Spine Surgery

A spinal segment consists of the following:

• Two vertebrae
• An intervertebral disc between the two vertebrae
• Two nerve roots that leave the spinal cord, one on each side

• In the vast majority of patients, spine surgery is only considered after a long course of conservative therapy. As stated earlier, back pain often takes quite some time to resolve. Therefore, rushing into spine surgery may not be the best idea. Most commonly, doctors will advise at least 3 to 6 months of conservative treatment before considering spine surgery
• Depending on the symptoms and the length of the problem, we can properly organize a treatment schedule.

• Microdisectomy
• Laminectomy
• Spinal Stabilsation

Although ankylosing spondylitis affects each individual differently in symptom severity and disease progression, the primary symptoms of ankylosing spondylitis typically include back pain and back stiffness, especially in the morning. Chronic inflammation and irritation of the spinal joints (vertebrae) cause changes to those joints, since the body’s natural process of healing and repair following inflammation can result in extra bone formation that eventually may lead to fusion of the vertebrae. The stiffening of the joints due to abnormal fusion is referred to as ankylosis. Thus if a person has severe ankylosing spondylitis for many years, the continuous inflammation and process of repair leads to bony fusion of ligaments in the spine and sometimes other joints as well.

Ankylosing spondylitis is characterized by enthesitis – inflammation at the junction where the joint capsule, tendons, and ligaments attach to the bone. In addition to the sacroiliac joint, enthesitis can take place in multiple sites called “hot spots” and may lead to painful swelling and tenderness. Subchondral tissue (smooth tissue at the ends of bones) becomes granulomatous (characterized by small or granular nodular inflammatory lesions) and is infiltrated with various types of immune cells such as plasma cells and lymphocytes. Joints that are affected show markings of sclerosis (hardening of tissue) and irregular erosion. The tissue is gradually replaced with fibrous cartilage and becomes ossified (bony) leading to ankylosis. Outer muscle fibers of the spine are replaced by bone which eventually fuses the vertebrae. When this process ascends the spine in the later stages of disease, the spine becomes a bony column and is often referred to as a “bamboo spine”.

The degree of fusion in ankylosing spondylitis can range from partial fusion (e.g., limited to the pelvic bones) to fusion of the entire spine. In its later stages, ankylosing spondylitis may cause total loss of spinal mobility and function, significantly impacting the individual’s quality of life. Since bone formed during fusion is inherently weak, there is an increased risk of spinal fracture for patients with ankylosing spondylitis.

Most patients with ankylosing spondylosis do not require spine surgery. However, there are situations where spine surgery is a consideration:

• The spinal deformity is in a fixed flexed position. The magnitude (angle) of the deformity is the most important consideration. An example is forward flexion so great the chin rests near or on the chest (commonly called chin-on-chest deformity). The functional limitations of this particular deformity are great. In the example, the patient would be unable to look forward, make visual contact, drive, and may even have difficulty eating.
• The stability of the spine is compromised. An unstable spine means that it moves too much and the joints aren’t controlling the spine mobility as they should (This usually happens following injury ). Spinal instability puts the patients more at risk for nerve damage.
• Neurologic deficit exists. Neurologic deficit involves problems with the nerves, such as weakness or numbness.
• A combination of any of the above.

• • Osteotomy:
    During an osteotomy, bone is cut to correct angular deformities. The bone ends are realigned and allowed to heal. Spinal instrumentation and fusion may be combined with an osteotomy to stabilize the spine during healing.
  • Decompression:
    Other procedures, such as laminectomies, decompress the spinal canal and associated nerves, restoring or preventing neurologic dysfunction. “Decompress” means to take pressure off the spinal cord or nerves.
  • Spinal Instrumentation and Fusion:
    These are surgical procedures used to correct spinal deformity and to provide permanent stability to the spinal column. These procedures join and solidify the level where a spinal element has been damaged or removed. Instrumentation uses medically designed hardware such as rods, bars, wires, and screws. These devices hold the spine straight during fusion. Fusion is the adhesive process joining bony spinal elements.
  • Recovery from Surgery for Ankylosing Spondylitis :
    Post-operative patients will be given medication to control pain.

Symptoms of a herniated disc include dull or sharp pain, muscle spasm or cramping, weakness, tingling, or referred pain.

