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There are several things you must do to prepare for your surgery. It is often recommended that the patient donate all or part of the blood required for surgery. If the patient is unable to donate all the blood needed, he/she can obtain donors that have a compatible blood type. This highly reduces the chances of contracting AIDS and/or hepatitis. The doctor or his/her nurse will discuss this further.

During the time prior to admission, a patient can also be getting his/her home "ready". No bending, stooping or heavy lifting is permitted during the recovery period. It is advisable to place frequently used objects at an easily obtainable height. For example, have dishes most often used in upper cabinets. You may want to "stock-up" on prepared meals such as frozen entrees and TV dinners. Make arrangements for someone to help with house cleaning, laundry and groceries prior to admission.

If a patient is to be braced post-operatively, t-shirts will be worn under the brace. The t-shirt must cover the buttocks. These t-shirts help absorb some of the body's perspiration and prevent skin breakdown. Men's boxer shorts are helpful if a patient must wear a brace with a thigh cuff. Brace application does require the help of another person. A patient may receive a second brace for showering.

Before your operation, it will be necessary to have blood tests, a chest x-ray and an EKG performed to evaluate a patient’s general condition before undergoing anesthesia. Sometimes a pulmonary evaluation is required. Adults may need to have a medical evaluation by an internist.

Lumbar microdiscectomy is an operation on the lumbar spine performed using a surgical microscope and microsurgical techniques. A microdiscectomy requires only a very small incision and will remove only that portion of your ruptured disc which is "pinching" one or more spinal nerve roots. The recovery time for this particular surgery is usually much less than is required for traditional lumbar surgery.

Lumbar microdiscectomy is usually recommended only when specific conditions are met. In general, surgery is recommended when a ruptured disc is pinching a spinal nerve root(s) and you have:

1. Leg pain which limits your normal daily activities
2. Weakness in your leg(s) or feet
3. Numbness in your extremities
4. Impaired bowel and/or bladder function

This surgery is performed to treat spinal stenosis, a narrowing of the spinal canal that puts pressure on nerves in the back, and a related condition involving slippage of the vertebrae known as spondylolisthesis. Both conditions cause pain and weakness in the lower back and legs, and many patients have difficulty walking. As with all spinal fusion surgery, a posterior lumbar interbody fusion (PLIF) surgery involves adding bone graft to an area of the spine to set up a biological response that causes the bone to grow between the two vertebral elements and thereby stop the motion at that segment.

Benefits of Anterior Decompression and Spine Fusion Surgery

In the past, cervical laminectomy (removing the posterior aspects of the spinal canal) to decompress (relieve pressure on) the spinal cord had been the procedure of choice to treat spondylotic myelopathy resulting from cervical arthritis.

However, the majority of the abnormal anatomy producing spinal cord compression is located anteriorly to (in front of) the spinal cord itself. This is only indirectly addressed by a posterior cervical laminectomy. In fact, chronic spinal instability exacerbating the disease process may be caused by cervical laminectomy. In addition, a thick fibrous scar forms at the operative site in the postoperative period, at times replacing the bony compression and reproducing the original symptoms after an extended postoperative period.

For these reasons, many surgeons prefer either anterior decompression of the spinal cord and nerve roots, or an adaptation of laminectomy known as laminoplasty, depending on the patient's anatomy. Anterior cervical decompressions have two significant benefits:

1. Direct removal of the anterior source of spinal cord compression
2. Stabilization of the spine by way of a fusion, eliminating motion and the development of further degenerative changes at the operated levels

Results

Overall, most surgical series point to a significant improvement for most patients who undergo an anterior cervical decompression and fusion (by either multiple discectomies or corpectomy) before irreversible spinal cord injury has occurred. At a minimum the operation can remove the source of spinal cord injury and arrest the progression of the disease. The prognosis is generally proportional to the severity of spinal cord compression, with more advanced cases having a poorer prognosis. Timely intervention may thus play a role in determining the patient’s final outcome.

