Spine Surgery in New York

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Executive Spine Surgery in Manhattan NY offers cost effective treatment for back pain and spinal injuries.

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Spine Surgery in New York

  1. 1. SPINE SURGERY A Patient’s Guide -An illustrated guide to spine diseases and treatments By Carl J. Spivak, MD Illustrated By Ginger Weatherford
  2. 2. Library of Congress Control Number: ISBN First printing : 1,000 copies : January 2007 Published by Carl Spivak Copyright © 2007 Carl J. Spivak All Rights Reserved.All rights reserved. No part of this book may be reproduced in any form,except for the inclusion of brief quotations in a review, without permissionin writing from the author or publisher..Important Note: Medical knowledge is ever-changing. As new research and clinical experiencebroaden our knowledge, changes in treatment and drug therapy may be required. The author ofthe material herein have consulted sources believed to be reliable in their efforts to provideinformation that is complete and in accord with the standards accepted at the time of publica-tion. However, in the view of the possibility of human error by the author, of the work herein, orchanges in medical knowledge, the author, or any other party that has been involved in thepreparation of this work, warrants that the information contained herein is in every respect accu-rate or complete, and they are not responsible for any errors or omissions or for the results ob-tained from use of such information. Readers are encouraged to confirmed herein with othersources. For example, readers are advised to check the product information sheet included in thepackage of each drug they plan to administer or use to be certain that the information containedin this publication is accurate and that changes have not been made in the recommended dose orin the contraindications for administration. Some of the product names, patents and registereddesigns referred to in this book are in fact registered trademarks or proprietary names eventhough specific reference to this fact is not always made in the text. Therefore, the appearanceof a name without designation as proprietary is not to be construed as a representation by theauthor that it is in the public domain.
  3. 3. DedicationThis book is dedicated to my wife Bridgette and three childrenChanelle, Luke and Nicholas, who are a constant source ofblessing, inspiration, encouragement and joy to my life.
  4. 4. TABLE OF CONTENTS INTRODUCTION1.Preface……………………………………………….i.2.Introduction…………………………………………..ii NECK DISEASE3.Cervical disk herniation. (slipped disk neck)..………14.Cervical spine stenosis (tightness)……..…………….14 MIIDLE BACK DISEASE5.Spinal compression fractures (broken back bone)……28 LOW BACK DISEASE6. Lumbar disk herniation (slipped disk) ……………….407. Lumbar spinal stenosis (tightness)…………………....528..Lumbar spondylolithesis (slipped spine)……..……….649. Glossary……………………………………………….79
  5. 5. PREFACE Today there is an enormous amount of medical informationavailable in textbooks, medical journals and on the internet.This information ranges from simple to very complex. Mostinformation is written for medical specialists and may bewordy, full of medical jargon, difficult to understand and ex-pensive to obtain. These obstacles are difficult for patients toovercome when trying to understand their disease and treatmentoptions. This book was written to help fill that gap. This book contains valuable medical information, diagrams,X-rays, CT and MRI images to help understand neck and backproblems. It is comprehensive, yet easy to understand. It re-views anatomy (the structure of the spine), pathology (spinedisease), treatments and outcomes of treatments. This book is best used to educate yourself about a medicaldisease. It will give you greater breadth of understanding of theproblem and will help you make an informed decision. Themore information you have the better decision you will make! i
  6. 6. INTRODUCTION Neck and back problems are very common medical problemsin North American society. Most people will be troubled byneck and back pain during their lifetime. The pain may rangefrom mild to severe. Many times this pain may resolve withrest, activity modification or anti-inflammatory medications andthe passage of time. Neck and back problems may become more severe and beassociated with dysfunction of the nervous system. This nerv-ous system dysfunction may present itself with pain, numbness,tingling or weakness of the arms or legs. It may also presentwith problems controlling bowel and bladder function with in-continence or severe constipation. In the following chapters I provide detailed, but easy to un-derstand information about spine disease. Each chapter de-scribes the relevant spinal anatomy, disease process, clinicaland radiological investigations, treatments, outcomes and com-plications. I have also included many drawings, X-Rays, CTand MRI scans to help increase your understanding of thiscomplex subject. I hope you find this book interesting and useful to you. ii
  7. 7. Chapter 1: Cervical Disk Herniation andAnterior Cervical Diskectomy, Fusionand PlatingWhat is the spine? The neck is made up of seven bones called cervical vertebrae(figure 1). These vertebrae surround and protect the spinal cordfrom damage. The front of the vertebrae is made up of a squareshaped vertebral body and the back of the vertebrae is made upof pedicles, facet joints, lateral mass and lamina, called the pos-terior elements. The vertebrae are held together by a spongydisk in the front and strong ligaments in the front and back. Thedisk helps cushion the neck bones. C3 Disk C4Vertebrae C5 Nerve Disk Root C6 Spinal Spinal Cord Cord C7 A. B.Figure 1. Normal cervical spine. A) Side view of cervical ver-tebrae C3-C7. B) Top view of a vertebrae on the right. 1
  8. 8. Chapter 1: Cervical Disk HerniationWhat is a cervical disk? Cervical disks are located in between the spinal vertebrae andare made up of a tough outer shell (annulus fibrosis) and a softgel-like center (nucleus pulposus). Their structure is similar toa jelly donut.Why do cervical disks pinch the spinalcord and nerves? As people age the spine slowly wears out through a processcalled degeneration. Degeneration is first seen in the nucleuspulposus (“jelly center”) and annulus fibrosis (“donut”) inadults. The annulus may weaken and bulge outward or tear, al-lowing the nucleus pulposus to squeeze (herniate) out of theannulus into the spinal canal (figure 2)1. This disease is referred to by many names including slippeddisk, bulging disk, ruptured disk, pinched nerve, herniated nu-cleus pulposus and disk herniation. The herniated disk may compress or “pinch off” the spinalnerves resulting in neck and arm pain, numbness, tingling andweakness. This pain may be worsened or maintained by inflam-mation around the nerve roots2,3. Compression of the spinalcord may cause myelopathy (spinal cord injury) producing elec-trical shocks down the spine, weakness, numbness and bladderincontinence. Possible risk factors for ruptured disks are hereditary, smok-ing, heavy work, injury to head or neck, heavy lifting or opera-tion of vehicles4,5,6. Sometimes the process begins after amemorable accident. 2
  9. 9. Spinal cord swellingA. B.Figure 2. Herniated cervical disk compressing the spinal cordwith evidence of spinal cord compression and swelling. A) Sideview of the herniated disk highlighted in black. B) top view ofthe herniated disk (large black arrow) compressing the spinalcord.How do I know I have a ruptured disk? The ruptured disk usually begins with neck and shoulder painfollowed later with the development of arm pain1. This armpain may be associated with numbness (loss of feeling in thearm or hand), tingling, burning and weakness. The neck andarm pain may be worsened by neck movements and relieved byplacing their hand on their head. Rarely, a herniated disk maycause electrical shocks running down the back or clumsiness,weakness or paralysis in the arms or legs or loss of bowel and-bladder control. These changes may come on quickly or gradu-ally over time, with slow transition to using cane, walker andfinally wheelchair. If any of these symptoms occur the patientshould seek emergency medical care. 3
  10. 10. Chapter 1: Cervical Disk Herniation What should I do? If you are experiencing neck pain associated with pain, numbness or weakness in your arm, unsteadiness on your feet or have bowel and bladder difficulties you should see your doc- tor. You will require a history and physical examination, which may include an examination of you neck, gait, strength, sensa- tions and reflexes. After an initial assessment, you may require radiological in- vestigations, including x-rays and magnetic resonance imaging (MRI) of the spine. MRI is the best test for looking for herni- Spinal cord Herniated disk Herni- ated disk Spinal cord A. B. Figure 3. MRI (T2WI) of the neck showing a C4/5 herniated disk compressing the spinal cord and exiting nerve root. A) The side view. The white fluid (cerebral spinal fluid) at the level of the disk. B) top view of the herniated disk. 4
  11. 11. Patients with pacemakers, spinal cord stimulators or othermetal within their body are unable to have an MRI. These pa-tients should undergo a computer tomogram (CT) with or with-out a myelogram. The CT myelogram produces better imagesthen the CT alone. A myelogram is the injection of contrastmedium (dye) into spinal canal to improve the visibility of thenerves on the CT (figure 4). Disk herniation Contrast (Dye) Spinal cordFigure 4. CT myelogram of the neck showing a herniated disk(arrows) top view on the right. Compliments Dr. A. Eisenberg.Should I have surgery? Many patients with neck and arm pain secondary to a rup-tured disk may improve with non-operative treatments includ-ing bed rest, physical therapy, head traction, neck collar, nonsteroidal anti-inflammatory drugs (NSAIDS), steroids (Medroldose pack), muscle relaxants, antidepressants and steroid injec-tions7,8. 5
  12. 12. Chapter 1: Cervical Disk Herniation Patients should consider surgery if they fail to improve with conservative therapy, have severe pain or significant neurologi- cal dysfunction (table 1). Additionally, patients with significant spinal cord compression and swelling on MRI scan may require surgery. Table 1 Indications for Surgery 1. Failure of conservative treatment 2. Severe pain 3. Weakness 4. Loss of bowel & bladder control 5. Compression and swelling of spinal cord What are the surgical treatment op- tions? Neck and arm pain are a result of the herniated disk com- pressing the spinal nerve. To relieve the pain surgery must re- move the herniated disk and take pressure off the nerve. The removal of disk is called a discectomy. Today most cervical herniated disks are removed through the front of the neck by an operation called an anterior cervical discectomy, fusion and plating (ACDFP). Cervical herniated disks are less commonly removed through the back of the neck by a posterior lami- notomy (parial removal of the lamina which is part of the back of the spine) and diskectomy. 6
