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Considering Spinal Surgery?

Ask Yourself These 7 Questions:

1. Have you tried all of the conservative care first?

a. Pain Management Techniques

Pain Management Techniques

When Back Pain is due to Scar Tissue

If a complete physical exam and diagnostic imaging indicates that the patient’s back pain or leg pain is due to a nerve root bound by scar tissue, the treatment options are fairly limited.

• In the early postoperative period (3 to 12 months), medications such as Neurontin may help limit back pain or leg pain, and exercises can help free up the nerve.

Beyond this time period, pain management techniques may help the patient cope with the back pain or leg pain. All of the above-describe techniques for coping with chronic back pain make use of four types of skills…

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b. Chiropractic Adjustments

What is chiropractic?

Chiropractic is a complete system of healthcare focused on restoring, preserving, and optimizing health by natural hands-on care.

Where conventional or “allopathic” medicine focuses on curing illness through surgery and pharmaceuticals, the goal of chiropractic is to optimize health with a non-invasive approach that does not use drugs or surgery. Chiropractic’s primary avenue of care is manipulation of the spine and the framework of the body.

The spine is an important structure that houses and provides protection for…

c. Lifestyle Changes

What lifestyle changes are recommended for low back pain?

Exercise and Physical Therapy

Physical activity plays a strong role in recovering from back pain and particularly in helping to prevent future pain and loss of function. An exercise program can include any or all of the following components: flexing, stretching, endurance training, strength building, and aerobic activity. There is no one-size-fits-all approach. Exercise programs are individualized because people have different levels of pain and differing injuries that caused the pain initially.

Improving the strength, endurance, and function of your back helps minimize the chance of…

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d. Exercise for Back Issues

Regular exercises to restore the strength of your back and a gradual return to everyday activities. Open the document below to see instructions and images on how to perform these exercises…

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e. Physical Methods of Healing

• Chiropractic care. Chiropractic adjustments keep the joints of the spine from interfering with the nerves that control healing and pain. Many surgeries have been prevented by chiropractic care. It is even more effective when combined with decompression therapy, physical therapy, massage therapy, and/or yoga…

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f. Pre and Post Surgery Massage Benefits

Certified and licensed massage therapists are well trained to safely massage patients before and after surgery. The improved blood flow, improved lymph drainage, and relaxed muscles help prepare the body for the trauma of surgery. Post-surgery healing is advanced in the same ways. Some believe that post-surgical pain is lessened by quality massage therapy.

Massage: Get in touch with its many benefits

By Mayo Clinic Staff

A soothing massage can help you unwind, but that’s not all. Explore the possible benefits of massage and what to expect. Massage is no longer available only through luxury spas and upscale health clubs. Today, massage therapy is offered…

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g. Acupuncture

What Is Acupuncture?

Acupuncture is a technique in which practitioners stimulate specific points on the body—most often by inserting thin needles through the skin. It is one of the practices used in traditional Chinese medicine.

Results from a number of studies suggest that acupuncture may help ease types of pain that are often chronic such as low-back pain, neck pain, and osteoarthritis/knee pain. It also may help reduce the…

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h. Medications for Spinal Stenosis

By Mayo Clinic Staff

If your pain doesn’t improve with self-care measures, your doctor may suggest;

Medications

To control pain associated with spinal stenosis, your doctor may prescribe:

• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) help relieve pain and reduce inflammation. Some NSAIDs, such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve), are available without prescription.

• Muscle relaxants. Medications such as cyclobenzaprine (Amrix, Flexeril) can calm the muscle spasms that sometimes occur with spinal stenosis.

• Antidepressants. Nightly doses of tricyclic antidepressants, such as amitriptyline, can help ease chronic pain.

• Anti-seizure drugs. Some anti-seizure drugs, such as gabapentin (Neurontin, Gralise) and pregabalin (Lyrica), are used to reduce pain caused by damaged nerves.

• Opioids. Drugs such as oxycodone (Oxycontin, Percocet, others) and hydrocodone (Lortab, Vicodin, others) contain substances related to codeine and can be habit-forming…

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i. Cortisone/Steroid Injections

By Mayo Clinic Staff

Cortisone shots are injections that may help relieve pain and inflammation in a specific area of your body. Cortisone shots are most commonly given into joints — such as your ankle, elbow, hip, knee, shoulder, spine and wrist. Even the small joints in your hands and feet may benefit from cortisone shots. Cortisone shots usually include a corticosteroid medication and a local anesthetic. In many cases, cortisone shots can be administered in your doctor’s office. However, the number of cortisone shots you can receive in one year generally is limited because of potential side effects from the medication.

