TREATMENTS & PROCEDURES

Symptoms/conditions addressed:

Patients suffering from lumbar stenosis and radiculopathy usually complain of back and leg pain, leg numbness, and sometimes weakness.  

The initial course of treatment involves activity modifications, physical therapy, home exercises, and anti-inflammatory medications.  If those treatments do not help, if the symptoms are severe, or if the symptoms are worsening, a steroid injection may be a good option.  The steroid medications used in these injections are very strong anti-inflammatory chemicals.  These chemicals are synthetic forms of cortisol – a chemical our body produces naturally to reduce inflammation.  

Rationale:

Whenever nerves in the lower back are compressed by a herniated disc or a degenerative bone spur, they also get inflamed.  The injection of steroids reduces this inflammation, which alleviates the symptoms. 

Description of the procedure:

The injection is usually done by a specifically trained pain management physician, a physiatrist, or an interventional radiologist.  There are a lot of sensitive structures in that area, which is why the injection is done using x-rays, so that the physician can constantly monitor where the needle is and inject the medication in the right spot.  This procedure can be done either with local anesthesia or with sedation.  It is usually done in a special procedure room with proper patient monitoring and x-ray equipment.  

How it helps:

The injection is effective 70-80% of the time and the effects last, on average, 3 months.  The injection does not “fix” the underlying problem of the disc herniation or the bone spur.  Instead, it alleviates the symptoms and helps the patient become more functional for a period of time.  During that time, the nerve can heal, or the disc herniation can get resorbed.  That way even after the medication has “worn off”, the symptoms do not come back.  If the symptoms do come back or if there was only partial relief, this injection can be repeated.  Typically, a patient can get 3 or 4 injections per year in the same spot.  

Ultimately, if this injection does not help or only helps for a short period of time, a patient might consider surgery to achieve permanent relief of symptoms.  

Symptoms/conditions addressed:

Lumbar facet joints are small joints in the back of the lumbar spine that connect lumbar vertebra together.  These joints can be damaged and get inflamed due to trauma, such as a fall or a car accident.  They can also degenerate and develop arthritis (spondylosis) through the normal process of aging and wear and tear.  When the joints are inflamed, they can become painful, causing low back pain and stiffness.

Rationale:

Initial treatments include activity modifications, physical therapy, home exercises, and anti-inflammatory medications.  If those treatments do not help, if the symptoms are severe, or if the symptoms are worsening, a facet injection (block) and radiofrequency ablation may be a good option.  

Description of the procedure:

First, the pain management doctor would need to determine if the back pain is truly caused by the painful facet joint.  Using a small needle, the joint and the sensory nerve near it are injected with long-acting numbing medication.  Because there are many sensitive structures in the back, this injection is done using x-rays to make sure the tip of the needle goes into the right place.  Once the injection is done, the patient will typically have relief of the back pain and stiffness for 4-6 hours.  This will confirm that the facet joint is the source of the pain.

The patient then returns for the second procedure.  A small probe that looks like a needle is then placed on the painful joint, near the sensory nerve, using x-ray guidance.  The probe then emits radiofrequency signal that gently heats the nerve and destroys it (the ablation).  

How it helps:

Once the nerve is not functioning, the pain signals from the joint cannot get to the brain, so the patient does not feel pain.  The procedure effect lasts until the nerve regenerates, which typically takes 6-12 months.  If the pain returns when the nerve grows back, the procedure can be repeated.  

Ultimately, if neither the injection or the ablation help, or only help for a short period of time, a patient might consider surgery to achieve permanent relief of symptoms.

Symptoms/conditions addressed:

Lumbar disc herniation can cause significant inflammation and compression of nerves in the lumbar spine.  This can lead to significant leg and back pain as well as leg weakness or numbness. 

Rationale:

Most disc herniations can be treated successfully without surgery.  Sometimes, however, the symptoms persist, worsen, or the disc herniation is so large that non-operative measures would not help.  In such cases, surgical removal of the herniated disc to relieve the pressure on the nerves may be recommended.

Description of the procedure:

Lumbar microdiscectomy is a very common spine surgery.  A small incision is made in the back, the lumbar muscles are moved out of the way and a small window is created in the bone in the back of the vertebra called lamina.  For that reason, this procedure is often called “hemilaminotomy.”  Once the bone overlying the herniated disc is removed, the nerves are gently pulled out of the way and the disc is exposed.  The herniated portion of the disc is then removed to relieve the pressure off the nerve.  The rest of the disc is left in place to continue its function.  The wound is then closed.  To visualize the small lumbar nerves, the surgeon usually uses an operative microscope or magnifying loupes, which is why the procedure is called “microdiscectomy”.  