The posterior cervical fusion is performed through an incision in the back of the neck. A posterior cervical fusion is used to:

• Stop the motion between two or more vertebrae
• Recreate the normal curve of the cervical spine and keep a spinal deformity from getting worse
• Stabilize the spine after a fracture or dislocation of the cervical spine

Procedure

This surgery is done through the back of the neck. A bone graft is placed on the back surface of the problem vertebrae. During the healing process, the vertebrae grow together, creating a solid piece of bone. This type of fusion is used in the cervical spine for fractures and dislocations. It is also used to correct deformities in the neck.

The goal of spinal fusion is to stop the motion caused by segmental instability. This reduces the mechanical neck pain caused from too much motion in the spinal segment.

You may also hear the term anterior fusion. This procedure is commonly used to treat neck problems. The surgeon works from the front (anterior) of the neck. A bone graft is placed between two vertebral bodies (interbody area) to replace the disc that normally sits between them. During the healing process, the vertebrae grow together, creating a solid piece of bone.

Lumbar laminectomy is a surgical procedure most often performed to treat leg pain related to herniated discs, spinal stenosis, and other related conditions. Stenosis occurs as people age and the ligaments of the spine thicken and harden, discs bulge, bones and joints enlarge, and bone spurs (called osteophytes) form. Spondylolisthesis (the slipping of one vertebra onto another) can also lead to compression.

The goal of a laminectomy is to relieve pressure on the spinal cord or spinal nerve by widening the spinal canal. This is done by removing or trimming the lamina (roof) of the vertebrae to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disc. Various devices (like screws or rods) may be used to enhance the ability to obtain a solid fusion and support unstable areas of the spine.

Endoscopic Discectomy is an outpatient surgical procedure to remove herniated disc material. Using local anesthesia with the help of X-ray fluoroscopy and magnified video for guidance, a small, specially designed endoscopic probe is inserted through the skin of the back, between the vertebrae and into the herniated disc space. Tiny surgical attachments are the sent down the hollow center of the probe to remove a portion of the offending disc. The microsurgical attachments can also sometimes be used to push the bulging disc back into place and be used for the removal of disc fragments and small bony spurs.

The procedure takes about an hour, on average. X-ray exposure is minimal. A patient normally will feel little, if any pain or discomfort. There are no stitches. Upon completion, the probe is removed and a small bandage is placed over the incision. The amount of nucleus tissue removed varies but the supporting structure of the disc is not affected by the surgery. The access route to the disc consists of only the probe's small puncture site, usually the size of a freckle, in comparison to large incisions required for open surgery.

Endoscopic discectomy is different from open lumbar disc surgery because there is no traumatic back muscle dissection, no bone removal, or large skin incision. The risk of complications from scarring, blood loss, infection, and anesthesia that may occur with conventional surgery are drastically reduced or eliminated with this procedure. Endoscopic discectomy was invented to be an effective treatment for herniated discs while avoiding these risks.

Kyphoplasty is an innovative technique that combines vertebroplasty with balloon catheter technology developed for angioplasty. The procedure shows great promise in the treatment of painful, progressive osteoporotic or osteolytic vertebral compression fractures.

Vertebroplasty, from which the kyphoplasty technique evolved, was developed in response to limited results of medical and surgical modalities to stabilize and strengthen collapsed vertebral bodies. Interventional neuroradiologists, first in France and then in the U.S., began transpedicular percutaneous bone cement injections in 1986. Vertebroplasty offers significant benefits; reduced or eliminated fracture pain, prevention of further collapse, a rapid return to mobility, and prevention of bone loss caused by bed rest. However, it does not address spinal deformity. It also requires high-pressure cement injection using low-viscosity cement, which leads to cement leaks in 30 to 80% of procedures, according to recent studies.

Kyphoplasty has several potential advantages over vertebroplasty. It restores vertebral body height with a low risk of cement extravasation. Kyphoplasty is well tolerated and is associated with statistically significant improvements in pain and function.

