Surgical Procedures

Anterior Cervical Discectomy and Fusion (ACDF)

What is anterior cervical discectomy with fusion?

Anterior cervical discectomy with fusion is an operative procedure to relieve compression or pressure on nerve roots and/or the spinal cord due to a herniated disc or bone spur in the neck.

In anterior cervical discectomy with fusion, the surgeon approaches the cervical spine through a small incision in the front of the neck and removes the total disc or a part of the disc along with any bony material that is compressing or putting pressure on the nerves and producing pain. Spinal fusion implies placing a bone graft between the two affected vertebral bodies encouraging the bone growth between the vertebrae. The bone graft acts as a medium for binding the two vertebral bones, and grows as a single vertebra that stabilizes the spine. It also helps to maintain the normal disc height.

Who needs this surgery?

Herniated disc is a condition in which the soft, gel-like center of the disc (nucleus pulposus) bulges out through the damaged or broken disc’s tough, outer ring (annulus fibrosus). Besides, bony out growths also known as bone spurs or bone osteophytes are formed due to the accumulation of calcium in the spine joints. The pressure induced by a herniated disc or bone spur on nerve roots, ligaments or the spinal cord may cause pain in the neck and/or arms, numbness or weakness in the arms, forearms or fingers, and lack of coordination.

As most nerves to the body (e.g., arms, chest, abdomen, and legs) pass through the neck region from the brain, pressure on the spinal cord in the neck region (cervical spine) can be very problematic. Patients with these symptoms are potential candidates for anterior cervical discectomy procedure but only after non-surgical treatment methods fail. Cervical discectomy can reduce the pressure on the nerve roots and provides pain relief.

Before recommending surgery, your surgeon considers several factors such as your health condition, age, lifestyle and anticipated level of activity following surgery. A thorough discussion with your surgeon regarding this treatment option is advised before scheduling the surgery.

How is the procedure performed?

Your surgeon makes a small incision in the front side of the neck and locates the source of neural compression (pressure zone). Then, the intervertebral disc that is compressing the nerve root will be removed. Afterwards, a bone graft will be placed between the two vertebral bodies. In certain instances, metal plates or pins may be used for providing enough support and stability, and to ease the fusion of the vertebrae.

How much time it will take for complete recovery?

A specific post-operative recovery/exercise plan will be given by your physician to help you return to normal activity at the earliest possible. The duration of hospital stay depends on this treatment plan. You will be able to wake up and walk by the end of the first day after the surgery. You would be able to resume your work within 3-6 weeks, depending on your body’s healing status and the type of work/activity that you plan to resume. Discuss with your spinal surgeon and follow the instructions for optimized healing and appropriate recovery after the procedure.

What are the possible risks or complications?

Treatment results are different for each patient. In addition to the anesthetic complications, spinal surgery is associated with some potential risks such as infection, blood loss, blood clots, nerve damage, and bowel and bladder problems. Failure to fuse the vertebral bones with the bone graft (fusion failure) is an important complication of spinal fusion which requires an additional surgery.

Please take your physician’s advice for a complete list of indications, clinical results, adverse effects, warnings and precautions, and other relevant medical information about the anterior cervical discectomy with fusion surgery.

Posterior Cervical Laminectomy and Fusion

Cervical stenosis refers to narrowing of the spinal canal in the neck region. This narrowing places pressure over the spinal cord resulting in neck pain. Other symptoms include lack of coordination, loss of balance during walking, tingling in the arms and/or legs, and even loss of bowel and bladder control. Some of the spinal conditions that may compress the spinal cord and nerve roots include disc degeneration, bulging or herniated disc, spinal stenosis, and spondylosis. Occasionally, there may be multiple disc bulges at various levels and the ligaments may buckle into the spinal canal, causing spinal stenosis.

Posterior cervical laminectomy is often performed for multilevel spinal cord compression from cervical spinal stenosis to decompress the spinal cord and nerve roots in the cervical region of the spine.

In cervical laminectomy, the lamina and spinous process are removed to create more room for the spinal cord and take pressure off it. In patients with severe stenosis, laminectomy may need to be performed at three or more segments and a posterior longitudinal ligament (OPLL) resection may also be required for decompression.In such cases, a posterior approach is preferred over an anterior approach as it is generally technically easier to perform. With multilevel laminectomy alone, there is a post-operative risk of developing instability that may lead to pain and deformity. To prevent this, usually a posterior fusion is also performed along with multilevel posterior cervical laminectomy. Fusion at three or more levels from the front can be difficult. Therefore the procedure will be accompanied by a posterior cervical fusion to support the vertebrae with a bone graft.

