Surgical intervention in patients who suffer Neurological Symptoms from
a herniated lumbar disc and/or surgically significant degenerative
arthritis of adjacent joints become indicated in those patients where a
serious trial of conservative treatment has failed; where neurological
deficits are initially so severe that further delay will probably result
in major permanent neurological deficit; where the neurological deficit
is advancing (worsening) despite the conservative treatment or where
nerve root compression, from narrowing (stenosis) of the spinal canal
or nerve root exit area (neural foramen) is causing severe symptoms of
Cauda Equina Claudication (see Lumbar Spine Information – Part 1.)
The presence of the symptom of Back Pain (by itself and not accompanied
by any mechanical physical signs of nerve root compression, neurological
involvement of the particular nerve root[s] or structural spinal
instability) is rarely a valid indication for surgery. Recognizing
that no reasonable person would wish to undergo an unnecessary
operation, it is, therefore, important for patients with back pain
to understand this concept if those who are not going to benefit
from surgery are to avoid it.
The following information reflects our philosophy and collective
experience, relating to the treatment of thousands of patients with
these problems over the many years of our active involvement in
Major advances in the field of NEUROIMAGING have improved the ability
of neuro-radiologists and neuroimaging techniques to provide us with
much more accurate information about the actual pathological situation
affecting the spinal column, spinal canal and nerve root(s). CT
(Computed Tomography) scan (also called CAT Scan-Computerized Axial
Tomography) is one of these techniques. It should be recognized that
this x-ray examination is subject to technical limitations and that
not all CT scan machines or the people who run them or the
radiologists who attempt to interpret the studies are as accurate
as we would want them to be. In the event that a CT scan is
supervised by a Neuroradiologist and interpreted by him (or her),
then the chance for error has been reduced. The CT scan is
"NON-INVASIVE" (no needles are used to penetrate the spinal canal).
The effects of the expected aging process frequently produce changes
that become evident on CT scan. A "degenerative disc," "disc space
narrowing," "degenerative arthritis with bone spur formation,"
"narrowing of the spinal canal" (the medical term is "stenosis")
and "bulging" (of one or more discs) are among the diagnostic
impressions frequently reported by radiologists who review and
interpret these studies. The patient must be prepared to realize
that many, if not all, of these "conditions" are the result of the
progressive changes of the aging process and may very well NOT
respond to any form of surgery and SHOULD NOT be operated upon in
the absence of an accompanying clear-cut neurological indication.
(There are rare exceptions to this.) What the foregoing should
mean to the informed patient is the following: "The mere presence,
on the CT scan, of a bulging disc (or discs) coupled with other
'pathological' situations does not mean (in and of itself) that
surgery should be done now or later."
MRI (Magnetic Resonance Imaging) has evolved as the single best
Neuroimaging technique for the initial evaluation of the lumbar
spine. It can be excellent for evaluating the spinal cord and
some disc anatomy but does not give as detailed information about
bone anatomy compared to CT. Often times when this information is
placed in the context of a reliable neurological examination, the
MRI derived information is sufficient for us to make an accurate
assessment and to make a definitive surgical recommendation. In
other words, the newer MRI technology has advanced to a point that
it is frequently the sole source of "Neuroimaging" required for
many patients. MRI scanning can also be of considerable help when
evaluating certain post-operative conditions.
There appears to be a trend toward elucidating new "diseases" of
the spine as more sophisticated and refined imaging methods become
available, the result of which is that some of our very aggressive
surgical colleagues have identified newer indications for surgical
intervention. Most Neurological Surgeons, have a somewhat different
and perhaps more conservative philosophy (and scientific understanding)
about the spine and the treatment of its problems. One of these
"new diseases", for example, is called the "black disc".
This appearance, seen on MRI (Magnetic Resonance Imaging) scans, is
a normal phenomenon of diminished water content (dehydration) of the
disc related to the natural process of aging and use. Depending on
the extent of one's life-long physical activity (at work and/or with
sports activities) and as we get older, our discs are subjected to
more or less "wear and tear". This process results in some internal
changes. The disc, which has a "rubbery" consistency under age 20,
becomes less viscous, more dehydrated and more like "crab meat"
as we age. The image of these changes appears on the MRI scan as
"black". We wish to caution patients against assuming that something
horrible is happening to their bodies or that this necessarily
requires surgical treatment. We want to point out that this is, in
most people, an entirely "natural" process of living and rarely is
indicative of a "disease" process. In our opinion this is not a
problem that should require surgical intervention in the absence of
other more significant problems such as instability of the spine or
neurological signs and symptoms.
For a number of reasons neither the CT nor the MRI scans may reveal
enough of the structural situation of the spine for the surgeon to
make a decision about the precise pathological anatomy upon which
treatment alternatives and recommendations would be made. In this
case the surgeon may request that a "MYELOGRAM" be done.