  13. 13. How is a discectomy done? The patient is given antibiotics prior to surgery. They arethen taken to the operating room and are put to sleep under ageneral anesthetic. A tube is placed down their throat to helpthem breath. They lie down on their back looking up at the ceil-ing. Their neck is washed and sterile drapes are placed aroundthe operative site. An incision is made just off midline, usually on the right side.The skin is separated, the esophagus (food “pipe”), larynx andtrachea (voice box and breathing “tube”) and carotid artery(supplies the brain with blood) are retracted to the side. Thisopens up a tunnel to the front of the spine. The level of the her-niated disk is found with the x-ray machine. The operating room microscope is used to magnify and lightthe disk space (figure 5). The disk is incised with a knife andremoved with a variety of biting and scraping instruments. Af-ter the disk is removed, the posterior longitudinal ligament isopened up. This ligament separates the disk from the spinalcanal. Removal of this ligament provides direct visualization ofthe thecal sac (with contains the spinal cord), the exiting nerveroots and herniated disk. The disk is then carefully removed re-lieving pressure off of the spinal cord and/or nerve roots. After the disk is removed, the ends of the vertebrae are cleanand prepared for the bone fusion. A bone fusion is when twobone heal solidly together. A graft is placed into the empty diskspace (figure 5). The graft holds the vertebrae apart and the ver-tebrae eventually fuse together through the graft. This de-creases movement across the abnormal vertebrae and helps re-duce pain. This graft may be made from the patient’s bone(autograft) and is usually taken from the hip, or may be takenfrom the bone bank (allograft). Recently cages made out ofplastic (polyetheretherkeytone, PEEK), metal (titanium) and 7
  14. 14. Chapter 1: Cervical Disk Herniation A. B. C. D.Figure 5. Anterior cervical diskectomy, fusion and plate sur-gery (ACDF). A&B) The disk is removed through the front ofthe spine relieving pressure off the spinal cord. C) After the diskis removed, the vertebrae are prepared for the fusion and thebone graft is inserted. D) The bone graft is held into position bythe metal plate and screws. 8
  15. 15. carbon fiber have become available. These cages are presentlyfilled with autograft or allograft but bone morphogenic protein(BMP) , a bone hormone which promotes bone growth in thebody, will soon be available. After the graft or cage has been placed into the disk space, thespine is stabilized with a metal plate and screws (figure 5&6).The size of the plate and screws depends on the number of disksremoved and the size of the patient’s vertebrae. The metal plateis made of titanium which produces minimal interference onMRI. The titanium plate does not trigger airport metal detectors.Plastic plated may soon be available. After the plate is secured,bleeding is stopped and the muscle and skin are brought to-gether with sutures. Sometimes a drain may be temporaryplaced to remove blood over night. Patients are woke up and A. B.Figure 6. An x-ray of the cervical spine with plate and screwsplaced after an anterior cervical discectomy and fusion of C5/6disk in (A) and C4-5-6-7 in (B). Cervical plates are labeled bywhite arrows. 9
  16. 16. Chapter 1: Cervical Disk HerniationDoes surgery work? Surgery is very effective for treatment of neck and armpain9,10,11. Approximately 75-90% of patients will have goodpain relief after surgery. The resolution of numbness, weak-ness and bowel and bladder function is less consistent. Aftersurgery there is a 3% chance of developing another disk herni-ation per year12. There is a low risk of complications (2%)11 butcomplications may potentially include: death, stroke, heart at-tack, weakness/paralysis, loss of bowel and bladder function,infection, clots in legs (deep venous thrombosis), clots in thelungs (pulmonary embolus), blood vessel injury, failure of fu-sion, breakage of screws and plates, movement of cage/graft,difficulty swallowing, hoarse voice, but not limited to thesecomplications. Neck pain, numbness and difficulty swallowingor speaking are the most common complaints after surgery andthey usually resolve.When can I go home?Most people are discharged home after surgery. Some patientsare kept over night. Dissolvable stitches are used to close thewound and do not require removal. Sometimes non-dissolvablestitches or staples are used and must be removed. Please askyour doctor prior to discharge.What if I have neck pain or arm pain af-ter surgery?It is normal to have neck pain and soreness from the operationfor few weeks. It is also normal to have pain, numbness andtingling that comes and goes after surgery. You should contactyour doctor right away if you develop difficulty breathing, neck 10
  17. 17. What are my limitations after surgery? Please remove the dressing over your incision the day aftersurgery and wash your incision in the shower. You may usesoap and water. Do not rub your incision. Please do not sub-merge your incision in the bath tub for 2 weeks after surgery.Soaking in dirty bath water may increase your risk of infection. Get plenty of rest after surgery. Avoid driving, bending, ex-tending and twisting of your neck. Most people can return towork 3 to 12 weeks after surgery. Please discuss your specificlimitations with your doctor.Should I use a bone stimulator? Bone stimulators have been found to improve bone healingrates by stimulation of bone cells by electrical fields. They areespecially useful in patients who are at high risk of malunion(the bones not healing together). Patients who should consider abone stimulator include multi-level fusion surgery, revision sur-gery for failed bone fusion, smokers and patients with osteopo-rosis, diabetes and metabolic bone disease. If the fusion doesnot heal this may result in multiple neurological and medialproblems and may require further surgery. The Orthofix, Inc.bone stimulator has been found to improve fusion rates by 15%,from 69% to 84% in high risk patients13. 11
  18. 18. Chapter 1: Cervical Disk HerniationDischarge Instructions1. Strict control of sugar levels in patients with diabetes. Poorly controlled sugar levels may increase risk of infection.2. Do not smoke or use non-steroidal anti-inflammatory drugs. They may interfere with bone fusion.3. Keep wound clean and dry. Please shower the day after sur- gery. Do not submerge your wound in the bath for 2 weeks.4. Use neck collar or bone stimulator as directed by your doc- tor.5. No driving, twisting, bending neck for up to 1 month after surgery.6. Watch for the development neck swelling, difficult breath- ing, problems swallowing, change in your voice, fever, red- ness or drainage from the wound.7. Pain, numbness and weakness often require days to months to resolve.8. Call your doctor if you have any concerns. 12
  19. 19. References1. Connell Md, Wiesel SW. Natural history and pathogenesis of cervical disk disease. Orthop Clin North Am. 1992 Aug;13(4):345-9.2. Omarker K, Meyers RR. Pathogenesis of sciatic pain: role of herniated nucleus pulposus and deformation of spinal nerve root and dorsal root ganglion. Pain 1998 Nov; 78(2):99-105.3. Hou SX, Tang JG, Chen HS, Chen J. Chronic inflammation and com- pression of the dorsal root contributing to sciatica induced by the in- tervertebral disc herniation in rats. Pain 2003 Sep;105(1-2):255-64.4. Sambrook PN, MacGregor AJ, Spector TD. Genetic influences on cervi- cal and lumber disk degeneration: a magnetic resonance study in twins. Arthritis Rheum. 1999; 42(2):366-72.5. Irvine DH, Foster JB, Newel DJ, et al. Prevalence of cervical spondylo- sis in a general practice. Lancet 1965; 1: 1089-1092.6. Kelsey JL, Githens PB, Walter SD et al. An epidemiological study of acute prolapsed cervical intervertebral disc. J Bone Joint Surg AM. 1984 Jul; 66(6):907-14.7. Tan JC, Nordin M: Role of physical therapy in the treatment of cervical disk disease. Orthop Clin N AM 23:435-449, 1992.8. Rexhtine GR: Nonsurgical treatment of cervical degenerative disease. Inst Course Lect. 1999; 48:433-5.9. Whitecloud TS, Werner J. Cervical spondylosis and disk herniation: The anterior approach. In Frymoyer J, (ed): The Adult Spine: Principles and Practice, 2nd ed. Philadelphia, Lippincott-Raven, 1997, pp 1357-1379.10. Sampath P, Bendebba M, Davis JD, Ducker T: Outcome in patients with cervical radiculopathy: Prospective, multicenter study with independent clinical review. Spine 24:591-597, 1999.11. Bruneau M, Nisolle JF, Gillard C, Gustin T. Anterior cervical interbody fusion with hyroxyapatite graft and plate system. Neurosurg Focus 10 (4): Article 8, 2001.12. Hillibrand AS, Carlson GD, Palumbo MA, et al: Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervi- cal arthrodesis. J Bone Joint Surg Am 81:519-528, 1999.13. Orthofix, Inc. PMA Randomized, Prospective Clinical Trial of Pulsed Electromagnetic Field Stimulation for Cervical Fusion, 2004 (unpublished). 13
  20. 20. Chapter 2: Cervical StenosisChapter 2: Cervical Stenosis, Myelopa-thy and Cervical Laminectomy, Instru-mentation and FusionWhat is the spine? The spine is made up of many bones called vertebrae. Thecervical spine or neck is made up of seven vertebrae (figure 1).These vertebrae surround and protect the spinal cord fromdamage. The front of the vertebrae is made up of a squareshaped vertebral body and the back of the vertebrae forms aprotective shield made up of pedicles, lamina and facet joints,called the posterior elements. The vertebrae are held togetherby a spongy disk in the front and strong ligaments in the frontand back. The disk helps cushion the neck. C3 Disk C4Verte-brae C5 Disk Nerve Root C6 Spinal Spinal Cord Cord C7 B.A.Figure 1. Normal cervical spine. A) Side view of cervicalvertebrae C3-C7. B) Top view of a vertebrae on the right. 14