Procedure

In posterior cervical laminectomy, the surgery is performed through a 3 to 4 inch longincision made in the midline of the back of the neck. After the muscles are elevated off of the lamina, the lamina along with the spinous process is removed as one piece with a high speed burr creating more space for the spinal cord. Usually, local autograft bone harvested from the patient’s neck or bone from the iliac crest is then inserted into the empty space between the affected vertebrae to stimulate new bone growth. Instrumentation such as rods and screws are also placed into the spine to hold the vertebrae together during the healing process.

Risks and complications

All major surgical procedures are associated with some risks. The potential risks of multilevel posterior cervical laminectomy and fusion includeinfection, bleeding, risks of anesthesia, nerve injury, and fusion failure.

The results of the surgery may be variable in some people with more extensive disease.

Generally most patients find improvement in their hand function and walking capabilities after the surgery.

Posterior Cervical Foraminotomy

Posterior cervical microforaminotomy/discectomy is an operative procedure that relieves pressure or compression on the nerve roots at the cervical spine.

The cervical region (neck area) forms the upper portion of the spine. A series of cervical vertebrae, C1-C7 connects the cervical spine to the skull. The massive nerve supply to the head, neck, and upper portions of the shoulders and arms is by the spinal nerve roots that branch out from the cervical spine. Nerves exit spinal cord through an opening called foramen- a tunnel or space through which a spinal nerve exits the spine. Herniation of disc (disc damage) or spinal stenosis (narrowing of spinal canal) can narrow the foramen, and pinches or compresses the nerve structures in the neck region leading to pain, weakness and limited movement in the hands and arms.

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Lumbar Microdiscectomy

Microdiscectomy is a surgical procedure employed to relieve the pressure over the spinal cord and/or nerve roots, caused by a ruptured (herniated) intervertebral disc. A herniated disc, common in the lower back (lumbar spine) occurs when the inner gelatinous substance of the disc escapes through a tear in the outer, fibrous ring (annulus fibrosis). This may compress the spinal cord or the surrounding nerves, resulting in pain, sensory changes, or weakness in the lower extremities.

It is usually indicated in patients with herniated lumbar disc, who have not found adequate pain relief with conservative treatment. This procedure involves the use of microsurgical techniques to gain access to the lumbar spine. Only a small portion of the herniated disc that compresses the spinal nerve is removed.

Procedure:

A microdiscectomy is performed under general anesthesia. Your surgeon will make a small incision in the midline over your lower back. Through this incision, a series of progressively larger tubes are placed and positioned over the herniated disc. The affected nerve root is then identified. Your surgeon removes a small portion of the bony structure or disc material that is pressing on the spinal nerve using microsurgical techniques. The incisions are closed with absorbable sutures and covered with a dressing.

Postoperative Care:

Following the surgery, patients will be discharged home on the same day or the next day. Post-operatively, patients are advised to gradually increase their activity levels. If required, physical therapy is started after four to six weeks of the surgery to improve strength and range of motion.

Benefits of microdiscectomy include:

  • Less muscle and soft tissue disruption
  • Shorter recovery time
  • Minimal postoperative pain and discomfort
  • Fewer risks of complications

 

Lumbar Laminectomy

Lumbar laminectomy is a surgical procedure that is performed in patients who have lumbar spinal stenosis and who have not responded to conservative treatment. To learn more about lumbar spinal stenosis, click here. Lumbar laminectomy is also referred to as "lumbar decompression". These two terms (laminectomy and decompression) essentially mean the same thing, as the purpose is to relieve pressure off of spinal nerves.

The most important point to understand about lumbar laminectomy is that it involves removing the bone (called lamina), bone spurs, and ligaments that are pinching the nerves. This surgery is very effective in decreasing or relieving symptoms in the buttocks, thigh, calf and foot. Although some patients also have improvement in back pain, the primary purpose of the surgery is to relieve your leg symptoms. If your main complaint is low back pain, this surgery is not a good option.