Risks

Cortisone shots carry a risk of complications, such as…

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j. Tips for Lifting and Bending

Anyone who engages in heavy lifting should take precautions when lifting and bending.

• If an object is too heavy or awkward, get help.

• Spread your feet apart to give yourself a wide base of support.

• Stand as close as possible to the object being lifted.

Bend at the knees, not at the waist. As you move up and down, tighten stomach muscles and tuck buttocks in so that the pelvis is rolled under and the spine remains in a natural “S’ curve. (Even when not lifting an object, always try to…

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k. Tips for Daily Movement & Inactivity

The way a person moves, stands, or sleeps plays a major role in back pain.

• Maintaining good posture is very important. This means keeping the ears, shoulders, and hips in a straight line with the head up and stomach pulled in. It is best not to stand for long periods of time. If it is necessary, walk as much as possible and wear shoes without heels, preferably with cushioned soles. Use a low foot stool and alternate resting each foot on top of it.

Sitting puts the most pressure on the back. Chairs should either have straight backs or low-back support. If possible, chairs should swivel to avoid twisting at the waist, have arm rests, and adjustable backs. While sitting…

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l. The Amazing Spine

The cervical, thoracic, lumbar, and sacral curvatures and the intervertebral disks absorb and distribute stresses that occur from everyday activities such as walking or from more intense activities such as running and jumping and lifting.

If any of these curves are altered by continuous malposition they put constant pressure on critical nerves that …

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2. Have you looked at alternative surgical procedures?

a. Laminectomy Surgery

The lumbar laminectomy is designed to remove a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the nerve root more space and a better healing environment.

The lumbar laminectomy (open decompression) differs from a microdiscectomy in that the incision is longer and there is more muscle stripping.

• First, the back is approached through a two-inch to five-inch long incision in the midline of the back, and the left and right back muscles (erector spinae) are dissected off the lamina on both sides and at multiple levels (see Figure 2).

• After the spine is approached, the lamina is removed (laminectomy), allowing visualization of the nerve roots.

• The facet joints, which are directly over the nerve roots, may then be undercut (trimmed) to give the nerve roots more room.
Post laminectomy, patients are in the hospital for one to three days, and the individual patient’s mobilization (return to normal activity) is largely dependent on his/her pre-operative condition and age.

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b. Needle Decompression Cervical Spine

ACDF: Anterior Cervical Discetomy & Fusion

A cervical disc herniation can be removed through an anterior approach (through the front of the neck) to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness and tingling.

• This procedure is called an anterior cervical discectomy and allows the offending disc to be surgically removed. A discectomy is a form of surgical decompression, so the procedure may also be called an anterior cervical decompression.

• A fusion surgery is almost always done at the same time as the discectomy in order to stabilize the cervical segment.

• Together, the combined surgery is commonly referred to as an ACDF surgery, which stands for Anterior Cervical Discectomy and Fusion.

While this surgery is most commonly done to treat a symptomatic cervical herniated disc, it may also be done for…

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c. Discectomy

Discectomy is done to remove a herniated disc from the spinal canal. When a disc herniation occurs, a fragment of the normal spinal disc is dislodged. This fragment may press against the spinal cord or the nerves that surround the spinal cord. This pressure causes the symptoms that are characteristic of herniated discs, including electric shock pain, numbness/tingling, and weakness.

The surgical treatment of a herniated disc is to remove the fragment of spinal disc that is causing the pressure on the nerve. This procedure is called a discectomy. The traditional surgery is called an open discectomy. An open discectomy is an operation where…

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d. Micro-Discectomy (Microdecompression) Spine Surgery

In a microdiscectomy or microdecompression spine surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and provide more room for the nerve to heal. A microdiscectomy is typically performed for a herniated lumbar disc and is actually more effective for treating leg pain (also known as radiculopathy) than lower back pain. Impingement on the nerve root (compression) can cause …

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e. What is Decompression Therapy

Each of us is constantly in a battle—with gravity! A frequent casualty is the soft disc material that separates each spinal bone. Pressure from our weight, trauma from an accident and other causes can increase the pressure on a weakened disc. In extreme cases, the soft pulpy center of the disc can escape. That can be quite painful.