  21. 21. What is cervical stenosis? The spine contains a central cavity called the spinal canal.The spinal cord and spinal nerves are found inside this canal.Normally the spinal canal is wide open and does not impingeupon the cord. Degenerative (“wear and tear arthritis”) maycause narrowing or tightening of the canal. This small canal iscalled cervical stenosis. This often affects people who were al-ready born with a small canal (congenital spinal stenosis).How does cervical stenosis form? As people age, the neck begins to “wear out”. This beginswith the drying out and collapse of the cervical disks1,2. Thiscollapsed disk changes the forces across the spine and results inabnormal motion. To stop this motion the body strengthens theneck by thickening the spinal ligaments and stabilizing the mo-bile joints with bone spurs. This is especially seen behind thevertebral bodies, around the facet joints located at the side ofthe spine and in the ligamentum flavum at the back of the spinalcanal. These changes lead to decrease in the size of the spinalcanal and may result in spinal cord compression (figure 2). Spinal stenosis may result in spinal cord injury and dysfunc-tion. This may be due to compression from the thickened liga-ments and bone spurs, abnormal spinal motion or from interrup-tion of the blood supply1,3,4. Spinal cord dysfunction(myelopathy) commonly presents in middle-age or elderly peo-ple with clumsy hands and difficulty walking. 15
  22. 22. Chapter 2: Cervical Stenosis Bone spurs Thickened ligaments Thickened ligamentsBone spur &disk bulgeA. B.Figure 2. Cervical stenosis is caused by bone spurs and thick-ened ligmaments. It may cause nerve root and spinal cord com-pression. A) Side view and B) top view.Do I have spinal cord dysfunction? Spinal cord dysfunction secondary to spinal stenosis in theneck is called cervical spondylotic myelopathy. This is themost common cause of spinal cord dysfunction in people over55 years old in North America5. Spinal cord dysfunction usuallybegins in middle-age to elderly people. It usually progressesslowly over many years, but may have a rapid progression withdisabling neurological dysfunction.. Spinal cord compression (cervical myelopathy) may be diffi-cult to diagnose because of the variable symptomatology. Itmay range from mild dysfunction with numbness in the handsto complete paralysis of the arms and legs. The symptoms de-pend upon the level of spinal cord affected, the location in thespinal cord and involvement of spinal nerves. The spinal cordbegins at the brain and runs down to the middle of the back to 16
  23. 23. approximately the first lumbar vertebrae (L1). Each part of thespinal cord has specific functions. Injury to the spinal cord af-fects the function of the spinal cord below it. Injury to the spinalcord in the neck may cause weakness or paralysis of the armsand legs. While injury in the upper back only affects the legs.Similarly to the vertical arrangement of function, there is alsoright to left and front to back arrangement of function. Injury tothe right side of the spinal cord may cause weakness on theright side of the body and numbness of the left side of the body(called the Brown Secord Syndrome). Lastly, the involvementof spinal nerves cause characteristic syndromes of pain, numb-ness and weakness and are clinically distinct from spinal cordcompression6. Cervical spinal cord compression most commonly presentswith poor hand coordination and a stiff, unsteady gait. Patientsmay or may not have neck pain. The spinal cord compressionmay increase with head movements (particularly bending thehead forward) resulting in electrical sensations shooting downthe back (Lhermite’s sign) or weakness or paralysis of an ex-tremity. The patient may notice numbness, tingling, weaknessin their arms and occasionally pain. It maybe difficult to per-form activities of daily living like buttoning a shirts latching abra or using fork and knife or chopsticks6. Walking may be-come difficult secondary to weakness, numbness or stiffness inthe legs. At times people may decline in a step wise coursefrom walking independently to using a cane, walker and finallyrequire a wheelchair. Bowel and bladder function are less oftenaffected. Bladder urgency is the most common presentation ofbladder dysfunction. Patients who experience bladder urgencydevelop a sudden need to empty their bladder. If they can notimmediately void they may wet their pants. 17
  24. 24. Chapter 2: Cervical StenosisWhat should I do? If you are experiencing neck or arm pain, numbness, weak-ness or bowel and bladder dysfunction you should see your doc-tor. You will require a thorough history and physical examina-tion, which may include examination of your neck, gait,strength, sensations and reflexes. After an initial assessment, you may require radiological in-vestigations, including x-rays and magnetic resonance imaging(MRI) of the cervical spine. MRI is the best test for looking forspinal cord compression (figure 3). Patients with pacemakers, spinal cord stimulators or othermetal within their body are unable to have an MRI. These pa-tientsA. B.Figure 3. MRI scan of the neck demonstrating severe cervicalstenosis (tightness), spinal cord compression and spinal cordswelling (arrow). Spinal cord swelling is white on T2WI MRI.A) Side view and B) top view. 18
  25. 25. should undergo a computer tomogram (CT) with or without amyelogram. The CT myelogram produces better images thenthe CT alone. A myelogram is the injection of contrast medium(dye) into spinal canal to improve the visibility of the nerves onthe CT (figure 4).Kyphoisis &slipping ofspineSpinal stenosis Small spinal canalA B.Figure 4. CT of the neck showing severe spinal stenosis, abnor-mal bending (kyphosis) and slipping of the C4 on C5 vertebralbodies. A) Side view and B) top view.Should I have surgery? Most patients with spinal cord dysfunction should considersurgery, especially if it is new or progressively worsening. Asmall amount of people may improve without surgery7,8. Thisis presently an area of research. Other indications for surgerymay include pain or severe spinal stenosis with evidence of spi-nal cord injury on MRI. 19
  26. 26. Chapter 2: Cervical StenosisWhat are the surgical treatment op-tions? Surgery for spinal stenosis may be done through the front ofthe neck (anterior) or the back of the neck (posterior) or a com-bination of both (anterior-posterior or 360 degree operation).There are many factors considered when deciding if surgery isthe best treatment and what type of surgery would best treat thepatient. These include the location of the disease in the spine(front, back or both), the stability of the spine (the ability of thespine to keep the spine aligned and prevent abnormal move-ments) and the extent of spinal disease. The patient’s age,medical health and neurological disability are also taken intoconsideration. Anterior surgery is done through an incision in the front ofthe neck. It usually involves removal of one or more cervicaldisks to take pressure off of the spinal cord or nerves.After the disk is removed the disk space is filled with a bonegraft. The spine is then held together with a plate and screws asdescribed in chapter 1. More extensive spinal cord compres-sion may require the removal of the spinal vertebra in additionto disks (figure 5). This removes bony pressure from the verte-bral bodies. This area is then reconstructed with a plastic ormetal cage filled with bone graft and is stabilized with a plateand screws. Posterior decompressive surgery is done through the back ofthe neck. There are many ways to remove pressure from theback of the neck. The treatment options include laminoplasty,laminectomy and laminectomy and lateral mass instrumenta-tion. Laminoplasty is more commonly done in children then adults.The lamina at the back of the spine is removed in one large 20
  27. 27. piece, the spinal cord is decompressed and the lamina is re-placed with small metal plates and screws. Laminectomy is the removal of the lamina to take pressureoff of the nervous structures. This is usually done in adults andis similar to a laminoplasty except the lamina are not replaced.This is similar to a lumbar laminectomy discussed in chapter 5. Laminectomy and lateral mass screw-rod instrumentation isneeded in patients with posterior spinal cord compression andinstability of the spine. This procedure combines decompres-sion with stabilization similar to lumbar spondylolithesis inchapter 6. The lamina are first removed to decompress the spi-nal cord and then small screws and rods are inserted into thelateral mass (the part of the spine beside the lamina whichmakes up part of the facet joints) of the spine to hold it to-gether. Bone graft is also laid onto the lateral mass to promotelong term stabilization through bone fusion. Front and back(anterior and posterior surgery) is sometimes needed for severespinal cord compression or instability. Since similar topics arecovered in other areas of the book, I will discuss the surgery forlaminectomy and lateral mass instrumentation in detail in thischapter.How is a laminectomy and lateral massinstrumentation done? The patient is given antibiotics prior to surgery. They arethen taken to the operating room and are put to sleep under ageneral anesthetic. A tube is placed down their throat to helpthem breath. The patient’s head is secured by a clamp. Thepatient is positioned face down on the operating table. Her 21
  28. 28. Chapter 2: Cervical Stenosis CageA. B.Figure 5. Before (A) and after (B) CT scan of a patient with se-vere cervical stenosis and angulation treated with removal ofcervical vertebral body compression, correction of abnormalangle and placement of plastic cage filled with bone graft andstabilization with plate and screws.head and clamp are secured to the table. The back of her neck isshaved, washed and draped around the operative site. An x-ray machine is used to find the level of the spinal steno-sis. After the correct levels are found, a midline incision ismade. The skin and muscle are retracted from the spine and thespinous process and lamina are exposed (figure 6). The spinousprocesses, lamina and thickened ligaments are removed with adrill and bone biting punches instruments. This removes thepressure off of the spinal cord and spinal nerves. After the neu-ral elements have been decompressed, efforts are then directedat strengthening the spine through the placement of instrumen-tation and fusion. This is done by using short screws placedinto the lateral mass (facet joints). These are usually placed withthe aid of an X-ray machine. After the screws have been suc-cessfully placed they are connected together with rods. Thissame processes is then repeated on the other side of the spine.The bone surfaces are then prepared for fusion by removal of all 22
  29. 29. Spinous process Lateral Lamina Mass / facet joints A. B. Lateral mass screws, rod Thecal sac and and bone spinal cord fusion C.Figure 6. A) The spinous process, lamia and facet joints of theneck were exposed by retraction of the skin and muscles. B)The spinous process and lamina were removed to decompressthe thecal sac containing the spinal cord. C) The spine was sta-bilized by screws, rods and bone fusion 23