You may be wondering what happens to the spine if the lamina is removed. A common question is whether anything is put back in its place. The answer is that in the absence of instability, nothing is put back in its place. A fusion is not performed unless the spine is unstable to begin with. For more discussion on spinal instability, click here. Consider the following analogy (it’s not a perfect analogy but it gets the point across). Think of the spine as a house. Now a house has a floor, wall/foundations and a roof. The spine also has foundations – these foundations are called the facet joints and the disc. Each level in your spine has 2 joints, one on the left and one on the right. You also have the disc in the front. So the foundations of the spine are these 2 joints and the disc. So a spinal level is similar to a tripod – the 3 legs of the tripod are the 2 joints and the disc. As long as the legs of the tripod are not disrupted, the spine remains stable. A laminectomy is akin to removing the roof of the house, without disupting its foundations (or joints). This procedure has been performed for decades and has had excellent results.

Preparing for Surgery

  • About 2-4 weeks prior to your surgery, you should see your primary care physician for a complete medical examination and for "medical clearance". Your doctor may order tests prior to your surgery to evaluate your risk of being put under general anesthesia.
  • If you take the following medications, stop taking them for 1 week prior to surgery:
    • Aspirin, anti-inflammatory drugs (Ibuprofen, Advil, Motrin, Aleve, Naprosyn, Celebrex, Mobic, Arthrotec, Voltaren, etc.), Vitamin E and Glucosamine, all prescription diet medications or herbal supplements
    • If you take Plavix, Persantine, Ticlid, stop these medications 1 week prior to surgery but be certain to notify your primary care physician or cardiologist before you stop taking these medications.
  • If you take Coumadin for any reason, you should stop taking Coumadin 5 days prior to surgery, but be certain to notify your primary care physician or cardiologist before your stop taking this medication to ensure it is safe for your situation.
  • YOU SHOULD CONTINUE all other medications that you normally take.
  • Please let me and the anesthesiologist know about alcohol use. If you drink more than 2 alcoholic beverages a day, you may experience withdrawal symptoms after surgery. Symptoms may include mild shakiness, sweating, hallucinations and other more serious life-threatening side effects. Interventions can be taken before surgery to minimize withdrawal symptoms.
  • Do not eat or drink anything (including water) after midnight the night before your surgery.
  • You should make plans to have some assistance at home after your surgery. The level of assistance you need depends on the extent of the surgery, your age, and general health.

Surgical Risks

A lumbar decompression is generally a very safe and effective surgery for relief of leg pain. Many precautions are taken to prevent or minimize risks but because human biology is at times unpredictable, no surgery is risk free. Risks of the operation include, but are not limited to: infection, anesthesia related complications, pneumonia, blood clots in the legs, tear of the nerve sac (called a "dural tear"), weakness of the legs and injury to the nerves. Some of these complications are more common if you have had previous surgery on your back. The most common complication is a dural tear, especially if you have had previous surgery on your back. If a dural tear does occur, it will be repaired during surgery, and after surgery you will remain flat in bed for a couple of days. The reason you will be flat in bed is to eliminate gravity and thus allow the repair to heal. There are no longtermsequelae from a dural tear if it is treated appropriately, but it will change your postoperative care for the first couple of days after surgery, the main change being the flat bedrest.

Hospital Care

On the day of surgery, I will see you before you go back to the operating room to answer any additional questions you may have. You will then be taken back to the operating room where the anesthesiologist will give you either a general or spinal anesthestic. The surgery itself usually takes between 45 minutes to 2 hours, depending on the severity of stenosis and the number of spine levels involved. The preparation time (positioning, anesthesia) may add another 20-30 minutes to the surgery.

After the surgery, you will be taken to the recovery room where your blood pressure, temperature, pulse and respiration will be checked frequently. You will stay in the recovery room for one to three hours. Meanwhile, I will speak with your family or friends in the waiting room regarding your condition. You will then be transferred to a regular hospital room. You will be given IV fluids until you are able to drink on your own. You will also be given IV pain medication initially, and then oral pain medication depending on your level of pain.

Although the nerves have been freed, they are still injured. The pain, numbness, or tingling in your legs usually begins to improve shortly after the surgery. In some cases, it may take longer (several days to a couple of weeks) before an improvement is noticed. Nerves sometimes heal slowly and the healing rate depends on how long the nerve has been pinched and how much damage there is to it. Every patient experiences this healing process differently.

You will be discharged from the hospital when the following goals have been met:

  • Your pain is reasonably controlled with oral pain medication
  • You are able to eat a meal without nausea or vomiting
  • You are able to walk safely on your own
  • You are able to urinate on your own.
  • Your vital signs (temperature, blood pressure, heart rate, respiration) are normal.