This x-ray examination, conducted by a Neuroradiologist, involves the
placement of a needle into the spinal canal. (The skin and
underlying tissues are anesthetized with locally injected anesthetic
agents.) A special dye substance is injected through the needle into
a particular place in the spinal canal (subarachnoid space) where it
mixes with the Cerebrospinal Fluid (CSF), and the pattern of the
flow of the dye is watched on a special x-ray screen (called
"fluoroscopy") similar to a television. In the event that a "mass
lesion" is present in the spinal canal, Myelography can frequently
outline its anatomical configuration. "Mass lesions" are any
abnormal conditions in the spinal canal, which take up space and
therefore, displace the nerve roots from their usual position.
Herniated Disc, Bone Spurs, Synovial Cysts or Spinal Tumors (which
are rare and most frequently completely benign) are examples of
"mass lesions." Once again, this test is subject to some technical
limitations, and the quality and accuracy of the study depends on
these and the technicians as well as the radiologists performing and
interpreting the study. Once the dye injection has been successfully
accomplished and appropriate routine x-rays have been taken, the
patient will be placed in the CT scanner. This phase of the study
(known as "post-myelographic CT scan") is the most helpful imaging
concept currently available. IT GIVES THE MOST PRECISE ANATOMICAL
DETAIL OF THE BONE ANATOMY AND THE EFFECT OF STRUCTURAL PATHOLOGICAL
CONDITIONS ON THE SPINAL CORD/NERVE ROOTS.
In the majority of patients who suffer from a herniated lumbar disc,
Myelography is not required. Usually the CT or MRI scan gives
sufficient information. Myelography is invasive; and although the
risks of adverse reactions to the patient are very low, there are
definite risks. An unnecessary myelogram is not in the patient's
There are some other forms of examination that are occasionally
utilized. "Discography" and "Disco-CT Scan" (injecting a dye
into the disc) is a painful procedure that has very limited
indications and even more limited usefulness in helping to make
clinical decisions. We strongly disapprove of this test and do not
Diagnostic Nerve Blocks (injecting anesthetic agents near a
nerve root or a facet joint) is being done with increasing frequency
by some doctors. Unfortunately these procedures offer little to
nothing diagnostically or therapeutically for patients with nerve
root problems that are the result of herniated discs and/or spinal
Electromyography (EMG) is an electrical test that is
sufficiently reliable only in the hands of very capable
Neurologists or Physical Medicine & Rehabilitation specialists.
Tiny needles, inserted through the skin, measure very small
electrical currents from nerves and the affected muscles. The test
can provide some useful neurophysiologic information if properly
done. The problem with the test is the wide variation of
reproducible findings, which may render poor results making the
examination unreliable. The degree of training and the extreme care,
which the doctor brings to the test and utilizes in interpreting
the results, are critical. This test is not necessary for most
patients who are candidates for surgery. For others it may provide
important information concerning fairly subtle neurological
Before undergoing any treatment, particularly an operation, it is
reasonable to try to understand what will happen to patients if no
treatment is undertaken.
Equally important is what will happen to patients who FAILED
conservative treatment (patients suffering Lumbar Radiculopathy
[injury to nerve roots] as a result of herniated or extruded discs
with or without a component of spinal or foramenal stenosis or spinal
stenosis and/or foramenal stenosis without the herniated disc) and a
definitive operation is not done.
Several statements can be made about the "projected natural history."
First, most Herniated Disc patients improve with a vigorous
attempt at conservative therapy (initially with strict and complete
bed rest) since the injury that resulted in a herniated disc is
usually one where the Posterior Longitudinal Ligament and most of
the Annulus Fibrosus remain intact (both are structures critical
to holding a disc in place.)
Second, the degree to which patients subsequently remain free
of symptoms depends on the extent of their initial injury
(particularly to the capsule and ligament confining the disc) and
the time that they allow, in the months following injury, for these
structures to heal adequately.
Third, in the event that a nerve root is injured, the patient
experiences pain and varying degrees of neurological deficit (such
as tingling, numbness and muscle weakness).
Fourth, those patients who decide against surgery will continue
to experience the pain for a fairly long time; however, the pain will
eventually disappear once the nerve root dies. This could take weeks
but more likely months to years.
Fifth, when the nerve dies the patient will be numb in the
leg/and or foot region supplied by that nerve root. The muscles that
receive their signals from the nerve will no longer work resulting
in permanent paralysis. The degree to which this happens is variable
in humans partly because of other nerve roots partially supplying
similar regions and muscles. Nevertheless, it is unreasonable to
expect, in these cases, to regrow a nerve supply to a paralyzed
Sixth, it is exceptionally rare for an "Extruded Disc" (one
that has torn completely through the Annulus Fibrosus and the
Posterior Longitudinal Ligament) to ever recede into its former
Seventh, when an extruded disc is not removed, more disc material
could herniate through the already compromised Annulus Fibrosus and
Posterior Longitudinal Ligament, placing more nerve roots at risk for
The surgical procedures available for patients with herniated lumbar
intervertebral discs and spinal and/or foramenal stenosis (narrowing
of these spinal bone passages due to problems that are congenital
and/or secondary to degenerative arthritis) have been utilized for
many years. They are among the oldest operations ever performed on
the nervous system. Modern trends have introduced some major
advances. These are particularly related to the use of
micro-neurosurgical techniques and specially designed instruments.