We use the latest technology to help relieve the effects of back pain due to herniated and degenerated discs. Since discs are constantly under weight-bearing pressure, they…

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f. Nerve Blocks for Pain Relief

A nerve block relieves pain by interrupting how pain signals are sent to your brain. It is done by injecting a substance, such as alcohol or phenol, into or around a nerve or into the spine.

Nerve blocks may be used for several purposes, such as:

• To determine the source of pain.

• To treat painful conditions.

• To predict how pain will respond to long-term treatments.

• For short-term pain relief after some surgeries and other procedures.

• For anesthesia during some smaller procedures, such as finger surgery.
Nerve blocks are used to treat chronic pain when drugs or other treatments do not control pain or…

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g. Lumbar Spinal Fusion Surgery

Fig 1: X-ray of pedicle screws in place (lateral view) during spinal fusion

A spinal fusion surgery is designed to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint.

There are many approaches to lumbar spinal fusion surgery, and all involve the following process:

• Adding bone graft to a segment of the spine

• Set up a biological response that causes the bone graft to grow between the two vertebral elements to create a bone fusion

• The boney fusion – which results in one fixed bone replacing a mobile joint – stops the motion at that joint segment

For patients with the following conditions, if abnormal and…

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h. Discography

Since many people have evidence of disk degeneration on their MRI scans, it is not always easy to tell if the finding on this MRI scan explains pain the patient may be experiencing. Discography is a test that is used to help determine whether an abnormal disk seen on MRI explains someone’s pain. When performed, it is generally reserved for patients who did not experience relief from other therapies, including surgery.

This procedure requires injections into disks suspected of being the source of pain and disks nearby. It can be painful. There is controversy among physicians who take care of…

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i. Posterolateral Gutter Spine Fusion Surgery

There are multiple methods for obtaining a spinal fusion, but the gold standard is a posterolateral gutter fusion. This type of spinal fusion, which involves placing bone graft in the posterolateral portion of the spine (a region just outside the spine), has a long history and is considered by many surgeons to be the…

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j. Percutaneous Disc Decompression

Percutaneous Disc Decompression (PDD) is a disc decompression method that works by
removing disc tissues and reducing the internal pressure in a herniated disc. Reducing
the pressure creates a partial vacuum that enables the disc to suck the herniation inside
and re-absorb the tissue. This procedure is primarily used to remove…

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k. Alternative Surgeries Review

While laminectomy is by far the most common type of surgery for spinal stenosis, there are other available surgical options including:

• Foraminotomy

• Laminotomy

• Interspinous process spacer

• Microendoscopic decompression

Like a laminectomy, the goal of these surgical options is to decompress…

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l. Epideral Steroid Injections

The most commonly performed injection is an epidural steroid injection. In this approach, a steroid is injected directly around the dura, the sac around the nerve roots that contains cerebrospinal fluid (the fluid that the nerve roots are bathed in). Prior to the injection, the skin is anesthetized by using a small needle to numb the area in the low back (a local anesthetic).

Epidural Injections Help Reduce Inflammation

Injecting around the dura sac with steroid can markedly decrease inflammation associated with common conditions such as spinal stenosis, disc herniation, or degenerative disc disease. It is thought that there is also a flushing effect from the injection that helps remove or…

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m. Cervical Spine Surgery

Cervical spine surgery is generally performed on an elective basis to treat either:

• Nerve/spinal cord impingement (decompression surgery)

• Spinal instability (fusion surgery).

The two procedures are often combined, as a decompression may de-stabilize the spine and create the need for a fusion to add stability. Spinal instrumentation (such as a small plate) can also be used to help add stability to the…

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n. Controversies About Spinal Fusion: Allografts, Antogafts, and Fusion Levels

While physicians agree on many things about spine fusion surgery, there are some areas that lack consensus. Two such areas are:

• The type of bone used (autograft vs. allograft), and

• How many levels should be fused

What Bone Type Should Be Used with the Fusion?

