Improving Your Quality Of Life
Spinal surgery has advanced exceptionally over the last few decades. Procedures which years ago did not have an acceptable success rate are now radically different in outcome due to technology and advances in technique.
Rest assured, our team of experts will provide you with the best in treatment and care
The need for spinal surgery often, though not always, occurs after a long history of physical therapies and other treatments. The realisation that the condition is not responding and a surgical procedure needs to be considered can be difficult.
It is not uncommon to see a patient do very well from a procedure today that they were advised would not be appropriate previously.
- An accurate and careful history, examination and review of imaging is the key to selecting if surgery would help and if so which procedure is appropriate
- In most cases, a simple decompression of the nerves will relieve the condition
- Providing stabilisation of the spine, when required, is a much less onerous task than the community expects and recovery is generally more rapid
- Recovery is a joint approach with good communication between treating surgeon, physical therapist and you the patient.
Services & Information
At Neuron, your treating Neurosurgeon is well versed in contemporary surgical and non-surgical spinal treatments that can improve your quality of life. Any prosthetic (implantable device) that is used is TGA approved and has been evaluated by your treating Neurosurgeon. Most spinal surgery does not require prosthetic devices; it requires neurological decompression to alleviate pain, sensory disturbance or often both. Some spinal surgeries are required to prevent further neurological decline and many even improve motor/movement dysfunction. Not all spinal pathologies require surgery and your Neurosurgeon will advise if this is the case. Secondly, not all symptoms can be treated through a surgical procedure. It may be, for instance that a neck operation or a lumbar spinal operation will improve considerably or even remove arm or leg pain, but may not change appreciably neck or low lumbar pain itself.
As with all fields of medicine, spinal surgery options have changed and improved over time, with new surgical techniques discovered frequently. If a newer procedure might offer the best outcome, your surgeon will advise of the theoretical advantages of such a surgery, but will not be able to suggest what the outcomes might be 15-20 years after such a procedure. Surgeries of this nature include arthroplasty, or disc replacement, within the neck or lumbar spine. This does not mean they ought not be performed, it simply means that surgery of this nature must be carefully selected when your treating Neurosurgeon believes it is more likely to provide you with a better outcome than another surgery or treatment.
It is also true, however, that longstanding surgical options such as fusion may be favoured over more recently developed surgeries due to a whole host of factors. The first is the known outcome over the course of a long time scientifically. Another may be that there is a reduction in the likelihood of pain that may not be as likely with another type of surgery. Thus to summarise spinal surgery, its assessment and provision can be a complex topic, one that can be very confusing particularly with information and misinformation from the internet. This is really something that requires careful assessment by your treating Neurosurgeon and a thorough discussion with you to come to the appropriate next step.
Stereotactic localisation is an intraoperative tool that your surgeon may need to use to plan and perform your spinal surgery. There are other localisation tools that are non-stereotactic which include intraoperative CT, plain x-ray, and anatomical assessment. All are often used together to assist and augment your treating neurosurgeon’s skills.
Stereotactic localisation is where a computer algorithm is used to identify the spinal anatomy through images taken otherwise prior to or during surgery. This is usually a CT, but potentially through x-rays, as well. What then occurs is registration with a computer system that is confirmed for its accuracy and the Neurosurgeon can use a GPS like system to improve the precision of the surgery. The stereotactic system can be utilised to identify anatomical landmarks when surgical access does not allow direct vision of that landmark, can be used to ensure the adequacy of neurological decompression, it can be used for checking surgery performed that does not require stereotactic localisation otherwise.
Stereotactic localisation is becoming an increasingly used tool in the provision of spinal surgery. Not all spinal surgery requires it, though your Neurosurgeon at Neuron may well consider it appropriate for you.