In recent years we have introduced the more advanced techniques of
Minimally Invasive Microendoscopic Surgery to spine surgery.
As a general rule patients who undergo these operations require a
general anesthetic. Fortunately, modern anesthetic techniques have
reduced the associated risk to life to a tiny fraction. The
anesthesiologist will discuss the matters relating to the anesthetic
and will be pleased to answer any questions that you may have.
There are certain basic surgical concepts to be understood before
recognizing which particular procedure is chosen for a patient.
Although degenerative changes affect more than one disc, it is
unusual for more than one disc to require surgical attention at any
particular time. Extruded discs (discs that have either broken
through the confining capsule and ligament or have so damaged the
ligament and disc capsule that they are no longer capable of holding
disc material in place) are only rarely found to have come from more
than one level. Removal of degenerative discs that have not frankly
herniated as a "prevention measure" is not appropriate except in
very isolated cases. The primary purpose of these operations is
to relieve the pressure on the nerve root(s).
In the case of an extruded disc, the primary surgical purpose is to
remove the fragment of disc that has escaped its confining capsule
and ligament and relieve pressure upon the nerve root(s) and/or
spinal cord. A secondary but equally important aim of surgery is to
try to reduce the risks of recurrence of the problem. In most
patients with an extruded disc, an attempt is made to remove as much
remaining disc as possible from the disc space itself. This is in
addition to removing the extruded fragment(s). In order for a
herniation to have occurred, the confining capsule and ligament must
have been severely damaged. Frequently there is a fairly large hole
in these structures. Other fragments of disc could subsequently
herniate from this disc space since the structures that help to prevent
this (the capsule and ligament) have been damaged irreparably.
Although it is not possible to remove every last fragment of disc
from within the disc space, no matter how vigorous an attempt is made,
the remaining disc is usually tenaciously bound to the bone of the
vertebral body. While many surgeons restrict their operation for
lumbar disc herniation to the removal of the herniated fragment(s),
the reader should understand our rationale for removing as much disc
material as possible in order to prevent the significant risk of
recurrent herniation. Our recurrence rate, over the years,
has been exceptionally low at less than 3 percent. This
compares very favorably with the generally recognized world wide
experience where recurrence rates run are as high as 17 percent.
In our hands, this operation is performed with Minimally Invasive
technique, which also means the procedure is accomplished, in almost
every case, on an out-patient basis.
In many patients compression of the nerve root results from a
combination of pathological conditions of which the herniated disc
is one. Where bony spinal canal and neural foramen narrowing are also
factors, it is important to remove the overlying bone which, then,
allows for complete "decompression" of the involved nerve root(s).
This is an essential part of the definitive operative management of
these clinical problems.
Once the majority of the Intervertebral Disc has been removed scar
tissue will eventually fill in the space from which the disc is
excised. It is never as effective as the original disc was. However
the scar can be sufficiently effective in subsequent "spine mechanics"
provided proper healing occurs. In a similar way, the tear in the
Posterior Longitudinal Ligament (which cannot be repaired surgically)
will ultimately heal through scar formation. For both structures - the
disc space and the Posterior Longitudinal Ligament - it will take
three (3) months for the scar formation to be "firm" and six (6)
months for it to become "solid". Allowing time for proper healing
and limiting some activities in the early postoperative period are
important factors contributing to the long-term success of these
The most frequent operations performed for these diseases involve an
avenue of approach from the back (posterior). All of these
techniques involve the removal of part or the entire "roof" (the
"Lamina") of the spinal canal in the affected area. Removal of the
lamina from both sides is a "LAMINECTOMY." Removal of the lamina
from only one side is a "HEMILAMINECTOMY."
The most common operation involves removing only a thumbnail-size
piece of bone from the lamina in order to gain access to the spinal
canal where the herniated disc fragment is lying against the nerve
root. This procedure is called a "LAMINOTOMY" (or opening in the
lamina). The bony canal through which the nerve root travels as it
leaves the spinal canal is called the "neural foramen". It is
almost always desirable, and frequently necessary, to remove part of
the roof of this foramen in order to decompress (relieve pressure
on) the nerve root. This is called a "FORAMENOTOMY."