But here’s something to consider: sometimes, a herniated disc doesn’t cause any symtpoms at all. That’s called an asymptomatic herniated disc. Your intervertebral disc may be bulging or herniated, but unless it’s pressing on a spinal nerve or the spinal cord, it will not cause any symptoms, such as pain.

This brings up an excellent point about herniated disc symptoms: your symptoms are dependent on where you have a herniated disc.

• neck pain
• muscle tightness or cramping in your neck
• pain that radiates (or travels) down your arm(s) (this is also called referred pain or cervical radiculopathy)
• tingling in your arm(s) or hand(s)
• weakness in your arm(s) or hand(s)

• low back pain
• muscle tightness or cramping in your low back
• pain that radiates down your leg(s) (this is also called referred pain, lumbar radiculopathy, or sciatica)
• tingling in your leg(s) or foot/feet
• weakness in your leg(s) or foot/feet
• very rare: loss of bowel or bladder control (Please, if this happens, seek immediate medical care.)

Referred pain means that you have pain in another part of your body as a result of the intervertebral disc problem. For example, if you have a bulging disc or a herniated disc in your low back (lumbar spine), you may have referred pain in your leg. This is known as lumbar radiculpathy or sciatica—a shooting pain that can extend from the buttock into the leg and sometimes into the foot. Usually just one leg is affected.

If you have a herniated disc in your neck (cervical spine), you may have referred pain down your arm and into your hand. Leg and arm pain caused by a herniated disc is also called radiculopathy.

Herniated Disc Symptoms: When Should You See a Doctor?

The pain from a herniated disc can make it difficult to enjoy your daily life; it can make it difficult to walk, sit, or even sleep comfortably. You should make an appointment with a doctor if your herniated disc symptoms linger for more than two weeks.

If you experience sudden onset of pain (after lifting something heavy incorrectly, for example), call your doctor.

It’s very rare, but herniated discs can cause you to lose bowel or bladder control (as mentioned above). If this happens, seek medical attention at once.

There are many causes of a Herniated Disc but it all comes down to this: your intervertebral disc (the cushion in between your vertebrae in your spine) pushes out or bulges or even ruptures. This very contained disc starts to take up more room than it should, and it can, as you’re probably well-aware, cause you a lot of pain.

Herniated Disc Cause : Wear and Tear on the Spine

Pain from a herniated disc is often the result of daily wear and tear on the spine. This is also called degeneration.

Our backs carry and help distribute our weight, and those intervertebral discs are made to absorb shock from movement (such as walking, twisting, and bending). Because our discs work so hard to help us move so well, they can become worn out over the course of time.

The annulus fibrous (the tough outer layer of the disc) can start to weaken, allowing the nucleus puplosus (the jelly-like inner layer) to push through, creating a bulging or herniated disc.

Herniated Disc Cause: Injury

A herniated disc can also be caused by an injury. You can herniate a disc in a car accident, for example: the sudden, jerking movement can put too much pressure on the disc, causing it to herniate.

Or you can herniate a disc by lifting a heavy object incorrectly, or by twisting extremely.

Herniated Disc Cause : A Combination of Degeneration and Injury

It may be that an intervertebral disc has been weakened by wear and tear (degeneration), making it more prone to herniation, should you experience a traumatic event.

Or it could be that your disc has become so weakened that something that doesn’t seem like a very traumatic event can cause a herniated disc. This is the case when people herniate a disc sneezing (it does happen!). A sneeze doesn’t seem like a traumatic event that could lead to injury, but if you have an already-weakened disc, then the sudden force of a sneeze can herniate a disc.

The 4 Stages of a Herniated Disc
There are 4 stages to the formation of a herniated disc, as shown here:

• Disc Degeneration:
  During the first stage, the nucleus pulposus weakens due to chemical changes in the disc associated with age. At this state, no bulging (herniation) occurs.
• Prolapse:
  During prolapse, the form or position of the disc changes. A slight bulge or protrusion begins to form, which might begin to crowd the spinal cord.
• Extrusion:
  During extrusion, the gel-like nucleus pulposus breaks through the tire-like wall of the annulus fibrosus but still remains within the disc.
• Sequestration:
  During the last stage, the nucleus pulposus breaks through the anulus fibrosus and even moves outside the disc in the spinal canal.