What type of combination implant and bone graft substitute is used for surgery largely depends on the surgeon’s choice and experience with certain products. Cost, risk, availability, safety and postoperative morbidity are all factors…

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o. Failed Back Surgery Syndrome (FBSS): What is it and How to Avoid
Pain After Surgery

Failed back surgery syndrome (also called FBSS, or failed back syndrome) is a misnomer, as it is not actually a syndrome – it is a very generalized term that is often used to describe the condition of patients who have not had a successful result with back surgery or spine surgery and have experienced continued pain after surgery. There is no equivalent term for failed back surgery syndrome in any other type of surgery (e.g. there is no failed cardiac surgery syndrome, failed knee surgery syndrome, etc.).

There are many reasons that a back surgery may or may not work, and even with the best surgeon and for the best indications, spine surgery is no more than…

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p. Causes of Failed Back Surgery Syndrome

A comprehensive physical examination and appropriate diagnostic imaging techniques can often pinpoint the responsible pathology – the underlying cause – of the patient’s pain. For instance, a definitive diagnosis of recurrent disc herniation or other disorders may be made.

In a number of cases, however, an MRI scan reveals only the presence of…

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3. Do you understand low back pain, stenosis and surgery?”

a. Axial Low Back Pain

Axial low back pain can vary widely. It can be a sharp or dull pain, it can be felt constantly or intermittently, and the pain can range from mild to severe.

The most common type of axial back pain is “mechanical” and is characterized as:

• Low back pain that gets worse with certain activities (e.g. certain sports)

• Low back pain that gets worse with certain positions (e.g. sitting for long periods)

• Low back pain that is relieved by rest

Axial pain represents the most common type of…

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b. Understanding Low Back Pain

What is low back pain?

Pain in the low back (waistline or below) is a very common problem and affects 80 percent of Americans at some time in their lives. Back pain is one of the most frequent reasons people seek medical care.

It is important to remember that back pain is…

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c. Low Back Pain with Referred Pain

Low back pain with referred pain can vary widely with regards to severity and quality. It tends to be achy, dull and migratory (moves around). It tends to come and go and often varies in intensity. It can result from the identical injury or problem that causes simple axial back pain and is often no more serious.

Area of Pain Distribution

Referred pain is usually felt in the low back area and tends to radiate into the groin, buttock and upper thigh. The pain often moves around, and rarely radiates below the knee. This type of low back pain is not as common …

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d. What is Spinal Stenosis?

Spinal Stenosis Could be the Source of Persistent Back Pain

ROCHESTER, Minn. — When back pain is persistent or slowly worsens, spinal stenosis may be the culprit, according to the January issue of Mayo Clinic Health Letter.

Spinal stenosis is a narrowing in one or more areas of the spine. Different types of problems can reduce the space within the spinal canal. Most are age related. One cause is osteoarthritis, which results in wearing away of the cartilage that cushions the ends of the bones in the joints. In the spine, osteoarthritis may narrow the space between the vertebrae. Bony growths or disk bulges may…

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e. Spinal Stenosis Treatment Options

While the term “stenosis” comes from Greek and means “choking,” spinal stenosis, however, has little in common with choking. So what is spinal stenosis?

There are two types of spinal stenosis: lumbar stenosis and cervical stenosis. While lumbar spinal stenosis is more common, cervical spinal stenosis is often more dangerous because it involves compression of the spinal cord, as explained below in more detail.

Lumbar Spinal Stenosis vs. Cervical Spinal Stenosis

• In lumbar stenosis, the spinal nerve roots in the lower back are compressed, or choked, and this can produce symptoms of sciatica — tingling, weakness or…

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f. Spine Surgery: The Last Resort

Written by Jason M. Highsmith, MD

Back surgery is usually an elective surgery. The exception is when there is an emergency or rare condition such as a tumor, infection, cauda equina syndrome, or trauma that causes damage to the spinal cord. But these situations are truly rare. Generally, it is up to you and your doctor to determine whether or not back surgery is the right choice for your particular condition.

Most back surgery is done to relieve pressure from the nerve or stabilize a segment of the spine. Diagnostic tests will…

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g. Wrong Level Spine Surgery

Excerpt from Wrong-level surgery: A unique problem in spine surgery
John Hsiang Department of Spine Center
Swedish Neuroscience Institute
550 17th Ave., Suite 500
Seattle, WA 98122, USA

Discussion:
No spine surgeon, no matter how experienced he or she is, dares to say wrong-level spine surgery would never happen to him or her. One can argue wrong site surgery or wrong side surgery is purely due to carelessness of the surgeon. On the other hand, the unique anatomy of the spine can be a set-up of wrong level surgery performed even when the surgeon pays a conscious effort…

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h. Treatment for Failed Back Surgery Syndrome

Written by Ralph F Rashbaum, MD

Orthopaedic spine surgeon Ralph Rashbaum, MD continues his discussion about failed back surgery syndrome (FBSS). In this segment, Dr. Rashbaum explains his approach to proper patient care when back surgery is not successful.