In the event that a bone spur is the culprit causing the nerve root
compression, it may be possible to remove it. This is usually the
case if the spur originates from the Facet Joint lying directly
behind the nerve root. However, if the bone spur comes from the front
of the spinal canal, it may not be possible to safely remove all
or any of the spur. The decompression of the spinal canal and the
affected neural foramen is most frequently very successful in treating
the symptoms and signs of this problem. While it is quite evident
that not all the bone spur is removed and that it could continue
to enlarge, it is actually unlikely to cause any further major
difficulties provided an adequate decompression has been
Most patients undergo these operations to relieve the pressure
being exerted on the Nerve Roots. They already have some Neurological
Deficit(s). The older the patient is at the time of operation, the
longer they have had the Neurological Deficit and the more severe
it is, the less likely they are to recover. Whatever Neurological
Deficit persists one year after operation, is likely to be
There are now two technical options available with which to perform the
surgery. The Minimally Invasive Microendoscopic Surgery
approach involves a very short incision just off the midline to the
side of the main problem. Rather than stripping muscle from the bone
of the spine, as is done in the case of the more traditional (and very
effective) Microsurgical Operation, this newer technique
separates the muscle fibres using a specially designed small tubular
retractor (called a "Port"). These "Paravertebral muscles", which run
vertically on the side of the Spinous Process and Lamina, would
customarily be removed from and then held in a retracted position
from the bone of the spine in the more traditional Microsurgical
approach. In both surgical methods a bone window is fashioned in the
Lamina. It is through this opening that we gain access into the
spinal canal. The nerve roots are protected by a "leather-like"
covering (the dura mater). Once this is identified, the interior of
the spinal canal is inspected. Frequently, the nerve root is tightly
stretched over the extruded disc fragment(s) and/or bone spur. It
must be protected and gently mobilized and perhaps moved a short
distance in order to allow access to the mass inside the spinal canal.
The extruded disc is then removed. In the event that the hole in
the ligament and disc capsule (created as a result of the disc
breaking through these confining structures) is not large enough
to permit easy placement of instruments used to retrieve the
remaining disc material from the disc space, then the hole is
enlarged. After the remaining disc has been removed, the tissues
are allowed to regain their former positions.
Permit us to repeat that our strong preference is to attempt to
remove as much disc material as possible in order to reduce the risk
of a recurrent herniation. The world-wide experience of recurrence
is as high as 17%. Our "recurrence rate" has been less than 3% for
over 25 years. This is partly due to the techniques that we have
developed and to our post-operative management. Please review the
information on pages 16 - 18 of this monograph as well as our
post-operative patient guidelines for more specific information.
In the Minimally Invasive Microendoscopic Surgery the large
back muscles, the fibres of which were spread apart by the special
tubular retractor, fall back together. (In the more traditional
technique these muscles would be scraped and separated from the bone
and then must be re-approximated with strong suture material.) The
skin incision is then closed in both types of surgery. In our cases,
this is accomplished with "hidden" sutures.
Most patients who undergo these operations awaken from surgery
essentially free of the severe pain that they had previously endured.
Patients generally report that the pain from the incision in the
back is not nearly as bothersome as that which they experienced
preoperatively. The majority of patients are mobilized out of bed
when they are awake and alert. It takes approximately three to
four hours to completely recover from the effects of the anesthetic. It is important to get out of bed early unless you have been instructed otherwise. You will be asked to avoid taking excessive narcotic analgesic (pain reliever) in the early postoperative period in order to allow you to be mobilized. Narcotics make people sleepy which would preclude our staff from allowing you to be out of bed. The discomfort from the incision is rarely seriously painful. Actually once you are out of bed and walking, the pain is usually lessened even further.
In our experience most patients leave the hospital on the same
day. Rarely does anyone stay overnight with the exception of U.S.
"Medicare" patients. In this unique situation, the government
sponsored program REQUIRES THE PATIENT TO REMAIN IN HOSPITAL FOR ONE
DAY OR ELSE THEY WILL NOT PAY THE HOSPITAL FEE. Invariably, these
patients are discharged on the morning following surgery.
Patients, who undergo a "laminectomy" procedure, should
recognize that this more extensive operation (compared to a
"laminotomy" for a herniated disc) may result in more discomfort,
more analgesic medication and a longer stay in hospital. These will
be discussed on an individual basis with the patient involved.
Bilateral Decompressive Laminectomy with Bilateral Foramenotomies
using a unilateral (one-sided) approach is now possible, in many
patients, using Minimally Invasive Microendoscopic Surgery.
This highly advanced and technically demanding operation constitutes
a major technical advance in the treatment of many patients with
spinal stenosis as a component of their clinical problem. Minimally
Invasive Microendoscopic procedures allow us to effectively remove
and "decompress" BOTH sides (bilateral) of the spine using a ONE-SIDED
(unilateral) APPROACH. This is a significant change compared with
the more traditional operation which requires the stripping of
paravertebral muscle from bone on both sides of the spinal column.
In this Minimally Invasive UNILATERAL operation the paravertebral
muscles are less affected resulting in significantly diminished
post-operative pain. This technique is not always possible in
all cases. Where it might apply, your surgeon will discuss it with
you. (This advanced procedure is also utilized for the Minimally
Invasive Microendoscopic management of certain spinal cord
In patients suffering "Cauda Equina Claudication" (pain in the legs
while walking) due to "Spinal Stenosis" (narrowing of the spinal
canal-usually resulting from severe degenerative arthritis with or
without "Spondylolisthesis" [see pages 13 & 14]) the option of
Minimally Invasive Microendoscopic techniques offers a considerable
advantage compared with standard Microsurgical operations. Multi-level
decompression procedures are usually accomplished using a multiple
"port" technique. In our practice experience we have used up to three
(3) ports in order to effectively "decompress" Lumbar Spinal
Stenosis at up to four (4) levels.
