, what spine surgery accomplishes, and what to expect.
Hearing the words “spine surgery” can be daunting to patients. Often when they hear this during an office visit, those will be only words they hear and the rest gets forgotten. Spine surgery is performed for a variety of reasons. Some of these reasons include degenerative discs, herniated discs, pinched nerves in the neck or back causing pain radiating down the arms or legs, spinal instability, scoliosis, and many others. Spine surgery can be emergent, but this is rarely the case. The majority of patients who undergo spine surgery have the time and ability to do their own research and choose the best options for themselves.
What is spine surgery?
Spine surgery is a very vast field. To answer the question directly, spine surgery is any surgical procedure that is performed on the spinal column or its associated nerves. This includes the cervical (neck), thoracic (mid back), or lumbar (lower back) spine. Over 95% of spine surgeries performed are either on the cervical or lumbar spine. Thoracic spine surgery is much less common. Thoracic spine surgery is much less common for a variety of reasons. One analogy to help understand the breakdown of the spine is comparing the spine to moving parts in an engine. Moving parts tend to break down, which is why engines require maintenance and tires on your car need to be changed. While the cervical and lumbar spine are quite mobile, the thoracic spine is protected by our ribs and there is much less motion compared to the cervical and lumbar regions. For this reason, there is less degeneration in the thoracic spine compared to the mobile cervical and lumbar spine. Since there is less degeneration, there is significantly less need for surgery.
Types of spine surgery
I tell patients that there really is two main types of procedures that spine surgeons perform: decompression and stabilization. Surgical decompression of the spine is an umbrella term with many different subtypes. When we refer to spinal decompression surgery, what we are talking about is taking pressure off of nerves or the spinal cord spinal decompression can be performed for a variety of reasons. The most common reason for spinal decompression include herniated disks that are pressing on the nerves causing pain radiating down the arms or legs. Another common reason is degenerative spinal stenosis, which is a phenomenon where the area for nerves, most commonly in the lumbar spine gets squeezed or pinched circumferentially.
The second type of surgery performed is stabilization procedures of the spine, often referred to as fusions. Fusions are designed to stabilize and immobilize a certain of the spine. Common reasons for spinal fusions include alignment issues, spondylolisthesis, scoliosis, hypermobility, among others.
It is possible for the surgeon to perform both of these procedures at the same time to achieve a decompression and a fusion. Deciding which surgery is best is a very individualized decision based upon a variety of factors including what symptoms the patient has, what their imaging shows, and what their physical exam is like.
There is a third ‘type’ of procedure that can be performed, which involves a little bit of both of these surgeries. It is a motion-preservation procedure, or disc replacement.
These involve taking the pressure off the nerves, but instead of fusing them, we place an artificial disc that is motion preserving. Not every patient is a candidate for disc replacement, but it can be an excellent option for some patients depending upon their presentation.
Benefits and Risks of Spine Surgery
The benefit of spine surgery will have different meaning for each person. This can mean improved pain relief, strength, posture, ability to walk, exercise or a combination of these things – it depends on what symptoms you are experiencing.
There are risks associated with the spine surgery, but fortunately most of these are mild and uncommon. However, when discussing the risks of spine surgery, it is important understand they are very specific based on the complexity and severity of your individual situation. Anytime an incision is made on the body there is a risk of infection. Thankfully infection rates from spine surgery tend to be quite low. That being said, the rate of infection does vary significantly based upon the type, complexity and individual situation for the patient. This can be discussed with your surgeon before every surgery.
Nerve damage: any time we are operating on the spinal canal and it’s nerves, there is a possibility the already damaged nerves could be damaged during surgery. Again, fortunately this is a quite an infrequent event, but it must be mentioned if discussing a comprehensive list about possible complications that can occur during surgery.
Hardware complications: if hardware is involved in your surgery, there is the risk of hardware related complications. This can include hardware that breaks at some point down the road. Another complication would be hardware that does not hold or moves. It is possible that your spine can develop fractures around the hardware. It is possible that your body does not heal all the way, a situation called pseudoarthrosis, where the bones never grow together. It is possible that the hardware is placed incorrectly, however with modern techniques this is extremely rare.