Although most patients with a herniated disc respond well to non-surgical treatments, some patients do need surgery. In general, surgery should be considered only after several months of non-surgical treatment. Many surgical procedures can be performed using minimally invasive techniques (meaning less cutting and entering the body). These techniques result in smaller incisions, shorter hospital stays, less pain after surgery, and a faster recovery.

The most typical surgery for a herniated disc is a discectomy . This is a surgical procedure that removes all or part of the damaged intervertebral disc. If the problem is in the neck, this procedure is usually done through the front and is called an anterior discectomy . Sometimes the surgeon may create more space for the disc and nerve by removing a portion of the bone covering the nerve. This is called a laminectomy.

More recently, surgeons are performing discectomies using various less invasive techniques (sometimes known as micro, mini-open, minimally invasive, or percutaneous discectomies). In these techniques, surgeons perform the entire surgery through a very small incision, or through a tube which allows them to insert a tiny camera and special surgical instruments.This is possible in selected cases. Sometimes the disc is replaced with an artificial disc, although this is more common in the neck than in the low back.

Sometimes multiple spinal procedures are needed to reduce the pain.

Other spinal surgeries include:

• Anterior Cervical Discectomy and Fusion:
  A procedure that reaches the cervical spine (neck) through a small incision in the front of the neck. The intervertebral disc is removed and replaced with a small plug of bone, which in time will fuse the vertebrae.
• Cervical Corpectomy:
  A procedure that removes a portion of the vertebra and adjacent intervertebral discs to allow for decompression of the cervical spinal cord and spinal nerves. A bone graft, and in some cases a metal plate and screws, is used to stabilize the spine.
• Laminoplasty:
  A procedure that reaches the cervical spine (neck) from the back of the neck. The spinal canal is then reconstructed to make more room for the spinal cord.
• Spinal Fusion:
  A procedure that often includes instrumentation and bone graft to stabilize the spine. Instrumentation refers to medical devices such as cages, plates, screws, and rods. There are different types of bone graft materials including the patient’s own bone (autograft), donor bone (allograft), and bone morphogenetic protein. A spinal fusion may be included with another surgical procedure such as a discectomy or laminectomy.
• Spinal Laminectomy:
  A procedure for treating spinal stenosis by relieving pressure on the spinal cord. A part of the lamina (a part of the vertebra) is removed or trimmed to widen the spinal canal and create more space for the spinal nerves.

If your doctor recommends surgery, always ask the purpose of the operation, results you can expect, and possible complications.

Before Your Surgery

Spine surgery should always be taken seriously. Therefore, it is a good idea to be in the best physical condition possible. Here are a few helpful tips:

• Eat right. Good nutrition is key to keeping your immune system healthy. Eat a balanced diet and take a vitamin supplement in the weeks before your surgery. This will help reduce your risk of infection.
• Get in shape. Weak muscles and low cardiovascular endurance make recovery from surgery more difficult. Talk to your doctor about how to start an exercise program that is right for your condition before and after spine surgery. If you already exercise regularly, make sure your doctor approves your exercise routine, and then keep it up!
• Lose weight. Back pain can make losing weight or weight maintenance a challenge. If you are overweight, it is a good idea to slim down before your surgery. Why? Because more body weight strains the spine and may slow the healing process and increase post-operative pain. If you need to lose more than 25 kg before surgery, ask your doctor about safe methods to shed those unwanted kg .
• Don’t smoke. If you are a smoker, being told to quit may be the last thing you want to hear! However, it is the most important step you can take to help ensure a safe and successful surgery. Quitting at least one month before surgery could decrease your chance of experiencing serious complications such as problems with anesthesia and post-operative pneumonia. Ultimately, patients who quit smoking increase the likelihood of a successful spinal surgery. If you think quitting may be difficult for you, talk to your doctor about smoking cessation programs in your area.

Pain is always a cause for concern. To recover and remain pain-free, follow the treatment plan your doctor has outlined. Make sure you have regular check-ups, and tell you doctor if you are not getting better. You may think a hurt back is the end of active life style. Think again! A herniated disc is no reason to stop enjoying life. With care and proper medical treatment, you will have a healthy back once again.