Additionally, we have recognized that the majority of patients
undergoing a two (2) or three (3) level Minimally Invasive Bilateral
Laminectomy using a Unilateral Approach, are able to and are
desirous of leaving the hospital on the same day as surgery. This
means that the operations are done through our "Day Surgery"
Interspinous Process Decompression System is a relatively new
Minimally Invasive procedure that is used to relieve symptoms of
lumbar spinal stenosis, a narrowing of the passages for the spinal
cord and nerves. There are several implantable devices, either made
from titanium and/or other materials, that are designed to be placed
between the "Spinous processes" (the thin projections from the back
of the spinal bones to which muscle and ligaments are attached) of
the symptomatic levels of the lower (lumbar) spine in order to limit
extension of the spine in the affected area. X STOP® is one such device
that has achieved FDA approval (others include the "DIAM device"; the
"Coflex"; the "Wallis", the "Spire" etc.) The primary goal for this
therapy is to relieve some or all of the symptoms of lumbar spinal
stenosis and may improve a patient's ability to function. However,
this does result in a larger, wider spinal canal as would occur with a
The implant is indicated for treatment of patients aged 50 or older
suffering from pain or cramping in the legs (neurogenic intermittent
claudication) secondary to a confirmed diagnosis of lumbar spinal
stenosis. The use of this device is indicated for those patients with
moderately impaired physical function who experience relief in flexion
from their symptoms of leg/buttock/groin pain, with or without back
pain, and have undergone a regimen of at least 6 months of nonoperative
treatment. The devices may be implanted at one or two lumbar levels.
This new technology also has the potential for use as "fixation" or
"stabilizing" procedure when combined with other Minimally Invasive
techniques such as in older patients with a mild form (Grade 1)
spondylolisthesis and spinal stenosis. In this case a Minimally Invasive
Decompressive Laminectomy may be combined with the insertion of the
Interspinous Decompression System in order to assist in maintaining
"stability" of the spine. This device should not be used in patients
There are some additional "alternative" procedures to the operations
described previously that are reviewed briefly for the reader's
interest. This list is not a complete compilation of all the techniques
available but it is reasonably comprehensive for most individuals who
are learning about this subject.
- an allergy to titanium or titanium alloy;
- spinal anatomy or disease that would prevent implantation of
the device or cause the device to be unstable in the body, such as:
- significant instability of the lumbar spine
- an ankylosed segment at the affected level(s)
- acute fracture of the spinous process or pars interarticularis
- significant scoliosis
- neural compression causing neurogenic bowel or bladder dysfunction;
- a diagnosis of severe osteoporosis
- active systemic infection or infection localized to the site of implantation.
"Anterior Lumbar Interbody Fusion" operations are done to
remove the disc from the front (anterior) and then insert some form
of device that ultimately will result in bone growing from one
vertebral body to the next. This is commonly used for disc disease
in the neck. However, it is a much more difficult operation through
the abdomen. It is also associated with a significant risk of impotence
in males. There are some very specific indications for this operation,
but rarely do they include a herniated disc in the lumbar region,
particularly if it is in a patient who has never been operated upon
for a previously herniated disc. WE DO NOT PERFORM THIS
"Artificial Disc Replacement" is being recommended by some of
our more aggressive colleagues, as a primary surgical option for
patients with degenerative disc disease and/or herniated disc. This is
a highly controversial area with protagonists using several different
types of devices. Although the U.S. FDA (Federal Drug Administration)
approved some of these mechanical devices for use in humans, the
concepts are still in experimental stages. Unfortunately this is one
operation that cannot be revised without significant risk to life and
neurological function should complications ensue from the primary
procedure. Currently there is no long term patient data on how long
the synthetic materials or the various designs will hold up to the
daily forces exerted on them with various postures. "Bench testing",
in the form of machines made to duplicate human motion, suggests that
there is a reasonable longevity to these products. However, it is
clear that in cases of replacement of other joints, such as knees
or hips, there are real limitations to how long these artificial
joints will last (frequently no more than 10 years.) The utilization
of such devices in the lumbar spine should be reserved for only those
patients who have no other options. This is one area where a second
or third opinion would be strongly advised.
- "Chemonucleolysis" involves injecting an "enzyme"
(digestive substance not unlike a meat tenderizer) into the disc
space. Although popularized in past years, it has progressively
fallen into disfavor. The object of this effort is to "dissolve"
the herniated portion of the disc. This procedure has become very
controversial for several reasons. The Federal Drug Administration
(FDA) took a strong hand in controlling the use and abuse of this
agent and technique resulting from the serious risk to life from
an uncontrollable fatal allergic reaction to the injected substance.