Vertebroplasty is a pain treatment for vertebral compression fractures that fail to respond to conventional medical therapy, such as minimal or no pain relief with analgesics or narcotic doses that are intolerable. Vertebroplasty, a nonsurgical treatment performed using imaging guidance by interventional radiologists, stabilizes the collapsed vertebra with the injection of medical-grade bone cement into the spine. This improves pain, and can prevent further collapse of the vertebra, thereby preventing the height loss and spine curvature commonly seen as a result of osteoporosis. Vertebroplasty dramatically improves back pain within hours of the procedure, provides long-term pain relief, and has a low-complication rate as demonstrated in multiple studies.

If the vertebra isn't shored up, it can heal in a compressed or flattened wedge shape. Once this occurs, the compression fracture cannot be treated effectively. It is very important for someone with persistent spinal pain lasting more than three months to consult an interventional radiologist, and people who require constant pain relief with narcotics should seek help immediately.

The standard surgical procedure for a disc replacement is an anterior (from the front) approach to the cervical spine. This surgical approach is the same as that presently used for a discectomy and fusion operation. The affected disc is completely removed including any impinging disc fragments or osteophytes (bone spurs). The disc space is distracted (jacked up) to its prior normal disc height to help decompress (relieve pressure) on the nerves. This is important because when a disc becomes worn out, it will typically shrink in its height, which can also contribute to the pinching on the nerves in the neck.

At this point, using X-rays or fluoroscopy, the artificial disc device is implanted into the prepared disc space. Postoperatively, the patient typically can go home within 24 to 48 hours with minimal activity limitations.

Lumbar disc replacement is similar to other types of joint replacement (such as hip and knee replacements). The concept is similar in that the surgeon is removing a damaged joint, and replacing this with a metal and plastic implant. In the lumbar spine, the goal is to remove the damaged, painful disc, and replace this with a metal and plastic implant. The implant is designed to move like a normal disc.

The theoretical advantage of lumbar disc replacement over spine fusion is that the replaced disc would allow motion at the damaged level and would not transfer stresses to adjacent levels. The goal is to achieve the same pain reduction as spinal fusion, but eliminate some of the complications.

Posterior foraminotomy and discectomy is one of the oldest operations for cervical disc disease, and remains effective with few variations from the original surgery. It is generally used for disc herniations off to one side, but is also effective in relieving arm pain caused by nerve pressure from arthritic bone spurs.

The patient is placed face down on the operating table and the head is secured with 3 pins and flexed forward. After the surgery the patient will have 3 small holes, usually behind the hairline, will heal up quickly and without the need for sutures.

An incision is made in the back of the neck and the muscles are removed from the bones on the affected side. A drill is then used to widen the opening through which the nerve passes, and any bone spurs pressing on the nerve are removed with special instruments. This is generally done with an operating microscope for improved vision.

After the opening for the nerve is widened, the disc space is explored. Any bulges or extruded disc material is removed, but the majority of the disc is left undisturbed. The incision is then closed with sutures and bandaged. The bandage can be removed 48 hours after surgery, but should be kept dry for about a week.

Anterior and posterior surgery is generally recommended for spinal curves that are very severe, stiff, or when previous attempts at fusion have failed.

Combined Anterior and Posterior Approach

When performing a spinal fusion from the posterior approach (the back side), it is possible to move the spinal nerves to the side and place bone graft in between the vertebral bodies themselves. This is sometimes referred to as a "posterior lumbar interbody fusion" (PLIF). Today, surgeons are also beginning to place intervertebral cages between the vertebral bodies to hold the two vertebrae apart as the fusion heals. In some cases, this can be done from the back side of the spine without the necessity of making an additional incision in the patient's abdomen (from the front).

Working between the vertebrae from the back side has limitations. The surgeon is limited by the fact that the spinal nerves are constantly in the way. These nerves can only be moved a slight amount to either side. This limits the ability of the surgeon to see the area. There is also limited room to use instruments and place implants between the vertebrae. For these reasons, many surgeons prefer to make a separate incision in the abdomen and actually perform two operations ¾ one from the front of the spine to perform an anterior spinal fusion and one from the back to perform a posterior fusion. The two operations are usually done at the same time; however, this is not necessary. They may be done several days apart.