Minimally Invasive Surgery
Spinal surgery can be highly varied in terms of what is required for any particular concern. It can range from keyhole decompression of a disc protrusion to the entire realignment of the spinal column due to deformity. There have been advances in the way that spinal surgery overall can be performed. The reason that smaller incisions, or keyhole operations, are performed is not just because it can be done, but rather to avoid soft tissue trauma to the person upon which the operation is performed. This provides less discomfort post-operatively, and a faster and perhaps even a better recovery with less downtime, overall. This is true of any operation on the spine.
Sometimes operations cannot be done through a keyhole approach, or if they can be, are not safe to do so. Your Neurosurgeon will be able to advise on what is appropriate to any given situation, though the general guidance is the less significant the operative intervention the more likely it can be performed safely through keyhole approaches.
It is not common to require intraoperative neurophysiology for a spinal operation. When it is required, it is a very useful and adds valuable information to the operating Neurosurgeon to ensure that the spinal operative procedure is performed safely and efficiently with as low a risk as possible to neurological structures.
When a general anaesthetic is given, the anaesthetist supports all aspects of physiological function, in addition to keeping you asleep, pain free and overall comfortable. However, this means that the normal mechanisms by which you would avoid a painful stimulus or a problem, such as movement or the perception of pain, are removed. One way of monitoring functionally what the nerves are doing when under anaesthetic is to monitor muscle and/or nerve function directly. There are various ways of doing this, and in essence what occurs is that small acupuncture-like needles are placed under the skin once your anaesthetic has been given, and are removed prior to you waking up. Those needles are attached to wires that are monitored through a computer system that can interpret whether there is a concern with neurological function throughout a surgical procedure. If a step within the surgery has been performed that causes unexpected functional decline, then often it can be reversed with that decline also reversed, avoiding complications or concerns post-operatively. This is most important in surgeries such as correction of spinal deformity or correction of instability, though your Neurosurgeon may choose to utilise this technology and many other aspects of spinal surgery for a variety of reasons.
A safe, effective monitoring system simply adds further information for the Neurosurgeon to utilise to perform the spinal surgery accurately, efficiently and achieve the expected result.
One of the most common causes of an arm or leg pain is neurological compression of a nerve root as it exits the spinal column. The complex anatomy of the neck means that a disc protrusion that compresses upon the nerve as it exits may be amenable to keyhole decompression from the back of the neck, but often it is not. A much more common scenario is the disc protrusion in the lumbar spine causing neurological compression that can be accessed through keyhole surgery from the back. The lumbar spine is anatomically quite different to the neck. The spinal cord, in fact, finishes just below the chest. The remaining lumbar spine carries the nerves that exit at each level on the way down within a fluid filled sac. Thus, surgical procedures from mid to lower lumbar complaints including disc protrusions do not put the spinal cord at particular risk.
Microdiscectomy is a procedure whereupon a disc protrusion in the lumbar spine has caused significant pain, sensory disturbance or motor functional loss in the legs that has not responded to non-operative treatments. Alternatively, the condition may be so severe and progressive that your Neurosurgeon has suggested operative intervention in the first instance. The aim of such surgery is to preserve the normal function of the lumbar spine post-operatively; there is no stiffening or fusion of the spine. You are placed face down with appropriate supports after general anaesthetic. An x-ray is taken to ascertain the most appropriate spinal level and after preparation, to reduce infection risk, a small incision is made in the skin. A corridor is then developed between the muscles, usually to one side of the spine off midline, accessing the space between the vertebrae. This space is often enlarged slightly by the removal of a few millimeters of bone only. With a microscope, the small corridor is used to access the spinal canal, identify the sac containing the fluid and the nerves, the nerve at that level and the disc protrusion. The nerve is protected whilst the disc protrusion is removed, usually in several small fragments until the nerve is relaxed into its normal position and there is no further loose disc material in the region. The vast majority of the intervertebral disc is, in fact, preserved. It is only the fragment of the disc that has extruded into the spinal canal that is addressed. The nerve is then checked to ensure that it exits satisfactorily, which is known as rhyzolysis. The surgical field is then checked for any bleeding, a barrier is placed that is subsequently absorbed to try to prevent scar tissue tethering the nerve once more during healing and the surgical corridor is closed within internal sutures.