In cases where the disc is extruded or the patient has serious
neurological deficit this procedure is not appropriate. Some
doctors have, in the past, or currently use this (and/or the other
"Alternative" procedures listed in this section) as an alternative
to surgery where the disc is not extruded but rather herniated
beneath an intact but severely stretched and damaged capsule and
ligament. The procedure requires the placement of a long needle
into the disc space in order to inject the medication. This may
not be possible at the lower lumbar level (L5-S1) in many patients
for anatomical and technical reasons.
In addition to the recognized risk of injury to the nerve root(s)
due to the insertion of the needle, the enzyme can digest the disc
material as well as nervous system tissue (nerve roots) if it is
placed on the root(s). This complication results in a possible
permanent paralysis of the lower extremities, bowel and bladder.
Chemonucleolysis may be more expensive if hospitalization is longer
and can only be used once in a patient's life because of the risk
of death from an allergic reaction.
- "Percutaneous Discectomy" (removal of the disc through
a skin puncture) is another procedure aimed at disc disease and
largely replaced Chemonucleolysis as a primary procedure by some
few practitioners. In a manner similar to chemonucleolysis, a
long probe (instead of a narrow needle) is pushed through the
skin into the disc space. The anatomical and technical limitations
to the needle placement for chemonucleolysis are similar for
this operation. The probe is a pneumatically driven device that
literally sucks in and bites off tiny pieces of disc in a
repetitive fashion. The procedure is not to be used for disc
fragments that have escaped through the confining capsule and
ligament (extruded disc) since the risk of biting a nerve root
is too high. This operation seems to have the same indications
for use as has chemonucleolysis namely a bulging,
centrally located disc that is herniated under but not through
the capsule and ligament at the L4-5 or L3-4 levels. The results
of the procedure are highly touted by the surgeons who promote
its use. These seem to include many of the surgeons who
formerly promoted, and later abandoned, chemonucleolysis. The
comparative results of this procedure relative to the best of
micro-neurosurgical results have not been scientifically
evaluated or presented despite the fact that the procedure has
been available for quite a long time. One cannot help but ask
the question: "If this procedure was worthwhile, why is it not
being generally adopted?" There has not been a sustained
vigorous debate in our scientific literature or at national
scientific meetings regarding this procedure. The fact is that
Percutaneous Discectomy cannot really compare except in an
isolated category since it is not used for extruded discs.
Additional information about this procedure is available if you
wish to have it.
- Another procedure ("IDET"- Intradiscal Electrothermal
Annuloplasty) involves the use of heat in an attempt to
"shrink" the disc that is "herniated" beneath the ligament. This
concept involves the placement of a "needle/probe" in a manner
similar to the "chemonucleolysis" procedure. Patients subjected
to this procedure usually endure considerable low back pain for
an extended period of time.
- "Coblation" (Radiofrequency Discal Nucleoplasty) is
another procedure that is similar to IDET, in that a needle is
inserted into the disc. Instead of a heating wire, a special
radiofrequency probe is inserted through the needle into the
disc. This probe generates a highly focused "plasma field" with
enough energy to break up the molecular bonds of the gel in the
nucleus, essentially vaporizing some of the nucleus. The expected
result is that 10-20% of the nucleus is removed to "decompresses"
the disc and reduces the pressure on the "bulging" disc and,
hopefully, on the surrounding nerve roots. This technique is
touted by proponents to be more beneficial for "sciatic" pain than
the IDET, since "nucleoplasty" can actually reduce the disc bulge,
which is pressing on a nerve root. The high-energy plasma field
is actually generated at relatively low temperatures, so danger
to surrounding tissues is minimized.
These last four procedures (Chemonucleolysis, Percutaneous
Discectomy, IDET and Coblation) are incapable of managing a case
with an extruded disc (one where the disc has actually escaped the
confines of the encircling disc capsule and the Posterior
Longitudinal Ligament) or those patients with bone spurs
(osteophytes) that are compressing the nerve root(s) either from
anteriorly or posteriorly. WE DO NOT PERFORM ANY OF THESE
While the indications for all four of these "alternative
treatments" are similar, the long-term follow-up on a large number
of patients does not reflect favorably on any of the procedures.
In our opinion, most of the patients who are being chosen for these
"alternatives" (by the procedures' advocates) would do better by
receiving appropriate "conservative" or non-operative care. In
those patients who have failed a serious trail of appropriate
physical therapy, Minimally Invasive microsurgical techniques are
more likely to offer a higher level of long-term relief.
One such device, the Charité disc, has been the subject of a large
number of medical malpractice claims relating to their structural
failure and the adverse consequences suffered by patients. The issue
surrounding the variety of results seen after surgery coupled with
the very limited scientific studies upon which the FDA approved this
device, has caused some considerable concern. The disk was first
approved in Europe, largely based on a highly limited study conducted
there on 53 back pain patients. That study came to the conclusion that,
"Proof that long-term results with the disk are at least as good
as fusion results is still missing." This study offered the longest
perspective of any to date, with a follow-up of 17 years.
A second European study of 107 back pain patients, with minimum
follow-up of 10 years, concluded that the outcomes seen with the
disc compared favorably with those typically seen with spinal fusion
surgery. In the USA, the FDA based its approval on results from a
study that found that back pain patients who received the disk did
no worse than those who underwent spinal fusion. Follow-up in that
study lasted for only 2 years.