Fusion is a surgical technique in which one or more of the vertebrae of the spine are united together ("fused") so that motion no longer occurs between them. The concept of fusion is similar to that of welding in industry. Spinal fusion surgery, however, does not weld the vertebrae during surgery. Rather, bone grafts are placed around the spine during surgery. The body then heals the grafts over several months - similar to healing a fracture - which joins, or "welds," the vertebrae together.

Many neck problems are due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints between each vertebra. Other problems are the result of injury to parts of the spine or complications of earlier surgeries. The vast majority of patients who have neck problems will not require any type of surgery. But if conservative treatments fail to control the pain, a surgeon may suggest a cervical fusion. There are two types of cervical fusion procedures ¾ anterior cervical fusion and posterior cervical fusion.

An anterior cervical fusion is performed through an incision in the front of the neck. An anterior cervical fusion is used to:

• Remove pressure from nerve roots or the spinal cord caused by bone spurs or a herniated disc
• Stop the motion between two or more vertebrae

Removing pressure from the nerve roots or spinal cord can ease arm pain. Problems from pressure on the nerves, such as numbness or weakness in the arm or difficulty walking, may also improve. Fusion of the problem vertebrae reduces mechanical pain caused from too much motion in the spinal segment.

The posterior cervical fusion is performed through an incision in the back of the neck. A posterior cervical fusion is used to:

• Stop the motion between two or more vertebrae
• Recreate the normal curve of the cervical spine and keep a spinal deformity from getting worse
• Stabilize the spine after a fracture or dislocation of the cervical spine

One of the most common surgeries for chronic back pain problems is spinal fusion surgery. It is a major surgery that is performed only when all more conservative treatment measures have failed, but it can help people suffering from chronic back pain or severe spinal deformities live normal lives again.

Now, orthopaedic spine surgeons have found a way to achieve the full benefits of spinal fusion for some patients with less bleeding, trauma, postoperative pain, time in the hospital, and healing time for the patient ¾ and reduced inpatient expenses for the health plan or insurance carrier. They are accomplishing this by applying minimally-invasive surgical techniques to spinal fusion surgery. The result is a new category of spine surgery called minimally-invasive spinal fusion surgery.

In a conventional thoracic spinal fusion procedure, surgeons must often perform a thoracotomy, or incision into the chest wall, then remove a rib to reach the spine for operative repair. The thoracotomy sometimes requires an incision up to 20 inches long. Using minimally-invasive techniques, surgeons can completely skip the thoracotomy and rib removal, instead performing their surgery through small incisions. Using a tiny, high-tech endoscopic camera, they can view the surgical site on a high-resolution TV monitor, while doing their work with long-handled instruments. Using small incisions instead of big ones offers another benefit to the patient ¾ small scars only, and thus a better cosmetic result after surgery.

Minimally invasive surgery may not be ideal for all patients, so be sure to discuss this option with your surgeon.

The two least controversial reasons for a lumbar fusion are for cases that involve trauma or tumor. In both of these cases, either:

·The situation in the spine appears unstable, meaning the spine is prone to unusual movements under normal conditions which can damage tissues or cause pain or deformity, due to the underlying pathology
·The surgery required to decompress the neural structures is deemed to render the spine unstable once this is achieved.

Fusion for degenerative disease (so called "wear and tear") is more controversial but is commonly performed. In this setting fusion can also be performed for many reasons. The most common reason to perform a fusion is for a spondylolisthesis. This is where one vertebra is slipped forward in relation to another. Not only does this throw the back out of alignment (so called "sagital balance") but it can cause pressure on nerves, particularly when they exit through their neural foramina.

A lumbar fusion is a major operation. Screws are placed between the vertebrae that are to be fused. The bone graft is placed around these. These screws are made of titanium and usually stay in for life.