Just like most spine surgeries, there is a lot of planning involved in arranging the lumbar microdiscectomy.  The patient needs medical clearance, preoperative tests, and the pre-certification from the insurance company.  The length of surgery depends on how many levels need to be decompressed and on the severity of the problem.  In general, this procedure is quick, complication rates are low, and many patients are be able to go home the same day.  If the pain is too severe, or if the patients have underlying medical problems, they are kept overnight for observation.  No brace is required after this surgery.  The patients are typically directed to start physical therapy to regain their strength and flexibility 2 weeks after the surgery.  Most patients can return to their normal activity in 6-8 weeks.  

Symptoms/conditions addressed:

Lumbar stenosis causes compression of the nerves in the lower back.  This can cause significant low back and leg pain as well as leg weakness or numbness.  In rare cases the stenosis is so severe that it can cause bowel or bladder incontinence (cauda equina syndrome).  Most of the time lumbar stenosis can be treated successfully with non-operative treatments.  When the symptoms persist, worsen, or if the stenosis is very severe surgery may be needed to remove the compression off the nerves.

Description of the procedure:

Lumbar lamina is the bony arch in the back of the spine that covers the nerves in the spinal canal.  In order to visualize the nerves and decompress them, the lamina needs to be removed.  The procedure to decompress the nerves in the lumbar spine under direct visualization is called laminectomy (or removal of the lamina).  First, a small vertical incision is made in the back.  The muscles are then gently removed off the lamina.  The lamina is then removed, and the nerves are decompressed.  Once all the nerves are free, the wound is closed.   If several levels need to be decompressed, a surgical drain may be placed to remove any residual collection of blood.  This drain is typically removed the next day.

Just like most spine surgeries, there is a lot of planning involved in arranging lumbar laminectomy.  The patient needs medical clearance, preoperative tests, and the pre-certification from the insurance company.  The length of surgery depends on how many levels need to be decompressed and on severity of the problem.  In healthier patients this surgery may be done on an outpatient basis.  Other patients would have the surgery done in the hospital and may go home after a 1 or 2 night stay.  The complication rate is low.  Most patients are ready to start physical therapy in 2 weeks after the surgery.  No bracing is required.  Most patients are back to normal function in 6-8 weeks after the surgery.

Symptoms/conditions addressed:

Fusion surgery is done to permanently connect, or fuse, two or more vertebrae in the spine together.  The most common reasons to perform a fusion procedure are instability (bones are moving too much and cause pain and nerve compression), deformity (bones are improperly aligned, causing pain), and degeneration (severe wear and tear of the disc and joints in the spine causes pain every time the spine moves).  Sometimes stenosis, or nerve compression, in the spine is so severe that the only way to properly decompress the nerves is to remove a significant amount of bone, which creates instability, so fusion is needed to “put everything back together.”  It is a significant surgery and is only offered as “last resort” if non-operative treatments fail, or if the problem is so severe that only the surgery will help.  

Description of the procedure:

There are multiple ways to perform a fusion procedure.  The best option will be recommended by your surgeon and will depend on multiple factors including anatomy, the reason for the fusion, history of prior spine procedures, overall health, etc.  

The minimally invasive advantage:

Minimally invasive spine fusions are new techniques that allow a surgeon to perform the procedure through a smaller incision with less soft tissue damage, while achieving the same successful fusion and nerve decompression as the traditional open techniques.  Minimally invasive lumbar fusions have been shown to cause less pain, a lower chance of complications, less blood loss, quicker discharge from the hospital, and quicker overall recovery and return to function.  With traditional open lumbar fusion, patients used to stay in the hospital for 3-5 days and had significant pain that required strong pain medications.  The recovery typically took 6-12 months.  The new minimally invasive surgical techniques allow the patients to go home after a one-night stay in the hospital, and in some cases even the same day.  Most patients will not need any pain medications beyond 2-4 weeks after the procedure.  The overall recovery is only 3-6 months.  

Lateral lumbar interbody fusion is a minimally invasive surgical technique.  It requires the surgeon to have specialized training and to utilize specialized instruments and monitoring.  The patient is placed on their side, s small incision is made on the flank, and the disc between the vertebrae is removed.  A spacer filled with bone graft material is then placed between the vertebrae where the disc used to be.  The spacer re-aligns and stabilizes the vertebrae.  The bone graft material slowly turns into a bony bridge that solidly and permanently fuses the two vertebrae together.  Screws are then placed into the vertebrae through the back and are connected with rods to rigidly hold the bones together while the bone graft slowly turns into solid bone.  Sometimes the LLIF is done with either computer navigation or robotic assistance, which makes the surgery safer and more efficient, with more precise placement of hardware.