  30. 30. Chapter 2: Cervical Stenosissoft tissues and outer bony surfaces from the facet joints/lateralmass with the high speed drill. This promotes strong bony heal-ing at the surgery site. Bone previously removed from thelaminectomy and Infuse ™ sponges (Medtronic, Inc, Memphis,TN) are placed over top of the prepared bone surfaces for fu-sion. Infuse™ is a bone morphogenic protein(BMP) which greatly increases bone healing. The bleeding isstopped and the muscle and skin are brought together with su-tures. Patients are then taken to recovery room.Does surgery work?Surgery is effective treatment for cervical myelopathy. The ma-jority of people see some improvements in their symptoms, butthis maybe small. Patients are rarely cured. Anterior(corpectomy and fusion), posterior (laminectomy, instrumenta-tion and fusion) or combination produced some improvement inapproximately 65-100% of people after surgery depending uponwhich study is reviewed9,10,11,12,13,14. Rates of complications varybetween studies but they may be as high as 8-38%9,10,11,12,14.Complications vary between studies but may include: death,stroke, heart attack, weakness/paralysis, loss of bowel and blad-der function, infection, clots in legs (deep venous thrombosis),clots in the lungs (pulmonary embolus), blood vessel injury,failure of fusion, breakage instrumentation, movement of cage/graft, difficulty swallowing, hoarse voice, but not limited tothese complications.When can I go home?Most people are discharged home 1 to 3 days after surgery. Sta-ples or stitches are removed 10 to 14 days after surgery. Pleaseask your doctor prior to discharge. 24
  31. 31. What if I have pain, numbness or weak-ness after surgery? These symptoms may require several weeks or months to im-prove. It is normal for the symptoms to vary over time. Youshould contact your doctor right away if you develop fever, dif-ficulty breathing, neck swelling, horse voice, severe pain orweakness.What are my limitations after neck sur-gery? You may remove your neck dressing 1 to 2 days after sur-gery. You may shower but do not scrub or submerge your inci-sion in the bath tub for 2 weeks to decrease risk of infection. Get plenty of rest after surgery. Avoid driving, bending, ex-tending and twisting of your neck. Most people can return towork 3 to 12 weeks after surgery. Please discuss your specificlimitations with your doctor.Should I use a bone stimulator? Bone stimulators have been found to improve bone healingrates by stimulation of bone cells by electrical fields. They areespecially useful in patients who are at high risk of the bonenot healing. Patients who are typically suggested to wear stimu-lators include multi-level fusion surgery, smokers, osteoporosis,diabetes, revision (second) surgery and patients with metabolicbone disease. If the cervical fusion does not heal you may re-quire further surgery. The Orthofix, Inc. bone stimulator hasbeen found to improve fusion rates by 15%, from 69% to 84%in high risk patients15. This data has not yet been peer re-viewed. 25
  32. 32. Chapter 2: Cervical StenosisDischarge Instructions1. Strict control of sugar levels in patients with diabetes. Poorly controlled sugar levels may increase risk of infec- tion.2. Do not smoke or use non-steroidal anti-inflammatory drugs. They may interfere with bone fusion.3. Keep wound clean and dry. Please shower the day after sur- gery. Do not submerge your wound in the bath for 2 weeks.4. Use neck collar or bone stimulator as directed by your doc- tor.5. No driving, twisting, bending neck for up to 1 month after surgery.6. Watch for the development neck swelling, difficult breath- ing, problems swallowing, change in your voice, fever, redness or drainage from the wound.7. Pain, numbness and weakness often require days to months to resolve.8. Call your doctor if you have any concerns. 26
  33. 33. References1. Parke WW: Correlative anatomy of cervical spondylotic myelopathy. Spine 1988; 13:831-837.2. Connell Md, Wiesel SW. Natural history and pathogenesis of cervical disk disease. Orthop Clin North Am. 1992 Aug;13(4):345-9.3. Nurick S: The pathogenesis of the spinal cord disorder associated with cer- vical spondylosis. Brain 1972; 95:87-100.4. Panjabi MM, White AA: Biomechanics of nonacute cervical spinal cord trauma. Spine 1988; 13:838-842.5. Cooper P R: Cervical Spondylotic Myelopathy. Contemp Neurosurge 1997; 19 (25): 1-7.6. Kumar VGR, Madden C, Rea GL: Cervical spondylotic myelopathy. In Winn HR (ed): Youmans Neurological Surgery 5th Ed. USA, Saunders, 2004, p 4448.7. Epstein N, Epstein J, Carras R, et al. Coexisting cervical and lumbar steno- sis: Diagnosis and management. Neurosurgery 1984; 15: 489-496.8. Kadanka Z, Mares M, Bednarik J et al.: Approaches to spondylotic cervical myelopathy conservative versus surgical results in a 3-year follow-up study. Spine 2002; 20:2205-2211.9. Rajshekhar V, Kumar GS: Functional outcome after central corpectomy in poor-grade patients with cervical spondulotic myelopathy or ossified poste- rior longitudinal ligament. Neurosurgery 2005 Jun; 56(6):1279-84.10. Chagas H, Domingues F, Aversa A, Vidal Fonseca Al, de Souza JM. Cervi- cal spondylotic myelopathy: 10 years of prospective outcome analysis of anterior decompression and fusion. Surg Neurol 2005; 64 Suppl 1:S1:30-5.11. Kumar VG, Rea GL, Mervis LJ, McGregor JM. Cervical spondylotic mye- lopathy: functional and radiographic long-term outcome after laminectomy and posterior fusion. Neurosurgery 1999 Apr; 44(4):771-7.12. Houten JK, Cooper PR. Laminectomy and posterior cervical plating for multilevel cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament: effects on cervical alignment, spinal cord compres- sion and neurological outcome. Neurosurgery 2003 May; 52(5): 1081-7.13. Chibbo S, Benvenuti L, Carnesecchi S et al. Anterior cervical corpectomy for cervical spondylotic myelopathy: experience and surgical results in a series of 70 consecutive patients. J Clin Neurosci. 2006 Feb; 13(2):233-8.14. Kabok S, Mehmet T, Ufuk T et al. Results of surgical treatment for degen- erative cervical myelopathy. Spine 2004; 29:2493-2500.15. Orthofix, Inc. PMA Randomized, Prospective Clinical Trial of Pulsed Elec- tromagnetic Field Stimulation for Cervical Fusion, 2004 (unpublished).. 27
  34. 34. Chapter 3: Spinal Compression FracturesChapter 3: Spinal Compression Frac-turesWhat is the spine? The spine or backbone is madeup of many bones called vertebrae T1(figure 1). There are 7 cervical ver-tebrae in the neck, 12 thoracic ver-tebrae in the upper back (thorax)and 5 lumbar vertebrae in the lower T6back. The front of the vertebrae ismade up of the vertebral body. Thenormal vertebral bodies have asquare to rectangular shape. Theback of the spine is made up of ped-icles, lamina and facet joints, T12named the posterior elements. Thevertebrae are held together by aspongy disk in the front and strongligaments in the front and back. Thedisk helps cushion the spine andsupport the body’s weight when L5upright. Figure 1. A side viewFigure 1. The side view of the of the spine.spine. 28
  35. 35. Why does the spine break? In young, healthy individuals the verterae are very strong andrequire substantial forces to break them, such as a fall from ahigh height or car accident. Spinal bones may weaken fromosteoporosis, infection or cancer and break from very littletrauma, such as sitting down on a chair, heavy lifting, rollingover in bed, swinging a golf club and falls (figure 2). Osteoporosis is a disease that affects the whole body and ischaracterized by thinning and weakening of the bones. Osteo-porosis affects approximately 10 million Americans and occursin as much as 30% of woman older then the age of 651. Riskfactors for osteoporosis include female sex, increased age,white race, family history of osteoporosis, prior fracture, lowestrogen and low body weight. Other secondary causes includelow estrogen, alcoholism, overactive thyroid or parathyroidglands, poor absorption of nutrients from the gut, anorexia, glu-cocorticoid (“steroid”) and seizure medications1. In the UnitedStates, 700, 000 vertebral compression fractures occur eachyear, more than the number of hip and wrist fractures com-bined2,3. Infection and cancer is a less common, but importantcause of spinal fractures.How do I know my spine is broken? Spinal compression fractures may present with severe pain,weakness, loss of bowel and bladder control or initially mayhave no symptoms at all. Pain is the most common symptom of vertebral body com-pression fractures; it may range from mild to severe. It may beimproved with lying down and worsened by moving, especiallywalking. Approximately 150,000 people per year are hospital-ized in the United States for compression fractures. Fortu-nately, the pain often improves the first month after the frac-ture4. 29
  36. 36. Chapter 3: Spinal Compression Fractures A. B.Figure 2. A) Normal square shaped vertebral body on the left.B) Broken squished wedge shaped vertebral body on right(arrow). Fractures resulting in compression of the spinal nerves or spi-nal cord may result in mild to extreme weakness in the legs, andsometimes paralysis (Figure 3). It may also compress the nervesto the bowel and bladder producing urinary retention or inconti-nence.What should I do? If you are experiencing back pain, weakness or bowel andbladder difficulties you should urgently see your doctor. Youwill require a thorough history and physical examination, whichmay include feeling your back for tenderness, checking yourstrength, sensations and reflexes in your legs. After an initial assessment, you may require radiological in-vestigations, including x-ray and magnetic resonance imaging(MRI) of the spine. MRI is best for finding spinal compression 30
  37. 37. Fractured Compressed vertebral spinal cord bodyFigure 3. MRI scan of T12 compression fracture with collapseof vertebral body compressing the spinal cord causing legweakness (white arrow)fractures and for determining the age of the fractures (figure 4).All MRI tests should include STIR (Short T1 Inversion Recov-ery) imaging, a sequence very sensitive for edema (swelling) inthe vertebral body. Spinal compression fractures with swellingrespond well to treatment5. Patients who are unable to haveMRI scans due to pacemakers, brain aneurysm clips or otherconditions should undergo a CT scan to look at the anatomy ofthe spine and bone scan to look at the age and activity of thefracture. After a vertebral body fracture or any spine disease is diag-nosed, the patient should be referred to a spine surgeon to deter-mine the best treatment for the problem. 31