Lumbar fusion operations involve greater risks than simple laminectomies or discectomies. Recovery is longer. However, the vast number of patients undergoing this operation do well. Because they are longer operations, there is more blood loss and blood transfusion is almost always required. Often, however, this can be blood that is autologously donated by the patient in preparation for surgery. The risks, including nerve injury, hardware problems and infection are probably in the order of 5 to 15%. The risks of general complications are slightly higher than those for a simple laminectomy. Typical operating time can be anywhere from 4 to 8 hours. Every operation is different. Most patients will spend 1 to 2 nights in ICU. Patients are given an epidural anesthetic after surgery to ensure that there is virtually no pain for the first 24 hours. A bladder catheter is usually in place. The patient will usually have a button for pain control (PCA). On the second or third day after surgery, the patient is mobilized in a lumbar brace, with the assistance of a physiotherapist. Most patients note that the first week after surgery is difficult, but by 6 weeks and 12 weeks after surgery most are very glad they had the surgery done.

Percutaneous Vertebral Augmentation

A minimally-invasive procedure known as percutaneous vertebroplasty treats painful vertebral compression fractures. Percutaneous vertebroplasty involves a small puncture through the skin with a biopsy needle. Specially formulated acrylic bone cement is injected into the fractured vertebra, filling the spaces within the bone. The needle is removed and the cement hardens quickly ¾ strengthening the vertebra and stabilizing the spine, thus stopping the pain and preventing further damage. The procedure is performed under light sedation, and the patient leaves the medical facility the same day.

Patients who undergo percutaneous vertebroplasty typically experience 90% or better reduction in pain within 24 hours and increased ability to perform daily activities shortly thereafter. Recent research has demonstrated that percutaneous vertebroplasty can relieve pain from vertebral compression fractures for up to nearly 3 years postprocedure.

Bone Morphogenetic Protein

The process of building, healing and remodeling bone in humans is called osteoinduction. In the 1960s orthopaedic investigators discovered a family of substances in human blood and bones that stimulates the process of osteoinduction, they called these substances bone morphogenetic proteins, or BMP. In the past 15 years, investigators have found a way to isolate and extract these substances from natural tissues, as well as produce them in laboratories. BMPs have been used to stimulate the production of bone in animals and humans.

In spine surgery, especially during spinal fusions, surgeons may opt to use transplanted bone grafts to aid in the healing and remodeling of the spine after surgery. The use of bone grafts can add increased postoperative pain, if the bone is transplanted from one area of the patient's body to another (called autograft), or a chance of disease transmission if the bone is transplanted from one person to another (called allograft). Spine surgeons hope the use of BMP and rhBMP (BMP that is produced in a laboratory) may someday aid them in generating and repairing bone without the drawbacks of grafts.

Although the Food and Drug Administration has not fully approved the use of BMPs, many clinical trials have found the substance to be effective in generating bone in the spine. Current research is also focusing on the most effective method of introducing the substance into the spine, such as collagen sponges in fusion cages or in a collagen putty. The research is ongoing and the spine community is encouraged by BMPs and hopes they may someday reduce postsurgical pain and improve the effectiveness of spinal surgeries.

An artificial disc is a device that is implanted into the spine to replace a degenerative disc, whose regular function is to carry weight and allow motion. A disc is the soft cushioning structure between the individual bones of the spine, called vertebra.

Artificial discs are usually made of metal and plastic-like (biopolymer) materials, or a combination of the two. These materials have been used in the body for many years. Total disc replacements have been used in Europe since the late 1980s.

The reasons for choosing to replace a disc may vary for each condition. Generally, if the pain caused by the affected disc has not been reduced enough with nonsurgical treatments such as medication, injections, or physical therapy, a doctor may suggest disc replacement.

The following is a list of several conditions that may prevent you from receiving a disc replacement:

- Spondylolisthesis (the slipping of one vertebral body across a lower one)
- Osteoporosis
- Vertebral body fracture
- Allergy to the materials in the device
- Spinal tumor
- Spinal infection
- Morbid obesity
- Significant changes of the facet joints (joints in the back portion of the spine)
- Pregnancy
- Chronic steroid use
- Autoimmune problems.