In the main, leg based symptoms from the nerve compression resolve immediately or certainly within the first few days to a week. The hospital stay is often overnight, but certainly can be considered day surgery. As with any surgical procedure, there are risks inherent and your neurosurgeon will take you through those preoperatively to ensure a thorough understanding of the procedure before it is performed.
In summary, microdiscectomy is a safe, common and appropriate procedure for some disc protrusion related nerve compression, mainly in the lumbar spine.
Nerve compression causing arm or leg pain does not always come from a disc protrusion or not primarily from a disc protrusion. The roof structure known as the lamina or other concerns coming from the facet joint (two at each level at the back of the spine) may be the cause. If this is the case, it is often a chronic degenerative process that is involved and often, therefore, the symptoms creep up rather than being acute. This is not always the case.
The foramen is the exit area for a nerve as it transits from the spinal canal to outside of the vertebral column. A foraminotomy is surgery whereupon that exit is enlarged through the removal of soft tissue and bone that does not destabilise the spine, but allows that nerve to once again exit satisfactorily aiming to resolve symptoms attributable to it. A foraminotomy can be performed at any area of the spinal column after the cause has been identified with clinical and radiological examination.
A foraminotomy is performed under general anaesthetic, and supports provided after you are moved onto your front. X-rays are performed to identify the appropriate level before a small keyhole procedure is performed to access the level or levels required to decompress the neurological structures. Multiple foraminotomies can be performed in any one procedure. Foraminotomies can be performed one sided or two sided, and really they relate to where the symptoms arise and where those symptoms correlate with the radiological findings. X-rays to confirm the level are performed and then a small amount of bone and soft tissue is removed under microscope magnification. The nerve is seen to exit appropriately after adequate decompression, blood loss is ensured to have ceased, and the barrier to scar re-tethering placed to give the best chance of short, medium, and long-term relief of symptoms. The surgical corridor is then closed, and dressings applied.
A laminectomy really is a larger bony decompression than a foraminotomy, where the lamina is completely removed. It allows for a greater visualisation, or the ability to remove more tissue, due to a demonstrated neurological compressive concern and access to the central aspect of the spinal canal. The steps to perform the procedure are similar to foraminotomy.
Surgery for spinal fusion has evolved considerably over the course of time. Stabilisation of the spine maybe required for really two reasons. The first is that there is instability inherent in the spine, which relates to the symptoms that are being caused. The second is that surgical decompression to alleviate symptoms will cause instability and thus in the absence of stabilisation, the surgeon would solve one problem and then create another. Debatably, a third reason may be to attempt to reduce pain in that spinal segment in the absence of instability concerns.
To be specific, stabilisation is what the surgeon does at the time of surgery to ensure that there is no instability in that segment or segments of the spine. Fusion is the growth of the bone thereafter that strengthens that stabilisation. One of the reasons that a stabilisation can fail a reasonable period down the track is when the bone itself does not fuse, thus, leaving the stabilisation device to potentially fail. The reasons that bone may not grow appropriately where it was expected or intended (pseudoarthrosis) are many and varied, but the most common risk factors for that are diabetes, smoking, ongoing movement (failure of the stabilisation device) and potentially even long term use of anti-inflammatory medications. Sometimes the reason for failure of fusion cannot be identified. Thankfully, failure of fusion is not a common occurrence.
There are pros and cons of surgical stabilisation and fusion. Sometimes it is an absolute necessity to prevent further significant concerns. Other times, however, it is an option in management comparative to other options and will need to be weighed up by you and your neurosurgeon to ensure that this is the right procedure for you.
Spinal fusions can be performed in any area of the spinal column, inclusive of the cranio-cervical junction. Spinal fusion can be performed from a midline or off midline incision (or incisions) from the back, can be performed in some areas of the spine from the side and particularly in the lumbar and neck region from the front. There are various reasons why a particular approach may be most valid in you. These reasons may include greater or lesser muscle discomfort post-operatively; it may include the most appropriate access to take the pressure off the neurological structures in the first instance. For example, it would not make a lot of sense to try to decompress nerve compression with an operation coming from behind when the nerve compression was coming from the front.