  38. 38. Chapter 3: Spinal Compression FracturesA. B. C.Figure 4. A) MRI of subacute T12 compression fracture. B)Side and C) Front X-rays of the fracture fixed with percutane-ous balloon kyphoplasty.What may happen without treatment? Vertebral compression fractures may result in pain, physicaland psychological dysfunction sometimes leading to death4. The pain may interfere with mobility and make everydaytasks more difficult or impossible to complete. People oftenrequire assistance at home, hospitalization or placement in anursing home. Without treatment the acute pain may improve,with a loss of swelling on the MRI scan. Sometimes this acutepain may be replaced by chronic long term pain due to changesin spinal shape and mechanics or from pressure of the rib cageon the pelvis4. Unfortunately, this chronic pain is not relievedby vertebroplasty or kyphoplasty. The pain and loss of independence may cause psychologicaldistress leading to sleep disorders, anxiety and depression. 32
  39. 39. The hunched back deformity from multiple thoracic (upperback) fractures may compress the lungs preventing the lungsfrom properly expanding leading to shortness of breath. Thehunched back may also compress the abdomen causing a loss ofappetite, weight loss and malnutrition. Vertebral body compression fractures have been associatedwith increased risk of death.. Woman over 65 years old appearto have a 23% higher death rate after a fracture6. These patientshave two to three times more likely to die of lung disease, espe-cially chronic obstructive pulmonary disease (COPD) and pneu-monia.What are the non-surgical treatment op-tions? There are many treatments for compression fractures rangingfrom bed rest to large spinal instrumentations and fusions4.Traditionally compression fractures have been treated with bedrest with progressive mobilization, spinal bracing (a brace islike a cast for the body), physical therapy, medications (musclerelaxants, anti-inflammatory drugs and narcotics) and surgery4. Immobilization of the broken vertebrae may relieve the pain.This can be accomplished by bed rest, bracing and physicaltherapy. Bed rest decreases movement across the broken spine.Compression fractures are aggravated by standing and walkingand relieved by lying down. Prolonged bed rest is poorly toler-ated and is associated with significant medical risks. Spinalbracing restricts spine movements by squeezing the abdomenand back, but some people find a brace to be uncomfortable.Physical therapy strengthens the back and abdominal musclesto reduce back movements and pain. 33
  40. 40. Chapter 3: Spinal Compression FracturesWhat are the surgical treatmentoptions? Vertebral body compression fractures may collapse, angleforward (kyphosis) or expand into the spinal canal and com-press the spinal cord or nerves. Compression of the spinal cord and nerves requires urgentdecompression to prevent permanent damage (figure 5). Unfor-tunately damage may already be irreversible. Pressure is re-lieved through surgery from the front and/or back of the spine.Afterwards the spine is reconstructed with metal cage filledwith bone and held together with screws, rods and plates. Sur-gery is associated with many risks including death and is rarelyrequired for osteoporosis compression fractures. Most osteoporosis fractures result in the collapse of the bonewithout compression of the nervous tissue. These fractures canbe fixed by the injection of bone cement through a needle.There are two common surgical procedures for treating verte-bral body compression fractures, vertebroplasty and ky-phoplasty4. Vertebroplasty involves the placement of a needle throughthe back into the broken vertebral body. After the needle is inthe correct position liquid plastic (polymethylmethacrylate) isinjected into the fractured bone. The plastic hardens and stabi-lizes the bone preventing painful movements of the vertebrae.Kyphoplasty ™ is similar to vertebroplasty except a balloon isinitially used to expand the vertebral body. Plastic is then in-jected into the cavity after the balloon is removed. Vertebro-plasty and kyphoplasty are very effective at relieving back pain. 34
  41. 41. A. B.Figure 5: Spinal fracture with spinal cord compression on MRIscan (figure 3) treated with removal of broken vertebral body.The spine reconstructed with metal cage and strengthened bymetal plates, screws and rods. A) Side view and B) front view.How is kyphoplasty done?The patient is sedated or put to sleep in the operating room.They are positioned face down on the operating table. Theirback is cleaned and draped for the operation. Under x-ray guid-ance two needles are inserted through the back into the spine(figure 6). Next a balloon is placed through the needle and isinflated to make a cavity and expand the flattened vertebralbody. The balloon is then removed and the cavity if filled withliquid plastic. 35
  42. 42. Chapter 3: Spinal Compression Fractures Normal vertebrae. Broken vertebrae. Needle & balloon inserted. Balloon expanding bone. Cement filling cavity. Broken bone fixed with cement. Figure 6: Fracture reduction and stabilization with balloon kyphoplasty. 36
  43. 43. How do people feel after surgery? Most people have significant improvement in back pain.Studies report greater than 80% significant pain relief 4. Thepain relief is usually immediate, but may be delayed due to lo-cal soreness from the procedure.What are the possible complications? The risk of significant complications with vertebroplasty andkyphoplasty are low, probably less than 1% per fracture treat-ed4. Complications may include death, stroke, heart attack, pa-ralysis, bowel and bladder dysfunction, infection, bleeding, al-lergic reaction and pulmonary embolus, but are not limited tothese complications7. Please discuss these risks with your doc-tor.When can I go home? Most people are discharge home after vertebroplasty. Pa-tients are often kept overnight after Kyphoplasty. Patients maystart showering the next day after surgery. Sometimes stitchesin the wounds may need to be removed 1 week after surgery.What are my restrictions? No heavy lifting, twisting or bending or strenuous activitythe first month after surgery.How do I prevent future fractures? Fractures of the wrist, hip or spine increases the risk of futurebone fractures8. Women who developed vertebral body com-pression fractures are at least 4 times higher risk of developingsubsequent vertebral compression fractures8. Elderly patientswith bone fractures should undergo investigation and treatmentfor osteoporosis. 37
  44. 44. Chapter 3: Spinal Compression Fractures Discharge Instructions 1. Keep wound clean and dry. 2. No lifting greater than 10 pounds, strenuous activity, crawl- ing, stooping, bending or twisting for 1 months after sur- gery. 3. Watch for the development of fever or redness and drainage from the wound. 4. Pain may require many days to resolve. Please alert your doctor of sudden onset of new pain. 5. Call your doctor if you have any concerns. 6. Evaluation and treatment for osteoporosis. 38
  45. 45. Reference1. Wei GS, Jackson JL, Hatzigeorgiou C et al. Osteoporosis managementin the new millennium. Prim Care Clin Office Pract 30 (2003): 711-741.2. Wasnich U. Vertebral fracture epidemiology. Bone 1996; 18:1791-6.3. Melton LJ. Epidemiology of vertebral fractures in women. Am J Epide-miol 1989; 129:1000-11.4. Truumees E, Hilibrand A, Vaccaro AR. Percutaneous vertebral augmen-tation. Spine J 2004; 4(2):218-229.5. Tanigawa N, Komemushi A, Kariya S et al. Percutaneous vertebro-plasty: relationship between vertebral body bone marrow edema pattern onMR images and initial clinical response. Radiology 2006 Apr; 239(1):195-200.6. Kado DM, Browner WS, Palermo L et al. Vertebral fractures andmortality in older women: a prosepective study. Arch Intern Med 1999;159:1215-20.7. Nussbaum D, Gailloud P, Murphey K. A review of complications asso-ciated with vertebroplasty and kyphoplasty as reported to the Food and DrugAdministration medical device related web site. J Vasc Interv Radiol 2004;15:1185-1192..8. Klotzbuecher CM, Ross PD, Landsmann PB et al. Patients with priorfractures have an increased risk of future fractures: a summary of theliterature and statistical synthesis. J Bone Miner Res, 2000; Apr 15(4):721-39. 39
  46. 46. Chapter 4: Lumbar Disk DiseaseChapter 4: Lumbar Disk Disease andLumbar DiskectomyWhat is the lumbar spine?The spine is made up of many bones called vertebrae. The lum-bar spine (low back) is made up of five vertebrae (figure 1).These vertebrae surround and protect the spinal nerves andlower part of the spinal cord from damage. The front of the ver-tebrae is made up of a oval shaped vertebral body and the backof the vertebrae is made up of pedicles, lamina and facet joints,called the posterior elements. The vertebrae are held togetherby a spongy disk in the front and strong ligaments in the frontand back. The disk helps cushion the spine when upright. Nucleus L1 pulposus L2Disk L3 AnnulusSpace Posterior fibrosis L4 ElementsVertebral L5Body S1 Facet Spinal Joint canal Lamina Spinous Process A. B.Figure 1. Side view (A) of the lumbar spine on the left and a topview (B) of a vertebrae with the inner “jelly” core (nucleuspulposus) and the outer doughnut (annulus fibrosis). on theright. 40
  47. 47. What is a lumbar disk? Lumbar disks are located in between the spinal vertebrae andare made up of a tough outer shell (annulus fibrosis) and a softgel-like center (nucleus pulposus). Their structure is similar toa jelly donut (figure 1).Why do lumbar disks pinch nerves? As people age the spine slowly wears out through a processcalled degeneration. Degeneration is first seen in the nucleuspulposus (“jelly center”) and annulus fibrosis (“donut”) inadults in their thirties to fifties1. With time the annulus mayweaken and allow the nucleus to bulge outward into the spinalcanal forming a bulging disk. If the annulus tears, the nucleuscan squeeze out through the tear into the canal and form a herni-ated disk (figure 2). This disease is referred to by many names including slippeddisk, bulging disk, ruptured disk, pinched nerve, herniated nu-cleus pulposus, disk herniation, disk protrusion, disk extrusionor disk sequestration. Even though these terms have specificmeanings they are used interchangeably by most health careproviders. The herniated disk may compress or “pinch off” spinalnerves resulting in back and leg pain, numbness, tingling andweakness. This is commonly referred to as sciatica. This painmay be worsened or maintained by inflammation around thenerve roots. Possible risk factors for ruptured disks are smok-ing, pregnancy, jobs with heavy lifting, repetitive lifting andtwisting or operation of vehicles2. Sometimes the process be-gins after a memorable accident. 41
