Herniated lumbar disc(lumbar micro discectomy, Percutaneous Disc Nucleoplasty)

A disc is composed of a tough outer covering known as the annulus fibrosus and a softer inner core known as the nucleus pulposus. As the disc wears down, the annulus fibrosus develop tears which can lead to back pain. If the outer fibers weaken enough, the inner core of the disc can rupture resulting in protrusion/herniation of the disc. A herniated disc can put pressure on a nerve and therefore result in sciatica which is the sensation of pain that travels from the low back area into the buttock and leg region.

The most common spine surgical procedure is a lumbar microdiscectomy. A lumbar microdiscectomy consists of removal of the portion of the disc which is herniated thereby relieving the pressure on the nerve resulting in the relief of leg pain.

The technique requires a small incision with removal of a small portion of bone and ligament overlying the disc and nerve. Once the disc herniation and nerve are identified, the remainder of the procedure is done under the aid of a microscope. The procedure usually lasts between 1 to 2 hours with a recommended one night stay in the hospital.

Another option our practice offers for herniated disc is known as Percutaneous Disc Nucleoplasty. A Percutaneous Disc Nucleoplasty is the insertion of a small probe into the disc with the aim of creating several channels within the disc material. The purpose is twofold in that it reduces the pressure within the disc and promotes a reparative healing process which ultimately strengthens the disc. The disc bulge disappears and the pressure on the nerve is alleviated.

The procedure takes less than an hour and patients go home the same day. The advantage is that it is less invasive than a lumbar microdiscectomy and the disadvantage is that it is an indirect manner of decompressing the nerve and therefore is less successful than a microdiscectomy in providing relief of sciatica.

Lumbar spinal stenosis (lumbar laminectomy, X-STOP® Spacer interspinous device, lumbar fusion, intstrumentation)

Spinal stenosis is the narrowing of the spinal canal, resulting in interference on the nerves. As we age, there is progressive degeneration of the spinal elements, including the disk, the joints, and the ligaments. Developing arthritis causes the joints and ligaments in the lumbar spine to enlarge and thicken and the disks to bulge. As a result, there is narrowing of the spinal canal. The classic symptoms of spinal stenosis is leg pain and numbness that is made worse by standing and walking and relieved by leaning forward or sitting.

The gold standard surgical treatment for spinal stenosis is known as a lumbar laminectomy. A lumbar laminectomy is the removal of the bony and ligamentous structures that are causing pressure on the nerves. The goal is to enable the patient to stand and walk without experiencing leg pain, weakness, and numbness. The surgery generally lasts 2-3 hours and usually requires a 2–3 day hospital stay. A lumbar laminectomy is effective in relieving leg symptoms as it is a direct decompression of the nerves.

A potential disadvantage of lumbar laminectomy is that by removing portions of the ligaments and joints, it could lead to lumbar instability which may require a lumbar fusion in the future.

Another treatment option that we offer for patients with lumbar stenosis is known as insertion of an interspinous device. The most popular device currently is known as the X-STOP.

This device essentially acts as a wedge between two spinal segments and keeps the joints of that segment from knuckling in and thus preventing nerve interference. It is intended for patients that have moderate narrowing of the spinal canal and who can obtain complete or near complete relief of their leg symptoms with sitting or leaning.

The procedure generally takes an hour and usually requires a one day stay in the hospital. The advantage over a laminectomy is that it is less invasive and avoids having to remove bone or ligaments as in a laminectomy. The disadvantage is that it may not be as effective as laminectomy for relieving pressure on the nerves and thus alleviating the leg symptoms.

There is a subset of patients for which a lumbar fusion will be recommended as the optimal surgical treatment. A lumbar fusion is the placement of bone and bone forming products in the spinal region. The goal of a lumbar fusion is to create bone formation in an area of the spine that is weak and thus strengthen that segment of the spine with the aim of reducing localized back pain and leg pain.

The two most common types of bone fusion locations are posterolateral and interbody. In a posterolateral fusion, bone is placed along the lateral aspect of the joints outside the spinal canal, mainly to help stabilize a weakened spinal facet joint. In an interbody fusion, bone is placed between the vertebra in place of the disc, in order to stabilize an area weakened by a non-working lumbar disc.

Newer techniques such as facet fusion are also employed in our practice for certain patients. We currently utilize bone that has been removed from the spine, necessary to relieve pressure on the nerves, in combination with newer products that promote bone fusion.