Spinal fluid leak: If your surgeon is performing a decompression around the nerves, it is possible there could be a small leak in the “dura” or outer layer of the nerves. If there is a spinal leak, most of the time this is able to be identified and repaired during surgery. Rarely patients can continue to leak after surgery and usually will present with severe headaches. Sometimes, this can require another procedure.
Other rare but possible risks of surgery include anesthesia complications, bleeding, or blood clots. These are more generalized surgical risks and not specific for spine surgery.
Preparing for spine surgery
Before most procedures, we will have you obtain generalized medical clearance. If you are considered mostly ‘healthy’, this is likely just routine blood work and an EKG. If you have a cardiac history, we may have you meet with your cardiologist to make sure everything is optimized prior to proceeding with surgery. We do recommend that patients are as active as possible as they can be before surgery and do some sort of rehabilitation.
From a diet standpoint, we do want patients to make sure that they are optimized. A high-protein diet will allow for better healing. At times, we may recommend supplementing with protein shakes such as Ensure or boost to help you heal.
Recovering from spine surgery
Recovery after surgery varies greatly depending on what type of surgery was performed. Our more minimally invasive surgeries have a pretty quick recovery and allow patient to get back to their day-to-day life in a short period of time within a few days to weeks. More extensive surgeries can take several months to recover from. Some surgeries are done as an outpatient, meaning you go home the same day, and some require a short hospitalization.
Regardless of the surgery, we do not recommend any sort of bed rest. We want patients to be as mobile as possible after surgery. In the beginning phases the majority of physical therapy/recovery is to just walk is much as possible.
Case studies
More common spinal procedures and their typical presentations will be outlined below.
Lumbar Disc Herniation
Patient presents with onset of severe back and leg pain shooting down the back and side of their leg. MRI demonstrates a disc herniation pressing on the nerves causing the pain shooting down the legs. After conservative care including anti-inflammatory medication physical therapy, or even epidural steroid injections if the patient is not getting better, a minimally invasive microdiscectomy can be performed. This is a short outpatient procedure which often provides near immediate relief of the patient’s symptoms. Typical recovery for day-to-day life is about 1 week. 6 weeks for full release of activities. (Read more)
Anterior Lumbar Interbody Fusion (ALIF)
Patient presents with a chronic history of back pain and pain radiating down the legs. X-rays and MRI show a condition called spondylolisthesis where the individual vertebra are slipped forward on each other and there is instability. This means that the bones are abnormally moving causing significant back pain and also putting pressure on the nerves. A cage, often a 3D printed piece of titanium, can be inserted to help stabilize and realign the spine. Patients with generalized pain 1 night in the hospital and her walking immediately after surgery. (Read more)
Anterior Cervical Discectomy and Fusion (ACDF)
Patient presents with chronic neck pain with pain numbness, tingling and weakness in 1 or both of the arms. X-ray and MRI will show degenerative disc in the neck that is putting pressure on the nerves. An outpatient procedure can be performed to take the pressure off the nerves in the neck and stabilize and align the spine. (Read more)
Cervical Disc Replacement
This procedure is often performed when the patient has an acute disc herniation in the neck putting pressure on the spinal cord or nerves. If they fail to improve with conservative care a motion sparing disc replacement can be performed to treat the patient’s problems. (Read more)
Lumbar Laminectomy
One of the more common procedures performed in the world, this is performed for spinal stenosis is a chronic condition where there is excessive pressure on the erves of the lumbar spine. This often leads to difficulty walking or standing for prolonged periods at times with pain shooting down the legs. This decompressive procedure takes the pressure off these nerves and often immediately improves the patient’s quality of life. (Read more)
Conclusion
Spine surgery is a very wide field with many nuances. Every patient’s presentation, imaging and situation is unique. We want you to feel comfortable with understanding your condition and the treatment options available to you. All questions are welcome! We look forward to meeting with you and talking to you more during your office visit.