  48. 48. Chapter 4: Lumbar Disk Disease A. B.Figure 2. Top view (cross section) of the spine. A) Bulgingdisk contain within annulus B) Herniated disk ruptured throughthe annulus (arrows).How do you know your disk is ruptured? The ruptured disk usually begins with back pain and is fol-lowed with the development of leg pain. The leg pain may takedays, months or years to develop after the back pain. The backpain often improves after the leg pain begins. This leg painmay be associated with numbness (loss of feeling), tingling,pins and needles, burning or cold feelings or weakness. Thepain may be worsened by sitting, standing, walking, coughing,sneezing or straining. Rarely, a ruptured disk may present withloss of control of bowel and bladder function with urinary orbowel incontinence or retention. If this develops the personmust seek medical care emergently. 42
  49. 49. What should you do? If you are experiencing back pain, leg pain, numbness or weakness or bowel and bladder difficulties you should urgently see your doctor. You will require a thorough physical examina- tion, which may include feeling your back, testing flexibility of low back and legs, walking and careful testing of strength, sen- sations and reflexes in your legs. After an initial assessment, you may require radiological in- vestigations, including x-rays and magnetic resonance imaging (MRI) of the spine. MRI is the best test for looking for herni- ated disk and nerve root compression (figure 3). Patients with pacemakers, spinal cord stimulators or other metal within their body are unable to have an MRI. These pa- tients should undergo a computer tomogram (CT) with or with- out a myelogram. The CT myelogram produces better images then the CT alone. A myelogram is the injection of contrast medium (dye) into spinal canal to improve the visibility of the nerves on the CT (figure 4). A. B.Figure 3. MRI scan of L4/5 herniated disk on the left side com-pressing the nerve (arrows). A) Side view and B) top view. 43
  50. 50. Chapter 4: Lumbar Disk Disease A. B.Figure 4. A) Saggital (side view) CT myelogram and B) axial(top view) CT myelogram showing a left herniated disk at L5/1compressing the exiting nerve root (arrows).Who should have surgery? Many patients with back and leg pain secondary to a ruptureddisk may improve with non-operative treatments includingphysical therapy, bed rest, non steroidal anti-inflammatorydrugs (NSAIDS), steroids (Medrol dose pack) and epidural ster-oid injections. Patients who should consider surgery include patients whofail to improve with 4 to 8 weeks of conservative therapy, pa-tients with severe pain requiring narcotic medications, like mor-phine, demoral, codeine, or hydrocodone or who require admis-sion to the hospital, patients with weakness, or bowel and blad-der dysfunction (table 1)3. 44
  51. 51. Table 1 Indications for Surgery 1. Failure of conservative treatment 2. Severe pain 3. Leg weakness 4. Loss of bowel & bladder controlWhat are the surgical treatment op-tions? As discussed previously, back and leg pain are a result of theherniated disk compressing the spinal nerve. To relieve thepain surgery must remove the herniated disk and take pressureoff the nerve. The removal of disk is called a discectomy. Adiscectomy can be done by many different techniques, the dif-ference between these procedures is the size of the incision andthe use of a magnification. Traditionally discectomies were done through a large incisionto visualize the disk and nerves. The skin incision and tissuedisruption decreased with the introduction of the operating mi-croscope. It provided better visualization of the vital neuralstructures through improved lighting and magnification. Thishas been further improved with the introduction of tubular re-tractor systems (METRx by Medtronic, Inc, Memphis, TN).This tube system provides the same visualization of the opera-tive site, but reduces incision size, tissue injury, blood loss, in-flammation, pain and hospital stay4,5 . These procedures mayalso be done with an endoscope (which is a snake-like tele-scope) but this technique has not been widely incorporated intoneurosurgical practice because it sacrifices the surgeon’s depthof perception. 45
  52. 52. Chapter 4: Lumbar Disk DiseaseHow is a discectomy done? The patient is given antibiotics prior to surgery. They arethen taken to the operating room and are put to sleep under ageneral anesthetic. A tube is placed down their throat to helpthem breath. They are positioned face down on the operatingtable. Their back is washed and sterile drapes are placed aroundthe operative site. This procedure can be down open or througha tube. The tube procedure is done similar to a standard micro-discectomy, except the skin incision is made just off midline,and the muscle is spread apart instead of stripped off the bone.The tube provides similar visualization of the bone, ligaments,nerves and ruptured disk (figure 5). METRx Disk X-RAY A. B.Figure 5. (A) X-ray machine used to locate the level of the her-niated disk (B) METRx tube docked on the spine over the her-niated disk. Compliments of Medtronics, Inc, Memphis, TN. 46
  53. 53. An x-ray machine is used to find the level of the herniateddisk. After the correct level is found, a small midline incision ismade. The skin and muscle is retracted from the spine and theback (lamina) of the spine is exposed. A window into the spinalcanal is made by removing a small amount of bone and liga-ment (figure 6). The nerve sac (thecal sac) and exiting spinalnerve are identified under the microscope . The sac and nervesare retracted and the herniated disk is identified and carefullyremoved to take pressure off the nerve. After the disk is re-moved, bleeding is stopped and the muscle and skin arebrought together with sutures. Patients are then taken to recov-ery room. Disk remover Disk Nerve RetractorA. B.Figure 6. (A) A window is cut into the bone and ligament illus-trating the herniated disk compressing the nerve. (B) The nerveis retracted and the disk is pulled out from underneath. 47
  54. 54. Chapter 4: Lumbar Disk DiseaseDoes surgery work? Surgery is very effective for relieving back and leg pain froma ruptured lumbar disk6,7,8. Approximately 90% of patients willhave good pain relief after surgery (table 2). This appears to belong lasting9. The resolution of numbness, weakness and boweland bladder problems is less consistent. There is approximately6 –10% risk of a recurrent herniated disk7,10 and 4-11% of com-plications. These complications are usually minor but may in-clude: death, stroke, heart attack, weakness/paralysis, loss ofbowel and bladder function, infection, clots in legs (deep ve-nous thrombosis), clots in the lungs (pulmonary embolus), largeblood vessel injury, scar tissue formation (arachnoditis) and in-stability6,7,8. Table 2: Outcome after disk surgery Pain Relief 90% Recurrent disk 6-10% Complications 4-11%When can I go home? Most people are discharged home the same day after surgery.The wound is closed with deep sutures and do not need to beremoved. Occasionally external sutures may require removal 1-2 weeks after surgery. The patients are seen 2 weeks after sur-gery and are released to return to work if they are doing well. 48
  55. 55. What if I have back pain or leg pain af-ter surgery? It is normal to have back pain for few weeks after surgery.Leg pain, numbness and tingling may come and go after surgeryas the inflammation in the nerve settle. You should contactyour doctor if you develop new pain, weakness or bowel andbladder problems.What are my limitations after back sur-gery? You may remove your back dressing the next day after sur-gery and begin to shower. Please return to work, house dutiesand recreational activities as soon as you feel able to. Most pa-tients return to work two weeks after surgery and can return tofull duty by 8 weeks11. 49
  56. 56. Chapter 4: Lumbar Disk Disease Discharge Instructions 1. Strict control of sugar diabetes. 2. STOP SMOKING! 3. Keep wound clean and dry. 4. You may remove your dressing and shower the day after surgery. 5. Return to work, housework and recreational activities as soon as you feel your are able to. 6. Watch for the development of fever and redness or drainage from the wound. Call your doctor if you have any concerns. 7. Pain, numbness and weakness often require days to months to resolve. Call your doctor if you worsen. 50
  57. 57. References1. Kramer J. Intervertebral disk diseases: causes, diagnosis, treatment and prophylaxis, 2nd ed. New York, Thieme, Medical, 1990.2. Hardy R. Extradural cauda equine and nerve root compression from benign lesions of the lumbar spine. In Youman’s Neurological Surgery. Philadelphia, WB Saunders Company, 1996, pp.2357-74.3. Erico TJ, Fardon DF, Lowell TD. Open discectomy as treatment for herniated nucleus pulposus of the lumbar spine. Spine 20, 16: pp 1829- 1833, 1995.4. Sasaoka R, Nakamura H et al. Objective assessment of reduced inva- siveness in MED compared with conventional one-level laminotomy. Eur Spine J. May 31, 2005.5. Foley KT, Smith MM. Microendoscopic discectomy. Techn Neurosurg 3:301-307, 1997.6. Pappas, CT, Harrington T, Sonntag VK.Outcome analysis in 654 surgi- cal treated lumbar disk herniations. Neurosurgery 30: 862-866, 1992.7. Davis, RA. Long-term outcome analysis of 984 surgically treated herni- ated lumbar disks. J Neurosurg 80:415-421, 1994.8. Sylvain Palmer. Use of a tubular retractor system in microscopic lumbar discectomy: 1 year prospective results in 135 patients. Neurosurg Focus 13 (2): Article 5, 2002.9. Findlay GF, Hall BI, Musa S, Oliveira MD, Fear SC. A 10-year follow- up of the outcome of lumbar microdiscectomy. Spine 23;10:pp 1168- 1171.10. Connolly ES. Surgery for recurrent lumbar disk herniation. Clin Neuro- surgery 39:211-216, 1992.11. Carragee EJ, Han MY, Yang B et al. Activity restrictions after posterior lumbar discectomy A prospective study of outcomes in 152 cases with no postoperative restrictions. Spine 24; 22:pp 2346-2351. 51
  58. 58. Chapter 5: Lumbar Spinal StenosisChapter 5: Lumbar Spinal Stenosis &Lumbar LaminectomyWhat is the lumbar spine? The spine is made up of many bones called vertebrae. Thelumbar spine or low back is made up of five vertebrae (figure1). These vertebrae surround and protect the spinal nerves andlower part of the spinal cord from damage. The front of the ver-tebrae is made up of a oval shaped vertebral body and the backof the vertebrae is made up of pedicles, lamina and facet joints,called the posterior elements. The vertebrae are held togetherby a spongy disk in the front and strong ligaments in the frontand back. The disks help cushion the spine and prevent the ver-tebral bodies from rubbing together. Nucleus L1 pulposus L2 L3 Annulus Posterior fibrosisDisk Space L4 ElementsVertebralBody L5 S1 Nerves to legs, bowel and bladder Lamina Spinous processA. B.Figure 1. The normal lumbar spine. A) Side view and B) topview (axial). 52