We strongly urge anyone who has been advised to undergo this
operation to do more research into the subject and obtain additional
Spinal manipulation, whether it is done by a chiropractor,
osteopathic physician, orthopedic or neurological surgeon is absolutely
contraindicated in the presence of an extruded disc or serious
neurological injury to the nerve root(s) or where degenerative
arthritis and bone spurs are factors producing the neurological
Spinal fusion, of any variety, is rarely ever indicated in patients
who have never previously undergone operation for a herniated disc.
The major indication, for any form of spinal fusion, should be
instability of the spine. Fortunately this is not common among
the majority of patients with herniated lumbar disc disease. In the
event that there is the additional problem of instability in a
particular patient, the surgeon will discuss the alternatives. The
conditions discussed in subsequent paragraphs are among those where a
"fusion" may be warranted, including our use of Minimally Invasive
Spinal fusion as a primary treatment for "back pain" and "degenerative
arthritis" is commonly performed in the USA. This author strongly
disapproves of this overuse of "fusion" procedures in the absence of
demonstrated spinal "instability" and/or multiple recurrent herniated
discs at that single level. We, again, urge anyone who has been advised
to consider this operation to seek additional consultation.
In patients with the condition known as "Spondylolisthesis"
(slippage of one vertebra upon another) the indication for a "fusion"
procedure is usually quite clear. This clinical problem may be the
result of a progressive degenerative change in the joints of the
vertebrae (facet joints), a traumatic disruption of these joints or
of a congenital structural defect. This term is almost exclusively
reserved for spinal alignment problems of the lumbar spine resulting
from a failure of "normal" bone structures to maintain the anatomical
alignment of the spine. This means that one vertebra (or occasionally
two vertebrae) "slips" forward (or backwards) relative to each other.
The degree of slippage is referred to as either Stage 1 (minor slip
of less than a 1/3 of the vertebral body distance); Stage 2 (slippage
of a distance of 1/3 to 2/3 of a vertebral body) or Stage 3 (slippage
of greater than 2/3 of the vertebral body distance.) There are some
additional "slippage" problems which include dislocation of the
vertebral body to one side (or "laterally" - called "Lateral
Listhesis") which makes surgical correction even more complicated.
In patients with a "Congenital" form of Spondylolisthesis,
the condition usually becomes apparent in the late teenage years to
the 30's. The "congenital" problem responsible for this is a defect
(failure to form) a small bridging vertebral bone element called
the "pars interarticularis". This means that one or both facet
joints of one of the vertebra have failed to connect to the
remainder of its vertebra resulting in instability.
Most cases of Spondylolisthesis due to "Degenerative Arthritis"
become apparent in the patient's life during or after the late 50's.
In these cases the facet joints have suffered advanced deterioration
and now are incapable of holding the patient's vertebrae in normal
alignment. This Degenerative Arthritis (Osteoarthritis) "deterioration"
is due to "trauma" occurring over the lifetime of that particular
patient and usually results from a combination of factors such as
obesity, activity in sports, weight lifting, heavy work activities,
"Traumatic" Spondylolisthesis is the least common form of
this entity. Fractures of one or both facet joints of a lumbar
vertebra may result in this slippage.
These anatomical "misalignments" frequently cause compression of
the neural elements (nerve roots either within the spinal canal
and/or as they exit the spinal canal through the neural foramena.)
This may injure those roots to produce a neurological injury
(weakness and/or sensory impairment in the lower extremities) which
is usually mild in the beginning. In unusually advanced case,
patients may suffer impairment of bowel and/or bladder function in
addition to weakness of the muscles of the legs and loss of sensory
function in the lower extremities and perineum.
Pain and/or neurological deficit(s) frequently bring this condition
to the patient's awareness. The degree of pain varies from one person
to the next. Some, with advanced degrees of slippage (Stage 2), may
not have had pain in previous years despite the fact that there was
instability for many years when their condition was only a Stage 1
variety. Others have minor degrees of slippage and suffer
The fundamental concepts of the surgical treatment for
Spondylolisthesis involves establishing and maintaining structural
stability while relieving pressure on the affected nerves of the spinal
column. In many cases we are able to re-establish the precise
anatomical integrity of spinal vertebral alignment. For most cases
with this condition, the surgeon can reduce the degree of slippage
without restoring "perfect" alignment and still obtain a very
satisfactory long term clinical result. The degree of the patient's
original slippage and certain anatomical features peculiar to that
patient may reduce the probability to achieve a complete anatomical
reduction of the slippage.
In most of these cases some form of "fusion" operation is required.
This usually means placing a device between the vertebral bodies
that were previously in misalignment. The goal will be for bone to
grow from one vertebral body to the adjacent one in order to
maintain long-term stability. Additional structural stability is
established with the incorporation of some other form of "fixation"
device(s) such as pedicle screws and rods, interspinous fixation
device and/or posterior (or postero-lateral) bone fusion. All of
this is meant to demonstrate that there are several modern
stabilization/fusion methods available. These alternatives will
be discussed on an individual basis as indicated.