SpineUniverse: When a patient comes to you and their surgery was not successful, what do you do?

Dr. Rashbaum: We find out what went wrong. Typically, the patients I see that clearly have failed back surgery syndrome (FBSS) go back to their doctor, only to find that their doctors are…

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i. Non-Operative Interventions for Failed Back Surgery Syndrome

Written by Ralph F Rashbaum, MD

Ralph Rashbaum, MD, an orthopaedic spine surgeon answers questions posed by SpineUniverse about failed back surgery syndrome. In this segment, Dr. Rashbaum explains when surgery is not elective and important considerations for both patients and surgeons.

SpineUniverse: You’re an orthopedic surgeon, yet a big proponent of non-surgical intervention. Can you explain why?

Dr. Rashbaum: One of the biggest problems I deal with in a patient population is the possibility of recurrence of the pain, for whatever reason. Our job as interventionists is to keep patients…

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j. Research Proving that Decompression Therapy Work

Effect of sustained loading on the water content of intervertebral discs: implications for disc metabolism

The fluid content of the intervertebral disc is not constant but varies with external load and load history. When a load is applied to a disc, resulting in a stress that exceeds the osmotic pressure of the tissue, fluid is expelled. The proteoglycan concentration and hence osmotic pressure are thus increased as fluid is lost, until equilibrium is reached and the osmotic pressure once again balances the applied stress. When the disc is unloaded, it imbibes fluid to achieve equilibrium. During daily activities, there is a…

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4. Is it the right surgery?

a. “It’s not a science”. Pros & Cons of Surgery by Atul Gawande, MD

As you look into options for your back pain/spinal stenosis, you may want to read from medical experts on the pros and cons of surgery. Complications is a book written by a well-established medical/surgical specialist who is not a medical renegade nor a primadonna surgeon who views surgery as the only solution to all things health.

Complications: A Surgeon’s Notes on an Imperfect Science
by Atul Gawande, MD (Author)

In vivid accounts of true cases, surgeon Atul Gawande explores the power and the limits
of medicine, offering an unflinching view from the scalpel’s edge. Complications lays
bare a science not in its idealized form but as it…

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b. Is Your Surgeon Sure the Level He’s Working on is the Right Level?

Surgery is Based on the Right Level Chosen by the Surgeon.

Methods to Determine Correct Surgery

Surgical thinking regarding spinal issues is mainly focused on finding the right spinal level to work on in addition to choosing the correct method. So the method of evaluation is almost as important as the type of surgery chosen.

MRI

Magnetic Resonance Imaging (MRI). Magnetic resonance imaging (MRI) can provide very well-defined images of soft tissue and bone. The test is not painful or dangerous, but…

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5. Are you strong enough to recover from and benefit from the surgery?

a. Water Intake—are you drinking enough to hydrate your cells? What about exercise?

Diet—Are you eating a good diet to make sure the nutrients are available as you recover from surgery?

Exercise—Are you getting regular, planned exercise so your cardiovascular and Musculature systems are strong enough to maintain and heal? Regular exercises to restore the strength of your back and a gradual return to everyday activities. Open the document below to see instructions and images on how to perform these exercises…

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b. Immune system—Is your immune/lymph system strong enough?

6. Have you considered all the possibilities of the surgery?

a. Have you considered all the possibilities of the surgery?

Perfect – what about the original cause? Ask your doctor.

No Change? What do you do now? Ask your doctor.

Gets worse? What do you do now? Ask your doctor.

7. Have you prepared your lifestyle for the 3-12 weeks of recovery?

a. Have you prepared your lifestyle for the 3-12 weeks of recovery?

    • Meals and healing supplements
    • Common items close to where you are resting?
    • Handicap stickers for parking
    • Scheduling Physical Therapy sessions
    • Home care assistance arranged
    • Constipation warning

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