  59. 59. The spinal vertebrae surround and protect the spinal canal.The spinal canal contains the spinal nerves (figure 1). Thesenerves connect the spinal cord to the legs, bowel and bladder.They control leg movements and emptying of the bowel andbladder and receive sensory information about touch, pain, jointposition and bladder fullness.What is spinal stenosis? Spinal stenosis is the narrowing of the spinal canal. As peopleage, the lumbar disks dry out and collapse. The body stiffensthe spine by thickening the spinal ligaments and hardening thedisk and facet joints with bone spurs1. Unfortunately, thesechanges result in the narrowing of the spine canal and compres-sion of the nerves and blood vessels (figure 2). This decreasesthe blood supply and oxygen to the nerves producing pain,numbness, tingling and weakness in the legs2. The brain thinksthe legs are the cause of the pain when it is actually the pressurein the back. Surgery relieves pain by removal of mechanicalirritation to the nerves and improving blood supply and drain-age.A. B.Figure 2. Spinal stenosis (narrowed spinal canal) from bonyspurs and thickened ligaments. A) Top view and B) Side view. 53
  60. 60. Chapter 5: Lumbar Spinal StenosisHow do I know I have spinal stenosis? Spinal stenosis usually develops in patients between 50 and80 years old. It is characterized by slowly worsening back andleg pain, numbness, tingling and weakness2,3. The pain may beconstant but is usually brought on by walking or certain posi-tions. It is relieved with sitting, lying down or using a shoppingcart. People sometimes feel like they are walking on a cloud,cotton wool or that their legs do not belong to them. Rarely patients may develop urinary and bowel incontinencewith wetting or bowel movement in their pants or retentionwith the inability to pee or have bowel movements.What should I do? If you are experiencing back pain, leg pain, numbness orweakness or bowel and bladder difficulties you should urgentlysee your doctor. You will require a thorough physical exami-nation, which may include feeling your back, testing flexibilityof low back and legs, walking and careful testing of strength,sensations and reflexes in your legs. After an initial assessment, you may require radiologicalinvestigations including X-rays and Magnetic Resonance Im-aging (MRI) of the spine. MRI is the best test for looking forspinal stenosis and nerve root compression (figure 3). Patients with pacemakers, spinal cord stimulators or othermetal within their body are unable to have an MRI. These pa-tients should undergo a computer tomogram (CT) with or with-out a myelogram. The CT myelogram produces better imagesthen the CT alone. A myelogram is the injection of contrastmedium (dye) into spinal canal to improve the visibility of thenerves on the CT (figure 4). 54
  61. 61. A. B.Figure 3: MRI scan of the lumbar spine with severe spinalstenosis with loss of white spinal fluid signal (arrows) side view(A) and top view (B). A. B.Figure 4: CT myelogram of the lumbar spine with severe spinalstenosis with loss of white spinal contrast dye (arrows) sideview (A) and top view (B). 55
  62. 62. Chapter 5: Lumbar Spinal StenosisWho should have surgery? Patients with spinal stenosis may improve, stay the same orworsen over time. If the spinal stenosis is found to be moderateto severe the pain usually continues to worsen without surgery.On the bright side, most people will not become paralysed orloose control of their bowel and bladder function. If you cantolerate the pain you can continue with normal activities. Many patients with back and leg pain secondary to spinalstenosis may improve with non-operative treatments includingphysical therapy, bed rest, back brace, non steroidal anti-inflammatory drugs (NSAIDS), steroids (Medrol dose pack)and epidural steroid injections. Unfortunately, like surgery thepain relief from conservative treatment maybe incomplete andtemporary. Patients who fail to improve with conservative treatment mayconsider decompression surgery, especially patients with legpain or weakness. Patients with loss of bowel and bladder con-trol may require urgent surgical treatment (table 1). Patients with multiple back surgeries, spondylolithesis(slipping of the spine), scoliosis (abnormal curvature of thespine) may require realignment and stabilization of their spinewith metal screws, rods and bony fusion. This is called a spinalfusion (please see chapter 6). A spinal fusion holds the weak-ened spine together to prevent abnormal movements which maycause back and leg pain. Table 1 Indications for Surgery 1. Severe pain 2. Leg weakness 3. Loss of bowel & bladder control 56
  63. 63. What are the surgical treatment op-tions? Bone spurs and thickened ligaments compress spinal nervesproducing back and leg pain. Surgery removes the pressure offthe nerves, improves blood supply and relieves the pain. Thissurgery is called a laminectomy since the lamina is removed(figure 5). Narrowed spinal canal Thickened spinous proc- ess and laminaFigure 5. The lamina and spinous process (striped area) are re-moved to decompress the nerves in the spinal canal. Spinal stenosis may be treated with a laminectomy through alarge midline skin incision or through a tube (METRx MD byMedtronics Sofamor Danek). Surgery done through a tube re-quires one or more small skin incisions, sometimes on bothsides of the back. This tube system provides the same visualiza-tion of the operative site but reduces incision size and tissue in-jury. 57
  64. 64. Chapter 5: Lumbar Spinal StenosisHow is a laminectomy done? The patient is given antibiotics prior to surgery. They arethen taken to the operating room and are put to sleep under ageneral anesthetic. A tube is placed down their throat to helpthem breath. They are positioned face down on the operatingtable. Their back is washed and sterile drapes are placed aroundthe operative site. An x-ray machine is used to find the level of the spinal steno-sis. After the correct levels are found, a large midline incisionis made. The skin and muscle is retracted from the spine andthe spinous process and lamina of the spine are exposed. Thespinous processes, lamina and thickened ligaments are removedwith a drill and bone biting instruments (figure 6). After thepressure is removed from the nerves, the bleeding is stoppedand the muscle and skin are brought together with sutures. Thepatients is then taken to the recovery room.Spinalcanal Facet joint Lamina and Expanded ligaments spinal canal A. B.Figure 6. Lumbar spinal stenosis, A) The spinal canal is re-duced due to overgrowth of lamina, facets and ligaments B) Theexpanded spinal canal after removal of posterior elements. 58
  65. 65. This procedure can be down through a tube. Procedures donethrough a tube have smaller incision size and are associatedwith less blood loss, pain and shorter hospital stay. They pro-duce less tissue injury and inflammatory response by thebody4,5. The tubular decompression is done similar to a stan-dard laminectomy once the bony lamina of the spine is reached.The main difference is the approach to the spine. In a standardlaminectomy the muscle is stripped off the spine and then re-tracted under high pressure. This may cause permanent muscledamage and back pain. In a tubular laminectomy the muscle isdilated with progressively larger tubes. There is no musclestripping and probably less muscle retraction pressure since thepathway to the spine is smaller. The tube provides good visuali-zation of the bone, ligaments and nerves (figure 7).Figure 7. Bilateral spinal decompression through the METRxMD tube (Compliments of Medtronics Sofamor Danek). 59
  66. 66. Chapter 5: Lumbar Spinal StenosisDoes surgery work? Surgery is effective for improving back and leg pain3,6,7,8,9,10Approximately 55 to 82% of people have good pain relief aftersurgery (see table 1). There is approximately 10-18% risk ofrequiring further surgery in the future8,9,11. Surgery for recurrentspinal stenosis is less successful (usually less than 50%) and areassociated with higher complication rates8. Surgery can besafely done in people older the 75 years old12. There is approximately 12% chance of complication for lum-bar laminectomy surgery7. Most complications are minor, butpossible complications may include: death, stroke, heart attack,weakness/paralysis, loss of bowel and bladder function, infec-tion, clots in legs (deep venous thrombosis), clots in the lungs(pulmonary embolus), large blood vessel injury, scar tissue for-mation (arachnoditis) and instability, but not limited to thesecomplications. Table 2: Outcome after laminectomy Pain Relief 60-70% Recurrent (new) stenosis 10% Complications 10%When can I go home? Most people are discharged home the day of surgery, or oneto two days afterwards. Sometimes stitches in the wound mayneed to be removed 1-2 weeks after surgery. 60
  67. 67. What if I have back pain or leg pain af-ter surgery? It is normal to have back pain related to the surgery for a fewweeks after surgery. Back pain which was present prior to sur-gery may or may not resolve after surgery. It is also normal tohave pain, numbness and tingling that comes and goes aftersurgery as inflammation settles in the nerves. You should con-tact your doctor if you develop severe leg pain or develop newweakness or bowel and bladder problems, especially inconti-nence or inability to urinate.What are my limitations after back sur-gery? You may remove your back dressing the next day after sur-gery and wash your incision in the shower. Please do not bathefor 2 weeks after surgery because bathing may increase yourrisk of infection. Please rest after discharge from the hospital. Remember youhave had recent surgery and do not overdo it! Do not liftgreater than 10 pounds or do any strenuous activities like run-ning, jumping, stooping, crawling, bending and twisting for 4-6 weeks after surgery. Most people can return to work afterthis time. Please discuss your limitations with your doctorsince every person is a little different. 61
  68. 68. Chapter 5: Lumbar Spinal StenosisDischarge Instructions1. Strict control of sugar levels in patients with diabetes. Poorly controlled sugar levels may increase risk of infec- tion.2. STOP SMOKING!3. Keep wound clean and dry. Please shower the next day after surgery, but no baths for 2 weeks.4. No lifting greater than 10 pounds, strenuous activity, crawl- ing, stooping, bending or twisting for 4-6 weeks.5. Watch for the development of fever and redness or drainage from the wound. Call your doctor if you have any concerns.6. Pain, numbness and weakness often require days to months 62
