Surgical treatments are considered only after conservative treatment options have failed. We are unique in our approach towards planning and performing each surgery – this approach has been tailored with a view to ensuring the best outcomes for our patients.
A herniated disc is a common problem that occurs in the lower back and neck. The intervertebral discs that lie between adjacent vertebrae (spinal bones) act as shock absorbers that take pressure off the spine during weight-bearing activities. When the inner portion of the disc protrudes past the outer portion and into the spinal canal, a disc is said to have herniated or slipped. Often times, a herniated disc can pinch a spinal nerve and cause back and/or extremity pain and a host of other unpleasant symptoms.
A herniated disc can occur when lifting an object without proper form or when lifting an object that is too heavy. It can also occur as a result of the following conditions:
- Degenerative disc disease
- Osteoarthritis of the spine
Smoking and overuse also increase the likelihood of a disc herniating.
The symptoms of a herniated disc may be experienced in the spine or the extremities. They include the following:
In rare cases, loss of bladder control may occur.
A herniated disc can usually be treated using non-surgical treatment options such as the following:
- Nonsteroidal anti-inflammatory drugs. Medications that reduce pain and swelling.
- Activity modification. Slowing down or stopping activities that are painful.
- Physical therapy. Strengthening and stretching the neck and back muscles help protect and take pressure off the spine.
- Ice. Applying ice to painful areas decreases pain and inflammation.
Patients with a herniated disc should be extra careful when lifting objects and/or bending over as those movements can make the condition worse. Patients who do not get relief from nonsurgical treatments may benefit from a cortisone injection. A quick procedure is performed to inject powerful anti-inflammatory medications into the painful area. If this does not work, the condition may need to be treated using surgical intervention.
A herniated disc may be repaired by removing the part of the disc that is herniated. This is known as a microdiscectomy. A procedure that removes the entire disc and then fuses adjacent vertebrae may also be used. This is known as a microdiscectomy and vertebral fusion. The decision regarding which procedure to perform is based on the severity of the condition and the opinion of the orthopaedic surgeon who is treating it.
Degenerative Disc Disease
Degenerative Disc Disease is a term used to describe the changes that occur to the intervertebral discs of the spine with age. While aging, the intervertebral discs decrease in size and height. They also lose water content. The combination of these factors may cause the discs to dry, weaken, or herniate. Osteoarthritis and spinal stenosis may develop as a result of degenerative disc disease.
Degenerative disc disease occurs to varying degrees with age. Risk factors that may cause patients to see greater disc degeneration and accompanying symptoms include the following:
- Performing manual labor that involves constantly lifting heavy objects
Any of the vertebral discs can degenerate; however, those of the neck and lower back are the ones that most often do.
Degenerative disc disease in its early stages typically does not cause symptoms. When symptoms do appear, they range in type and severity. Pain in the neck, back, buttocks, or leg may occur. So may tingling, weakness, numbness, and burning. In some cases, symptoms may not bother patients. In others, they can be limiting or debilitating.
A medical history, physical exam, and medical imaging studies are used to diagnose degenerative disc disease.
Non-surgical treatment options that are used include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs). Pain and anti-inflammatory medications. Examples include naproxen and ibuprofen.
- Ice. Pain and inflammation can be reduced with ice.
- Physical therapy. Exercises improve muscle flexibility and strength, which decreases pain and may prevent future injury.
- Activity modification. Modifying activities that cause pain helps manage symptom frequency and severity.
- Immobilization. A temporary brace may be worn to take pressure off the spine.
Diet and exercise may be used to improve bone health. A diet high in calcium and vitamin D ensures bones grow and remain strong. Exercise increases bone density and muscle mass.
Degenerative disc disease is not treating using surgery. However, osteoarthritis, spinal stenosis, and vertebral compression fractures that occur due to degenerative disc disease may need to require surgical intervention. Several minimally invasive and open procedures are used, including a laminectomy, cervical discectomy, disc replacement, and kyphoplasty.