Just like most spine surgeries, there is a lot of planning involved in arranging the LLIF.  The patient needs medical clearance, preoperative tests, and the pre-certification from the insurance company.  The length of surgery depends on how many levels need to be fused and on severity of the problem.  Most patients can get out of bed and walk the day of the surgery and go home the next day.  They usually do not need strong intravenous pain medications.  Patients wear a lumbar brace for 6 weeks after the surgery to allow for initial healing.  Physical therapy is then started and lasts about 6 weeks.  Most patients are allowed to return to full physical function, sports, and manual labor work 3 months after the lateral lumbar interbody fusion.

Symptoms/conditions addressed:

Fusion surgery is done to permanently connect, or fuse, two or more vertebrae in the spine together.  The most common reasons to perform a fusion procedure are instability (bones are moving too much and cause pain and nerve compression), deformity (bones are improperly aligned, causing pain), and degeneration (severe wear and tear of the disc and joints in the spine causes pain every time the spine moves).  Sometimes stenosis, or nerve compression, in the spine is so severe that the only way to properly decompress the nerves is to remove a significant amount of bone, which creates instability, so fusion is needed to “put everything back together.”  It is a significant surgery and is only offered as “last resort” if non-operative treatments fail, or if the problem is so severe that only the surgery will help.  

Description of the procedure:

There are multiple ways to perform a fusion procedure.  The best option will be recommended by your surgeon and will depend on multiple factors including anatomy, the reason for the fusion, history of prior spine procedures, overall health, etc.  

The minimally invasive advantage:

Minimally invasive spine fusions are new techniques that allow a surgeon to perform the procedure through a smaller incision with less soft tissue damage, while achieving the same successful fusion and nerve decompression as the traditional open techniques.  Minimally invasive lumbar fusions have been shown to cause less pain, lower chance of complications, less blood loss, quicker discharge from the hospital, and quicker overall recovery and return to function.  With the traditional open lumbar fusion patients used to stay in the hospital for 3-5 days and had significant pain that required strong pain medications.  The recovery typically took 6-12 months.  The new minimally invasive surgical techniques allow the patients to go home after one-night stay in the hospital and in some cases even the same day.  Most patients will not need any pain medications beyond 2-4 weeks after the procedure.  The overall recovery is only 3-6 months.  

In the MIS TLIF procedure two small incisions are usually made in the back.  Gentle dissection is then made between muscle fibers down to the spine.  The nerves are then decompressed, the disc is removed, and a spacer and bone graft material are placed inside the disc.  The spacer realigns the bones and the bone graft material slowly turns into a solid bridge of bone permanently connecting the two vertebrae together.   Screws are then placed into the vertebrae and connected with rods to rigidly hold the bones together while the bone graft slowly turns into solid bone.  Sometimes MIS TLIF is done with either computer navigation or robotic assistance, which makes the surgery safer and more efficient, with more precise placement of hardware.

Just like most spine surgeries, there is a lot of planning involved in arranging the MIS TLIF.  The patient needs medical clearance, preoperative tests, and the pre-certification from the insurance company.  The length of surgery depends on how many levels need to be fused and on severity of the problem.  Most patients can get out of bed and walk the day of the surgery and go home the next day.  They usually do not need strong intravenous pain medications.  Patients wear a lumbar brace for 6 weeks after the surgery to allow for initial healing.  Physical therapy is then started, and it lasts about 6 weeks.  Most patients are allowed to return to full physical function, sports, and manual labor work 3 months after the transforaminal lumbar interbody fusion.

Symptoms/conditions addressed:

Fusion surgery is done to permanently connect, or fuse, two or more vertebrae in the spine together.  The most common reasons to perform a fusion procedure are instability (bones are moving too much and cause pain and nerve compression), deformity (bones are improperly aligned, causing pain), and degeneration (severe wear and tear of the disc and joints in the spine causes pain every time the spine moves).  Sometimes stenosis, or nerve compression, in the spine is so severe that the only way to properly decompress the nerves is to remove a significant amount of bone, which creates instability, so fusion is needed to “put everything back together.”  It is a significant surgery and is only offered as “last resort” if non-operative treatments fail, or if the problem is so severe that only the surgery will help.  

Description of the procedure:

There are multiple ways to perform a fusion procedure.  The best option will be recommended by your surgeon and will depend on multiple factors including anatomy, the reason for the fusion, history of prior spine procedures, overall health, etc.  