  69. 69. References1. Yong-Hing K, Kirkaldy-Willis WH. The pathophysiology of degenera- tive disease of the lumbar spine. Orthop Clin North Am 14:491-504, 1983.2. Watanabe R, Park WW: Vascular and neural pathology of lumbosacral , spinal stenosis: J Neurosurg 64:64-70, 1986.3. Lemaire JJ, Sa5r2utreaux JL, Chabannes J, et al: Lumbar canal stenosis: Retrospective study of 158 operated cases. Neurochirurgie 41:89-97, 1995.4. Sasaoka R, Nakamura H et al. Objective assessment of reduced inva- siveness in MED compared with conventional one-level laminotomy. Eur Spine J. May 31, 2005.5. Foley KT, Smith MM. Microendoscopic discectomy. Techn Neurosurg 3:301-307, 1997.6. Herron LD, Mangelsdorf C: Lumbar spinal stenosis: Results of surgical treatment. J Spinal Disord 4:26-33, 1991.7. Atlas SJ, Deyo RA, Keller RB, et al: The Main lumbar spine study, Part III. 1 year outcomes of surgical and non-surgical management of lumbar spinal stenosis. Spine 21(15): 1787-1794, 1996.8. Jonsson B, Annertz M, Sjoberg C, et al. A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part II. Five year fol- low-up by an independent observer. Spine 22:2938-2944, 1997.9. Katz JN, Lipson SJ, Larson MG, et al. The outcome of decompressive laminectomy for degenerative lumbar spinal stenosis. J bone Joint Surg Am 73:809-813, 1991.10. Turner JA, Ersek M, Herron L, et al. Surgery for lumbar spinal stenosis: Attempted meta-analysis of the literature. Spine 17:1-8, 1992.11. Herno A, Airaksinen O, Saari T: Long-term results of surgical treatment of lumbar spinal stenosis. Spine 18: 1471-1474, 1993.12. Vitaz TW, Raque GH, Shields CB, Glassman SD: Surgical treatment of lumbar spinal stenosis in patients older than 75 years old of age. J Neu- rosurg 91(2 Suppl): 181-5, 1999. 63
  70. 70. Chapter 5: Lumbar SpondylolisthesisChapter 6: Lumbar Spondylolisthesis &Lumbar FusionWhat is the lumbar spine? The spine is made up of many bones called vertebrae. Thelumbar spine or low back is made up of five vertebrae (figure1). These vertebrae surround and protect the spinal nerves andlower part of the spinal cord from damage. The front of the ver-tebrae is made up of a square shaped vertebral body and theback of the vertebrae is made up of pedicles, lamina and facetjoints, called the posterior elements. The vertebrae are held to-gether by a spongy disk in the front and strong ligaments in theback. The disk helps cushion the spine. Nucleus L1 pulposus L2 L3 Annulus Posterior fibrosisDisk Space L4 ElementsVertebralBody L5 S1 Nerves to legs, bowel and bladder A. B.Figure 1. The normal lumbar spine. A) the side view and B) thetop view (axial). 64
  71. 71. What is lumbar spondylolisthesis? Lumbar spondylolisthesis is the slipping of the spine. Thevertebral body slips forward over the lower vertebral body(figure 2). There are many possible causes of spondylolisthesis. Thespine may slip because the spine was made abnormally frombirth (congenital spondylolithesis), broke in early childhood(isthmic spondylolithesis), from an injury (traumatic spondylo-lithesis), infection or tumor (pathologic spondylolithesis) or“wearing out” from aging (degenerative spondylolithesis). Thespine may also weaken and slip after back surgery. The mostcommon causes of spondylolithesis are isthmic (the pars of theposterior elements break in early childhood) and degenerative(the spine wears out and can no longer hold the bones to-geather). Isthmic spondylolithesis usually presents in early adulthood.It may be caused by repeated injuries to the posterior elementsof the spine by walking, gymnastics or football1. The posteriorelements act as a hook to hold the spine together. If part of thishook breaks (that is the pars interarticularis) then the spine cannot hold itself together and may result in spinal instability andthe spine slipping apart (figure 2). This instability and slip maycause back pain. The body forms scar tissue around the brokenpars in attempt to heal the break, unfortunately this scar tissuemay compress spinal nerves and cause leg pain, numbness andweakness. Degenerative spondylolithesis presents in later adult hood andis more common in black females2. It is usually associated withspinal stenosis (chapter 5) and presents with severe back and legpain. The spine is held together by the disk in the front and theposterior elements in the back. The posterior elements form ahook (made up of the pars and facet joint) which keeps it 65
  72. 72. Chapter 5: Lumbar Spondylolisthesis A. B. Figure 2: Isthmic spondylolithesis. The posterior hook holds the spine together. If the pars interarticularis (arrows) breaks the spine can no longer hold the vertebrae together and they may slip apart. Side view (A) and rotated view (B). attached to the vertebrae above and below. As the spine ages and becomes worn out the disk and facet joints weaken and al- low the spine to slip apart (figure 3). This “wear and tear” re- sults in thickening of ligaments, scar tissue and formation of bone spurs which may compress nerves causing pain, numbness and weakness in the legs. How do you know your back is slipping? Patients with spondylolithesis present with back pain and leg pain, numbness and weakness. The back pain may be constant but usually varies with positon. The pain is worsened by stand- ing or walking and improved by lying down. Patients with lytic spondylolithesis may develop disabling deformities of their body including stiffness, “square” buttock, scoliosis, waddling gait3. It is uncommon to have problems with bowel and bladder function with spondylolithesis. 66
  73. 73. What should you do? If you are experiencing back pain, leg pain, numbness orweakness or bowel and bladder difficulties you should urgentlysee your doctor. You will require a thorough history and physi-cal examination, which may include feeling your back, testingflexibility of low back and legs, walking and careful testing ofstrength, sensations and reflexes in your legs. After an initial assessment, you may require radiological in-vestigations including X-rays and Magnetic Resonance Imaging(MRI) of the spine. MRI is the best test for looking for spinalstenosis and nerve root compression (figure 4). Patients with pacemakers, spinal cord stimulators or othermetal within their body are unable to have an MRI. These pa-tients should undergo a computer tomogram (CT) with or with-out a myelogram. The CT myelogram produces better images A. B.Figure 4. MRI scan of lumbar spondylolithesis of L5 on S1 ver-tebrae (see arrows). A) Side view and B) top view on the right. 67
  74. 74. Chapter 5: Lumbar Spondylolisthesisthen the CT alone. A myelogram is the injection of contrastmedium (dye) into spinal canal to improve the visibility of thenerves on the CT (figure 5). A CT scan may also be ordered inaddition to a MRI scan to look more closely at the bone anat-omy for planning the placement of the screws. A. B.Figure 5. CT Scan of lumbar spondylolithesis of L5 on S1 ver-tebrae. A) Side view and B) top view.Who should have surgery? Some patients with back and leg pain secondary to spinalspondylolithesis may improve with non-operative treatmentsincluding physical therapy, bed rest, back brace and non ster-oidal anti-inflammatory drugs (NSAIDS), steroids (Medrol dosepack) and epidural steroid injections. Unfortunately, half of the patients fail to improve with con-servative treatments alone. These patients who fail to improvemay consider surgery (table 1). The treatment for spondylo-lithesis is spinal decompression, instrumentation and fusion(table 1). Patients with significant spinal deformity may requirerealignment of the spine. 68
  75. 75. Table 1 Indications for Surgery 1. Severe pain 2. Leg weakness 3. Loss of bowel & bladder control (rare) 4. Slip worsening over time 5. Severe slipWhat are the surgical treatment op-tions? Surgery for spinal spondylolithesis have significantly ad-vanced over the years. Initial surgery consisted of a decompres-sive laminectomy with removal of the back of the spine (seechapter 5) to decompress the spinal nerves and relieve leg pain.Unfortunately this did not treat the back pain and resulted infurther slipping of the spine. This lead to development of bonyfusions to make the spine solid and prevent slips. Unfortu-nately, it takes a long time for the body to fuse the spine andsometimes fusion did not occur. Most people believe the intro-duction of metal screws and rods fixed these problems. Thespine is now held rigidly together by screws and rods until thebones heal (figure 6). The newest advancement in spinal fu-sions are the discovery of bone morphogenic protein (BMP), abone “hormone” which improves fusion rates and minimal inva-sive surgery which decreases tissue injury and increases patientlevel of satisfaction4. 69
  76. 76. Chapter 5: Lumbar Spondylolisthesis A. B.Figure 6. Post operative X-rays of the lumbar spine after de-compression, pedicle screw instrumentation and fusion. A) Sideview and B) front view.How is a fusion done? The patient is given antibiotics prior to surgery. They are thentaken to the operating room and are put to sleep under a generalanesthetic. A tube is placed down their throat to help thembreath. They are positioned face down on the operating table.Their back is washed and sterile drapes are placed around theoperative site. An x-ray machine is used to find the level of the spinalspondylolithesis. After the correct level is found, a midline in-cision is made. The skin and muscle is retracted from the spineand the back of the spine (spinous process and lamina) are ex-posed. The spinous processes, lamina and thickened ligamentsare removed with a drill and bone biting instruments. After thelaminectomies are completed and the pressure has been 70
  77. 77. removed from the nerve roots and nerve sac, efforts are thendirected towards placing the instrumentation and fusion. Placement of the pedicle screws requires a detailed three di-mensional knowledge of the spine. Pedicle screws are usuallyplaced with the aid of an x-ray machine. The pedicle (which ispart of the posterior elements) is located using bony spinal land-marks and the x-ray machine. A tunnel is then created throughthe pedicles into the vertebral body (figure 7). After verifyingthe correct pathway, the screws are placed. Two screws areplaced in each vertebral body. To hold the screws together andprevent abnormal spinal movement between the vertebral bod-ies the screws are connected by a rod on each side of the spine(two rods in total). The rods are sometimes connected to eachother with a cross connector to increase the strength of the in-strumentation.InterbodygraftFigure 7. L4-5 transforaminal interbody fusion (TLIF) with in-terbody graft in the front and pedicle finding instruments in theback of the vertebrae. 71

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