Lumbar Spinal Stenosis
Lumbar Spinal Stenosis is a condition characterized by the narrowing of the spinal canal in the lumbar or lower back region of the spine. The spinal canal is a narrow canal formed by adjacent vertebrae of the spine. The spinal cord runs through the spinal canal as it branches out to innervate the muscles and organs of the body. Lumbar spinal stenosis can pinch the spinal cord and cause it to become irritated and inflamed. This results in pain and other symptoms.
Lumbar spinal stenosis occurs as the lumbar vertebrae deteriorate with age—loosing height and size. It also occurs for congenital reasons. Patients born with a narrow spinal canal may experience spinal stenosis sooner in life.
In its early stages, lumbar spinal stenosis may not produce symptoms. As patients age, they should pay attention to the following symptoms as they may be indicators of lumbar spinal stenosis:
- Balance problems
These symptoms may be experienced in the back and/or the legs.
A medical history, physical examination, and medical imaging studies (X-rays, MRIs, and CTs) are used to diagnose lumbar spinal stenosis.
After being officially diagnosed by an orthopaedic spine specialist, spinal stenosis is first treated non-surgically. Common treatment options include the following:
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Physical therapy
- Activity modification
If these options are not effective, corticosteroid injections may be used. During a quick procedure, the powerful anti-inflammatory medication is injected near the inflamed nerve.
Surgical treatment may be required for severe cases of spinal stenosis. A spinal fusion is a procedure that is commonly performed. During the procedure, an orthopaedic spine surgeon removes bone to widen the canal. Adjacent vertebrae are then joined using a small rod and screws. As the vertebral bone heals, the vertebrae fuse together to form a single, solid bone. Following surgery, the spinal cord has room to travel through the canal and symptoms decrease.
A spinal fusion procedure can now be performed minimally invasively. Patients who undergo minimally invasive spine surgery experience less pain, recover faster and have a less noticeable scar following surgery.
Spine Compression Fractures
Spine Compression Fractures are tiny fractures in the anterior (front) part of a vertebra. They are most commonly seen in thoracic vertebrae and sometimes seen in the lumbar vertebrae. Patients who suffer spine compression fractures usually do so because they have osteoporosis—a disease that weakens the bones. Spine compression fractures are treatable fractures; however, they need to be taken seriously as they often times are a strong indication that osteoporosis is at an advanced level.
Osteoporosis is the number one cause of spine compression fractures. As osteoporosis progresses, it causes the vertebrae to weaken and decrease in size and height. Patients with osteoporosis may sustain vertebral compression fractures from simple, everyday movements like walking, running, twisting, or turning. Lifting, bending, and falling are also common movements that can cause fractures. Because osteoporosis is more prevalent in women than men, women experience fractures at a higher rate.
Acute, sudden back pain is the first symptom of spine compression fractures. Pain typically lasts 4-6-weeks while the fractures heal. In some cases, pain can linger and turn into chronic pain when the fractures are not given time to heal. Additionally, fractures left untreated can worsen over time and create multiple fractures.
Spinal compression fractures are often times hard to diagnose. They are easily mistaken for a minor injury, such as a sprain or strain, and are not always seen on x-ray. For these reasons, orthopaedic spine specialists take special precautions when patients over the 50 present with acute, sudden back pain. A complete medical and family history is taken and a thorough physical examination is performed. If a spinal compression fracture is suspected, medical imagining studies in the form of an X-Ray, MRI, CT scan, and/or nuclear bone scan is ordered and examined.
The majority of spine compression fractures will heal on their own when patients rest for 4-6-weeks. Over-the-counter and prescription medications and ice are typically used to reduce pain and inflammation during this time. In some cases, spine compression fractures may require surgical intervention. The following procedures are commonly performed:
- Vertebroplasty: The fracture is stabilized when high viscosity cement is injected into it and settles.
- Kyphoplasty: The fracture is stabilized and vertebral height is restored when a tiny balloon is inserted into the fracture and inflated.
Both of these procedures are performed minimally invasively.
Patients who suspect they have osteoporosis or spinal compression fractures are advised to make an appointment with an orthopaedic spine specialist.
Spondylolisthesis is a condition characterized by a severely weakened vertebra due to a stress fracture not being able to maintain its structure and shifting or moving as a result. The condition is typically experienced by young athletes who over participate in strenuous sports. Proper treatment of the condition is important, as it will get worse when left untreated.