Depending on how soon the above goals are met, some patients are able to go home the same day or the day after surgery while others require two days in the hospital.

At Home After Surgery

The post-operative instructions outlined below will give you the best chance of having a positive outcome from this surgery:

  • Take short walks as your comfort allows. You can start walking the morning after your surgery. Gradually increase the amount of walking you do each day. Walk 15-30 min three times a day. Your goal is to walk 1 mile by end of one month after surgery.
  • Avoid bending over at the waist, twisting or bending motions for the first 6 weeks. Do not bend over to tie your shoe laces. Also avoid lifting anything heavier than 20 lbs for the first 6 weeks.
  • Avoid all strenuous activities for 6-8 weeks. Do not lift heavy bags or luggage. Use proper lifting technique: when picking an object off the ground, bend at your knees, not at the waist.
  • Wound care:
    • On the second day after your surgery, you can take a shower but keep your incision covered with gauze and Tegaderm dressing to keep the incision dry. After showering, pat the incision dry and cover it with a new dressing.
    • Keep your incision covered with Tegaderm dressing for 1 week when you take a shower. After that, you can shower without anything covering your dressing as long as there is no drainage from the incision. Do not take baths or soak your incision (swimming, etc.) until your wound is fully healed, usually at around 3 weeks.
    • Do not apply any lotions or creams to the incision.
  • Reasons to contact us immediately:
    • If there is any redness around the incision
    • If there is any drainage from the incision after the second day.
    • If you have a fever higher than 101 deg F.
    • If your leg pain or numbness is significantly worse than before surgery. You should expect some pain and stiffness in your low back from the surgery. This improves with time as the wound heals.
    • If you have any problems with bowel or bladder function, you should go to the emergency department right away.
  • Returning to work depends on your occupation and your employer’s acceptance of your activity restrictions.
  • You may resume sexual activity as your comfort allows. Please keep in mind the activity restrictions listed above.
  • I will see you in the office 2-3 weeks after your surgery. If you do not have an appointment, please contact the office.
  • After 6 weeks, you may need physical therapy depending on your progress. The therapist will help you strengthen your back muscles with back exercises. These exercises should be part of your lifelong fitness program. The therapist will also teach you about doing everyday tasks with proper body mechanics.

 

Posterior Lumbar Fusion

Spinal fusion, also called arthrodesis, is a surgical technique used to join two or more vertebrae (bones) within the spine. Lumbar fusion technique is the procedure of fusing the vertebrae in lumbar (lower back) portion of the spine.

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Pedicle Subtraction Osteotomy

Spine osteotomy is a surgical procedure in which a section of the spinal bone is cut and removed to allow for correction of spinal alignment. Spine osteotomy is usually needed for correction of severe deformed, rigid and fixed spinal deformity when nonsurgical treatments do not relieve symptoms such as numbness, weakness, or pain due to nerve compression or when deformity is getting worse over time. A mild or flexible deformity is usually corrected through positioning and instrumentation.

Severe spinal deformity may occur in conditions such as Scheuermann’s kyphosis, iatrogenic flat back, post-traumatic, neuromuscular, congenital, degenerative disorders and ankylosing spondylitis. Severe deformity causes symptoms that may include a subjective sense of imbalance, leaning forward (stooping), early fatigue, intractable pain and difficulty of horizontal gaze. A spine osteotomy procedure significantly improves these symptoms. A spine osteotomy reduces pain and restores balance so that the patient can stand erect without the need to flex their hips or knees. It also improves the gross appearance (cosmesis) of the patient and even makes a horizontal gaze possible to perform. Functional improvement of the visceral organs may also occur.

Spine osteotomies can be broadly divided into three main types. The type of osteotomy used depends on both the location of the spinal deformity and on the amount of correction that is required. A spinal fusion with instrumentation may also be performed along with spine osteotomy to stabilize the spine and prevent further curvature. The three main types of osteotomy are:

Pedicle Subtraction Osteotomy (PSO): PSO is recommended generally in patients in whom a correction of approximately 30° is required mainly at the lumbar level. PSO involves all three posterior, middle, and anterior columns of the spine. It involves the removal of posterior element and facet joints similar to a SPO and also removal of a portion of the vertebral body along with the pedicles. PSO allows for more correction of the lordosis than SPO.