Anterior lumbar interbody fusion is done through the front of the body.  Because there are a lot of organs in front of the spine, this procedure is usually done with the help of a vascular or general surgeon.  They help to safely move the intestines and large blood vessels out of the way.  The spine surgeon then removes the disc between the two vertebrae and replaces it with a spacer filled with bone graft material.  The spacer realigns and stabilizes the bones while the bone graft slowly turns into a permanent and solid bridge of bone to fuse the two vertebrae together.  To hold the bones in place while the fusion is happening, a metal plate and screws can be applied to the front of the vertebrae or pedicle screws and rods can be inserted in the back.  The general or vascular surgeon then checks to make sure there is no damage to the blood vessels and intestines and closes the wound. 

Just like most spine surgeries, there is a lot of planning involved in arranging the ALIF.  The patient needs medical clearance, preoperative tests, and the pre-certification from the insurance company.  The length of surgery depends on how many levels need to be fused and on severity of the problem.  Most patients are able to walk the day of the surgery and can go home the next day.  The brace is worn for the first 6 weeks to allow for initial healing.  After that, patients start physical therapy, which lasts another 6 weeks.  Most patients are allowed to return to full function, sports, and physical activity 3 months after the surgery.  

Minimally invasive surgery of the spine can be quite complex.  It is not easy to perform an operation through small incisions while minimizing complications and achieving surgical goals of nerve decompression, hardware placement, and bony fusion.  A lot of times the hardware is placed using x-ray guidance or computer navigation.  Spine surgery robots and navigation devices have been recently developed.  They allow a surgeon to pre-plan the best possible placement of the hardware prior to surgery and then execute the plan precisely and efficiently using the robot during the operation.  This minimizes chances of complications, especially improper screw placement.  The robot uses computer navigation guidance which significantly reduces exposure of the patient to x-ray radiation.  This new and amazing technology allows a surgeon to perform minimally invasive spine procedures through smaller incisions with high precision and efficiency.  

Minimally invasive surgery of the spine can be quite complex.  It is not easy to perform an operation through small incisions while minimizing complications and achieving surgical goals of nerve decompression, hardware placement, and bony fusion.  A lot of times the hardware is placed using x-ray guidance or computer navigation.  A CT scan of the spine can be done before or during surgery and the images are then loaded into the computer navigation system.  That way the computer knows the exact 3D anatomy of the spine.  The instruments used in navigated surgery have special trackers that allow the computer to know where they are in space relative to the spine.  This way a surgeon can place instruments and hardware accurately into the spine through small incisions with no additional x-rays.  This makes the operation more efficient and minimizes the amount of radiation exposure to the patient.

Symptoms/conditions addressed:

Fusion surgery is done to permanently connect, or fuse, two or more vertebrae in the spine together.  The most common reasons to perform a fusion procedure are instability (bones are moving too much and cause pain and nerve compression), deformity (bones are improperly aligned, causing pain), and degeneration (severe wear and tear of the disc and joints in the spine causes pain every time the spine moves).  Sometimes stenosis, or nerve compression, in the spine is so severe that the only way to properly decompress the nerves is to remove a significant amount of bone, which creates instability, so fusion is needed to “put everything back together.”  It is a significant surgery and is only offered as “last resort” if non-operative treatments fail, or if the problem is so severe that only the surgery will help.  

Description of the procedures:

There are multiple ways to perform a fusion procedure.  The best option will be recommended by your surgeon and will depend on multiple factors including anatomy, the reason for the fusion, history of prior spine procedures, overall health, etc.  Minimally invasive techniques in spine surgery have been developed in the last 10-20 years.  These techniques offer a lot of benefits, but they are more difficult to perform.  Most of the minimally invasive spine surgery techniques assume that the spine anatomy is at least close to normal.  Sometimes, a traditional open spine surgery can be a better option for the patient, especially if the anatomy is significantly altered, or if there is old hardware in the spine from prior surgery.  Even with open techniques, care is always taken to minimize bleeding or damage to the surrounding tissues.  

Just like most spine surgeries, there is a lot of planning involved in arranging open lumbar fusion.  The patient needs medical clearance, preoperative tests, and the pre-certification from the insurance company.  The length of surgery depends on how many levels need to be fused and on the severity of the problem.  Open spine fusion typically requires a larger incision to properly visualize the nerves and bones.  The nerves are decompressed, the hardware is placed to stabilize the bones, and bone graft is packed near the bones to achieve permanent fusion.  The wound is then closed, and a surgical drain is usually placed to remove any residual collection of blood.  This drain is typically removed the next day.  The hospital stay is usually 3 days.  Most patients would need to wear a brace for 6 weeks.  This is followed by at least 6 weeks of physical therapy.  Most patients can return to normal function, sports, and activity in 3-6 months.