Strenuous exercise and overuse cause spondylolisthesis. Athletes who participate in sports that require lots of twisting, turning, bending, and jumping are most at risk. Parents should be aware of this and take proper precautions, especially if their child complains of back pain.
Initial symptoms of a fracture include back pain that may radiate into the thigh and buttocks. Typically, pain increases with activity and decreases with rest. Patients who develop spondylolisthesis may experience any of the following symptoms:
- Muscle spasms
- Spine stiffness
- Hamstring tightness/pain/tenderness
- Difficulty weight bearing
Because of the nature of the condition, patients with these symptoms should make an appointment with an orthopaedic specialist.
A medical history, physical examination, and medical imaging studies (x-ray, MRI, and/or CT scan) are used to diagnose spondylolisthesis.
The goal of treatment is to control symptoms while the vertebra heals and the spine aligns. Strenuous activity should be avoided for many weeks. Nonsteroidal anti-inflammatory drugs (NSAIDs), rest, ice, and bracing are typically used during this time. Physical therapy may also be used to stretch and strengthen targeted muscles. An orthopaedic specialist will take x-rays every 2-4-weeks to make sure healing and realignment are taking place.
A spinal fusion may be needed to treat severe cases of spondylolisthesis. During the procedure, an orthopaedic specialist realigns the vertebra and joins it to an adjacent vertebra using small rods and screws. Following surgery, the joined vertebrae heal as a single bone. Spine anatomy is restored and symptoms decrease. The range of motion decreases due to the joint being fused.
Athletes may return to competition after their condition heals. They should be watched carefully to ensure they do not injure themselves again.
Lumbar Microdiscectomy (Microdecompression)
One of the most commonly performed minimally invasive spine surgeries is a lumbar microdiscectomy or microdecompression. The procedure is indicated to treat lower back and extremity pain caused by a herniated disc.
A Herniated Disc
In-between adjacent spinal vertebrae lie shock-absorbing discs known as intervertebral discs. The inner portion of a disc is made up of a soft, gel-like substance known as the nucleus. When the nucleus protrudes past the outer portion of the disc and into the vertebral canal, the disc is said to have slipped or herniated. Sometimes, a herniated disc can pinch a spinal nerve and cause pain and any of the following symptoms:
A herniated disc in the lumbar region of the spine can cause these symptoms to be experienced in the lower back, buttocks, thighs, and legs.
A Lumbar Microdiscectomy (Microdecompression)
A lumbar microdiscectomy is typically performed under general anesthesia. During the procedure, an orthopaedic spine specialist removes the part of the disc that is pinching the spinal nerve. Fragmented parts of the disc are also removed. After the surgery is performed, the incision is closed. Total procedure time is approximately one hour.
Patients report significant pain relief following a microdiscectomy procedure. In some cases, patients may return to normal everyday living in as little as two weeks. In other cases, it may take longer. Because the procedure is performed minimally invasively, patients recover faster, experience less post-surgical pain, and have a smaller scar.
Anterior Cervical Discectomy and Fusion (ACDF)
An Anterior Cervical Discectomy and Fusion (ACDF) is a common surgical procedure used to treat several neck conditions and injuries, including the following:
- Cervical radiculopathy. A pinched cervical nerve.
- Cervical disc herniation. A portion of a cervical intervertebral disc slips or herniates and protrudes into the spinal canal.
- Cervical spinal stenosis. The narrowing of the cervical spinal canal.
- A fracture. A cervical vertebra is fractured or broken.
Recent surgical advancements and technologies have allowed ACDF procedures to be performed minimally invasively. Because a smaller incision is used to access the surgical site, patients who undergo a minimally invasive ACDF procedure recover faster, experience less post operative pain, and have a smaller scar than patients who undergo traditional open surgery.