A lumbar fusion is often accompanied by instrumentation. Instrumentation of the spine is the placement of implants, most commonly made of titanium, that help to give the spine immediate fixation and stabilization. It takes anywhere between 6 months to 2 years for the bone to fuse and form solid bone. Until the bone fuses, the instrumentation maintains stability. Pedicle screws are the most common and effective fixation mode of the lumbar spine. They are composed of titanium screws attached to a rod and act as internal fixator for an unstable spine segment.

An interbody cage is a device that is placed in the disc space and acts as a wedge for immediate fixation. It is hollow in the center to allow for the placement of bone graft materials and also has holes on its surfaces to allow for the bone graft material to fuse with the adjacent vertebra.

Spondylolisthesis (laminectomy, posterolateral fusion, interbody fusion, transforaminal lumbar interbody fusion)

Spondylolisthesis is a misalignment or "slippage" of the upper vertebra over the lower vertebrae. This slippage is evident on X-ray or MRI study. The vertebra "slips" because the facet joint is too weak or arthritic to maintain the alignment. Another type of spondylolisthesis is a result of a defect in the bone called the pars interarticularis.

Spondylolisthesis can cause localized back pain but more commonly also results in pressure on a nerve as a result of the narrowing it produces within the spinal canal. Typically, spondylolisthesis is managed surgically with laminectomy and posterolateral fusion with pedicle screw instrumentation.

Fusion of the lumbar disc, known as interbody fusion, is indicated when the disc is the major source of low back pain. This occurs when the disc has been weakened over time as a result of trauma, or incidences of repetitive trauma of a smaller nature.

The disc fails to maintain the proper cushion and support for the spine and this condition can result in back pain. The most commonly used procedure to fuse a disc in our practice is transforaminal lumbar interbody fusion (TLIF).

The procedure involves removing some bone and the disc and placing an interbody cage and pedicle screws. The procedure can also be done using a minimally invasive approach that requires several small incisions. A small tube is inserted to relieve pressure on the nerve. The advantage of a minimally invasive approach is that it reduces the damage to the muscle and other soft tissue structures that occurs with traditional approaches.

Compression fracture (kyphoplasty)

A compression fracture of the thoracic vertebra is a common condition that typically occurs in elderly people with underlying osteoporosis. Patients with osteoporosis have a tendency to develop fragile bones which can lead to a fracture of the vertebra. The fracture can result from a fall or from even minor trauma such as twisting or turning.

In the past, the treatment for these compression fractures included pain medications (usually narcotics), bedrest, and bracing. These treatments, however, have some limitations. Narcotics may cause nausea, constipation, confusion, and oversedation which can further increase the risk of falling. Bracing can be cumbersome and most patients will avoid wearing the brace. Bedrest can lead to further muscle weakness and wasting.

Kyphoplasty is a technique developed within the last 10 years that has been effective in managing compression fractures. Kyphoplasty involves the injection of cement into the fractured vertebra with the goal of relieving pain associated with the fracture and also preventing the fractured vertebra from further collapse which can lead to further spinal instability. Patients usually go home on the following day and usually experience a significant reduction in their pain level.

Neuropathic pain (spinal cord stimulation)

Neuropathic pain is usually felt as a burning or throbbing, is typically constant, and sometimes worsens at night time. Neuropathic pain can be a common result of a damaged nerve that was initially affected by a disc or bone spur or other form of trauma.

The treatment of neuropathic pain may include medications and spinal cord stimulation. Spinal cord stimulation is a technique whereby electrodes are placed in the spinal canal alongside the spinal cord. The electrodes deliver electrical stimulation to the region of the spinal cord with the aim of blocking the transmission of pain signals from the back, arms, and legs. Various medications may help to treat neuropathic pain. If the pain does not respond to pain medications, then spinal cord stimulation is a reasonable option.

A spinal cord stimulation trial is first done to determine if the pain is responsive to stimulation. It involves the placement of a lead into the spinal canal and externally connected to a battery. It allows for the patient to experience the degree of pain relief for several days. If there is a significant pain reduction then a permanent spinal cord stimulator is placed.

A spinal cord stimulator consists of an electrical lead that is connected to a wire which is connected to a small generator/battery typically at the level of the hip. The procedure usually takes 1–2 hours and usually will require one night stay in the hospital. The goal of a spinal cord stimulator is to reduce pain and therefore to reduce or eliminate use of pain medications.