As the number of options, complexity and nuances of spinal stabilisation and fusion surgery are considerable it is really only appropriate to suggest that should stabilisation or fusion surgery be required, a thorough physical assessment, radiological assessment and discussion should occur to look at all the factors regarding why it ought to or ought not to be performed.
Correction of Deformity and Reconstruction
The spine can have various contours within it that are abnormal. This can be congenital (present from birth) which may of may not progress through life, such as scoliosis. Acquired deformity of the spine is often due to degenerative phenomena, though trauma can also have a role. Other conditions, such as infections and tumours, can bring on angulations and deformity within the spine at any age, though thankfully these are significantly uncommon. Deformity of the spine can occur in the absence of having any prior concerns with the spine, it can occur in the context of having previous disc protrusion or other concerns and it can also occur in association with previous spinal surgery. Deformity here means that the normal curves of the spine may or may not still be present, but there are superimposed angulations or curves within the spine causing abnormal vertebral column position. This may only cause mild discomfort or not even discomfort at all. It may, however, be progressive and significant causing balance problems, falls, severe pain, lung dysfunction and neurological compression.
When these latter symptoms occur, there is a consideration of whether surgery can correct this deformity, alleviate neurological symptoms, prevent further progression, and/or improve the functional capacity of any one patient. Sometimes surgery is not appropriate. Often, however, it is. Spinal reconstruction over a long segment of the spine is no small undertaking and will need to be carefully planned with the utilisation of cell-saving devices (to reduce the risk of autologous blood transfusion) neurophysiological monitoring, the potential for more than one surgeon, the requirement for stereotactic localisation and perhaps even a staged procedure (doing part of the surgery at one time and a subsequent part at another). Not all of these requirements are necessary, but they are certainly considerations. In smaller surgery for deformity, many of these same considerations still hold true but it is unlikely that a staged procedure would need to occur.
This surgery is often performed through a midline open procedure, though minimally invasive options may be appropriate. The general principles of the surgery are to decompress any neurological concerns directly (take the pressure off) or indirectly (take the pressure off by straightening or balancing the spine), preventing excess blood loss, aligning the spine through corrective operative manoeuvres and then stabilising the spine in that position. Fusion is usually, but not always, intended thereafter. Recovery from such surgery can often be protracted and may require pre-operative physical therapy and rehabilitation assessment as well as post-operative assessment and treatment of that nature with an inpatient rehabilitation stay quite common.
Again, the risks of an extensive surgery such as this are not to be underestimated and it is important to speak with your treating Neurosurgeon about how those risks may impact on your other medical conditions, the intended outcome (this procedure may improve some pain, but not other pain, it may improve balance, but limit movement), what the timeframe to recovery is likely to be and other important concerns all must be discussed at length prior to moving to the operating theatre.
Spinal trauma is like cranial trauma, something that can cause a minor degree of disability through to significant disability in the short, medium, and, sometimes, lifelong situations. Minor trauma to the spine may cause disc protrusion; this protrusion may then require microdiscectomy or other surgical endeavour to correct. Spinal trauma can also cause paraplegia or quadriplegia if the spinal column is grossly disrupted and the spinal cord and neurological structures within are in turn also grossly traumatised. In that severe instance, stabilising surgery may be required to restore vertebral column alignment and stability as well as reduce pain, but may not necessarily improve neurological function.
Many spinal traumatic events do not require surgery, but can cause significant dysfunction, not the least of which is vertebral fracture that is not unstable. You may need to avoid certain activities such as lifting, or you could be required to wear an external brace for a period of time with radiological and clinical assessment over time. These bones can heal of their own volition and surgery may simply not be warranted. In other instances, treatment may begin in a non-operative fashion, but either further deformity occurs, the bone fails to heal or both, and surgery may subsequently be required in a delayed fashion.