The goal of an ACDF is to create space for the spinal cord and nerve roots, realign the spine, and limit motion. After a 1-2-inch incision is made in the front of the neck, the cervical spine is visualized. If they are present, the following are removed:
- Pieces of fragmented bone and disc
- Portions of herniated disc
- Bone spurs
And any other structures/bony abnormalities. Once disc height is restored and there is space for the spinal cord and nerves, adjacent vertebrae are joined using small plates and screws. Bone graft is packed into the area to promote healing. Following the procedure, the vertebrae fuse to form a single, solid bone. The goals of surgery are met and symptoms decrease.
Patients are usually required to spend the night in the hospital and return home wearing a soft collar the day after surgery. After two weeks, patients have their first postoperative appointment. At that time, the orthopaedic spine specialist who performed the procedure gives patients important information regarding recovery steps, including instructions regarding when to start physical therapy—an important component of the recovery process. Typically, a full recovery from surgery takes 6-12-months.
Minimally Invasive Lateral Lumbar Interbody Fusion
A Minimally Invasive Lateral Lumbar Interbody Fusion is a special type of spinal fusion procedure. What makes it different from typical spinal fusions is its approach. An incision is made laterally (on the side) rather than anteriorly or posteriorly. This type of approach is advantageous to patients because it avoids damaging the muscles and nerves of the spine.
A small incision is made on the flank. A special retractor holds muscles away from the surgical site so the surgeon can view the lumbar spine. The diseased or damaged disc that is causing symptoms is completely removed. A special surgical implant cage packed with bone graft is placed in-between the vertebrae where the disc once sat. The cage is secured to bone using small screws. After the cage is in place, the incision is closed and the procedure is complete. Typical procedure time is 1-2-hours.
Patients may be required to spend the night in the hospital after surgery. Pain following surgery is to be expected. Medications are given to manage it. A soft collar is typically worn until the surgeon says it is okay to take it off. The first postoperative appointment occurs two weeks after surgery. It may take 6-12-months for vertebrae to completely heal and fuse. However, symptom improvement may occur at any time. Typically, symptoms gradually improve and are eventually eliminated.
Patients who may benefit from a minimally invasive lateral lumbar interbody fusion are those that suffer from the following conditions:
- Lumbar spinal stenosis. The narrowing of the lumbar spinal canal.
- Spondylolisthesis. The weakening of a vertebra due to an untreated fracture
- Degenerative disc disease. The weakening of the vertebrae with age.
Patients who are in pain because of these conditions should have a conservation with their orthopaedic spine surgeon to determine if a lateral lumbar interbody fusion is a surgical procedure that can help them.
Anterior Lumbar Interbody Fusion (ALIF)
An Anterior Lumbar Interbody Fusion (ALIF) is a type of spinal fusion procedure. It is used to treat a lumbar intervertebral disc that is damaged or diseased and is causing symptoms, namely lower back and extremity pain. What makes an ALIF different from other fusion procedures is the approach—an incision is made near the abdomen as opposed to on the back. Patients may benefit from this type of approach because the back muscles and nerves experience less trauma.
An incision is made near the abdomen. The abdominal muscles are retracted and the lumbar spine is visualized. Small surgical instruments are used to completely remove the disc. This creates space for once compressed spinal nerves. A cage implant packed with bone graft is inserted into the intervertebral space. Screws are used to fixate the cage to the bone. The incision is closed. Typical procedure time is 2-3-hours.
Patients who undergo an ALIF procedure remain in the hospital for 1-3-days. During this time, pain is controlled and the patient is made as comfortable as possible. After being discharged, patients return home with special instructions from their orthopaedic surgeon and hospital staff. The first postoperative appointment occurs two weeks after surgery. A full recovery typically occurs in 6-12-months.
After surgery, bone healing occurs and the adjacent vertebrae fuse to form a single, solid bone. Symptom improvement occurs—sometimes quickly—as the bone heals and compressed nerves regain function.
Patients who suffer from the following conditions may be candidates for an ALIF procedure:
- Degenerative disc disease. The weakening of the intervertebral discs with age.
- Scoliosis. A condition in which the spine is abnormally curved.
- Spinal stenosis. The narrowing of the lumbar spinal canal.
- Spondylolisthesis. The weakening of a vertebra due to an untreated fracture.
It is important to note that surgery is always the last option. Non-surgical treatment options should always be tried before surgery is performed.