Treatments & Surgery

a.    Lumbar spine fusion (arthrodesis) is the most common surgical option for treating low back pain when nonsurgical treatment does not relieve back pain. Spinal fusion eliminates motion between vertebrae and prevents the stretching of nerves and surrounding ligaments and muscles. It is an option when motion is the source of pain, such as the movement that occurs in a part of the spine that is arthritic. The theory is if the painful vertebrae do not move, they will not hurt.

While lumbar fusion helps many patients, others do not improve. Some surgeons believe this is because fusion prevents normal motion in the spine. Though fusion takes away some spinal flexibility, most spinal fusions involve only small segments of the spine and do not limit motion very much.

b.    Artificial disk replacement (ADR) is an alternative to spinal fusion for lower back pain.  Not all patients that are candidates for spinal fusion are candidates for artificial disc replacement. However, all candidates for ADR are candidates for spinal fusion (arthrodesis).

General considerations for artificial disc replacement are:

·        Back pain caused by one or two problematic intervertebral discs in the lumbar (low back) spine

·        No significant facet joint disease or bony compression on the spinal nerves

·        Significantly overweight

·        No major lumbar surgeries

·        No significant spinal deformity (scoliosis)

·        Normal quality bone

There are several different techniques and approaches that your surgeon can use to fuse the spine, including an:

• Anterior approach, when your surgeon approaches your spine from the front. This is called anterior lumbar interbody fusion and requires an incision in the lower abdomen.
• Posterior approach, which is done from your back and called a posterior lumbar interbody fusion
• Lateral approach, when your surgeon approaches your spine from the side. This is called lateral interbody fusion.
• Minimally invasive techniques, which allow fusions to be performed with smaller incisions.

The surgical goal is the same with all of these procedures—fusion of the involved vertebrae. The right procedure for you depends on the nature and location of your particular anatomy and disease process.

In most cases, you will stay in the hospital for one to three days after your surgery, depending on your pain and return to function. Most patients are encouraged to walk by the first day after surgery. Depending on your pain, you may start a form physical therapy program shortly after surgery.

The postoperative rehabilitation program will vary somewhat, depending on your specific condition, your general physical conditioning before surgery and whether you have had a fusion (arthrodesis) or an ADR.

Most patients’ lower back pain improves in weeks to months after their surgery. However, disk replacement, as with spinal fusion (arthrodesis) may not completely eliminate pain.

MISS fusions and decompression procedures, such as a discectomy and laminectomy, are performed with special tools called tubular retractors. During the procedure, your surgeon will make a small incision and then insert the tubular retractor through the skin and soft tissues down to the spinal column. This creates a tunnel to the small area where the problem exists in the spine. The tubular retractor holds the muscles open and stays in place throughout the procedure.

Your physician then accesses the spine using small instruments that fit through the center of the tubular retractor. Any removed bone or disk material exits through the retractor, and any devices necessary for fusion — such as screws or rods — are inserted through the retractor. Some surgeries require more than one retractor.

To see where to place the incision and insert the retractor, your surgeon is guided by fluoroscopy, which displays real-time x-ray images of your spine on a screen throughout the surgery. The surgeon also uses an operating microscope to magnify the view through the retractor. It provides excellent illumination and magnification during minimally invasive spine procedures.

At the end of the procedure, the tubular retractor is removed, and the muscles return to original position. This limits the muscle damage that is more common during open surgeries.

Minimally invasive lumbar (low back) discectomy and minimally invasive lumbar (low back) fusion are two of the most common MISS procedures.

Essentially, this is a decompressive procedure to relieve pain caused by a damaged disc pressing on the nerve in your lower back, causing severe leg pain, numbness or weakness. Your physician will remove part or all of your damaged (herniated) disc to relieve your pain.

To perform this procedure, the surgeon will make a small incision (usually less than one inch) over the damaged (herniated) disk as the patient lies facedown. Then, he or she will insert the retractor and remove a small amount of the lamina bone. This enables the surgeon to view the spinal nerve and the disk. Then, the physician carefully removes the damaged disk and replaces it with bone graft material.

This minimally invasive technique can also be used for herniated disks in the neck. The procedure is done through the back of the neck and called an MIS posterior cervical discectomy.

Minimally invasive lumbar fusions can be performed from the back, through the abdomen or from the side.

Transforaminal lumbar interbody fusion (TLIF) is a common type of MISS fusion. With this technique, the surgeon approaches the spine a little bit from the side, reducing how much the spinal nerve must be moved. In an MIS TLIF, the surgeon places one retractor on either side of the spine while the patient lies facedown. This approach prevents disruption of the midline ligaments and bone. Using the two retractors, the surgeon can remove the lamina and the disk, place the bone graft into the disk space, and place screws or rods to provide additional support.

Minimally invasive spinal fusion is also commonly performed from the side. There are two procedures that use a side approach: extreme lateral interbody fusion (XLIF) and direct lateral interbody fusion (DLIF). The benefits of lateral fusion surgeries are that they do not injure the back muscles or pull on the nerves in the spinal canal.

MISS patients typically go home in two to three days, depending upon the procedure. Because minimally invasive techniques do not disrupt muscles and soft tissues, postoperative pain is usually less than with traditional, open procedures.

How long it will take to return to your daily activities after MISS depends on your procedure and condition. To help speed your recovery, your doctor may recommend physical therapy. Specific exercises will help you become strong enough to return to work and daily activities.

If you have had a fusion procedure, it may be several months before the bone is solid, although your comfort level will often improve much faster. Your doctor will evaluate you after surgery to make sure that your recovery is progressing as expected.