Workplace and sporting trauma to the spine is actually quite common. However, outside of major industrial accidents or significant events in contact sports the trauma seen is often an aggravation of an underlying degenerative concern or the progression of an underlying degenerative concern. Degenerative spinal conditions maybe and often are asymptomatic. Superimposed trauma can, but does not always, cause acute and perhaps even persisting symptoms of which the most common is pain.
Trauma sufficient to cause neurological symptoms such as sensory disturbance, motor dysfunction, or severe pain ought to be assessed by your Neurosurgeon. The vast majority will not require surgical intervention, but some just may and certainly and in particular with trauma the initial symptoms may be relatively insignificant though subsequent symptoms maybe more severe. It is prudent to ensure that this is prevented.
Major spinal trauma is dealt with through an emergency department in a tertiary referral hospital. Such hospitals have an intensive care environment in general, a spinal specific rehabilitation program and acute bed stay for surgical intervention should it be required. Lesser spinal trauma that results in subsequent symptoms that do not necessarily resolve where the patient is still independent can generally be treated on an outpatient/clinic basis.
Arthroplasty (disc replacement) is a surgical procedure where an intervertebral disc is replaced within the cervical (neck) or lumbar spine. The intention of disc replacement is to remove a dysfunctional disc and replace it, just like any other joint replacement in the body, with a functional one preserving motion. Arthroplasty is a relatively recent technology. The original devices for arthroplasty where rudimentary in comparison to the ones now and due to that the long-term data for the efficacy of arthroplasty will not be known for some time. The theoretical advantage of reconstructing a spinal segment with a device that maintains close to normal movement is to prevent other segments of the spine above and below from having to do more work over time and advancing a degenerative phenomenon over and above the natural history. Secondly, it can restore normal motion to that segment, particularly in the context that abnormal motion may be contributing considerably to the symptoms. Arthroplasty is often considered in the same conversation as fusion surgeries. Fusion surgeries often are those that remove the disc (though not always), realign the spine and then prevent motion occurring at that segment to ensure reduction in the symptoms at hand.
Fusion surgery has a longer history and the long-term outcome is more accurately known. Secondly, particularly in the context of facet joint concerns in addition to disc related problems, arthroplasties do not confer an advantage as maintaining motion where a facet joint is significantly dysfunctional and contributes quite a lot to pain is of no value. That said, and in certain instances and certain pathologies, an arthroplasty may be a reasonable consideration.
In this country due to the lack of longitudinal data, as described above, arthroplasties are only approved for insurance funding at a singular spinal level. In other countries around the world, that is not the case and multi-level arthroplasties are considered and performed when multiple disc pathologies manifest. Outside of self-funded surgery, multilevel disc replacement is not performed in Australia, and in fact there is very little data to support it.
Sometimes an arthroplasty will be performed in association with a fusion at another level. In these instances, the rationale is that the level that has been dealt with by fusion is significantly dysfunctional, is inappropriate to consider arthroplasty and requires surgical intervention. The further rationale is that another level may similarly need to be addressed but that segment may not be as problematic or maybe problematic in a different way, and an arthroplasty is considered. These so called hybrid procedures are not very common.
Arthroplasty surgery must generally occur from the front. This means an operation from the front of the neck or an operation on the abdomen. This is due to the device covering the vast majority of where the disc used to be and the requirement for it to be biomechanically well centred. The fact is that it simply cannot be placed from a posterior approach. There are some novel and perhaps even experimental ways of placing an arthroplasty through a lateral approach. That is not offered at Neuron.
In summary, arthroplasty is a surgery that is performed in the neck or the lumbar spine, at a singular level, when the disc is causing a number of symptoms that have failed conservative management and surgical intervention is warranted. There are certain aspects radiologically and clinically that preclude consideration of an arthroplasty. There are certain symptoms that would make it, theoretically at least, more appropriate.