Of particular interest now is the introduction of Minimally
Invasive Spinal Fusion techniques. This has some significant
advantages with operations done through very small incisions since
there is less "surgical trauma" to local tissues compared to more
traditional (or "open") techniques. Patients undergoing Minimally
Invasive Lumbar Spine Fusion are usually walking around the
hospital ward within 4 hours of surgery and are generally
discharged from hospital the morning following surgery.
All surgical procedures carry with them some element of risk. For
lumbar laminectomy, foramenotomy, and discectomy, there are the
general risks of any operation carried out under general anesthesia
as well as risks specific for this operation. As a general rule,
the degree of risk for any surgical misadventure or complication
relating to these operations is very small. The risk to life is
essentially that of the general anaesthetic. This actual risk is
a tiny fraction on the order of 1/1000 of 1%.
The risk of injury to structures in the area of operation is
present in any operation. Modern Micro-Neurosurgical and
Minimally Invasive Microendoscopic techniques have helped to
reduce these risks to very small fractions. The likelihood of
paralysis of bowel and/or bladder function, paralysis of one or
both lower extremities or impotence in males is remote. Likewise
the risk to hemorrhage, infection, failure to relieve pain and/or
the worsening or recurrence of the pain is small provided the
patient adheres to the advice about postoperative care. It is
possible that the neurological deficit, already present at the
time of operation, will either worsen or fail to improve. In
most cases it does improve quite quickly. As a general rule,
whatever neurological deficit (sensory and/or motor function
impairment) is still present one year after surgery, is probably
permanent. The more advanced the neurological deficit is at
the time of surgery, the longer it will take to improve and the
less likely it is to completely recover. This does not mean
that a patient with advanced neurological deficit cannot hope
to improve; however, it is possible that some degree of
neurological injury and disability will persist (sometimes it
is only a small patch of numbness while in others a slight
amount of weakness in the muscles that lift the top of the foot
while walking.) Alternatively the numbness and weakness could
be quite bothersome and limit many activities.
Although all operations are carried out with considerable caution,
the sharp edge of bone or an instrument could inadvertently cut
the Dura Mater (the tissue covering the nerve roots within the
spinal canal.) This is an uncommon occurrence which, when
recognized, usually only requires one small suture to close it.
However, in the event where the small tear is not recognized
or occurs at a later date, a postoperative leakage of
cerebrospinal fluid (CSF) can occur requiring another operation
to close the leak. The surgical incidence of this complication
is reported to be 2%. Our experience is lower. It is important
to understand that straining in the early post-operative weeks
could also result in a tear of the dura mater (since straining
could force the dura mater to bulge through the Decompressive
bone opening in the spine which then tears as it rubs against
the bone) and subsequent CSF leak One post-operative rule to
One of the exceptionally rare complications reported in medical
literature is an injury to the large blood vessels (and adjacent
structures) in the abdominal cavity. This could occur if an
instrument that is being used to remove disc material from the
disk space is inadvertently pushed into the abdominal cavity.
This would usually require an emergency repair of the
hemorrhaging vessels within the abdominal cavity. Fortunately
we have never personally experienced this serious problem.
Another potential serious complication is the postoperative
occurrence of Arachnoiditis. The arachnoid is a thin
filamentous membrane that lies inside the dura mater adjacent to
the nerve roots. On rare occasion the arachnoid may react to
injury (which may be from the trauma of the ruptured disc itself
and/or Myelography as well as operation) by developing scar
tissue inside the dura mater around the nerve roots. It is a
very painful and potentially disabling condition. (Please see
our "Arachnoiditis" Monograph, available in this website
relating to our treatment experience with this difficult
For patients undergoing Lumbar Fusion Operations there
are some additional risks such as the dislocation of the fusion
device that was placed within the disc space. This unfortunate
event could result in compression and injury to the nerve root(s)
lying behind this dislocated device. This must be an uncommon
experience and fortunately one which we have not ever had in any
of our patients. It would, most likely, require another
operation to correct the situation. Pedicle screws (that are
used as part of some "fusion" operations) may injure nerve roots,
become "loose" or require removal and replacement if suboptimally
positioned. Rarely do the rods (that are placed as part of the
"pedicle screw" implantation system) ever break. In the unlikely
circumstance where this occurs, re-operation to remove or
re-position the hardware may be required.
The postoperative care for individuals undergoing lumbar
laminectomy/laminotomy and discectomy consists of very important
steps towards as complete recovery as possible for the particular
patient. Although most patients may go home on the same day of
surgery, some remain overnight and are discharged from the hospital
the following morning. There are circumstances, which may delay
this. If you wish to take advantage of the "Same Day Discharge"
opportunity, it is important to be sure that you are walking
satisfactorily. After the first efforts at walking in the room,
the nursing staff will assist you to walk in the hallways.
For those patients who undergo operation for the removal of a
herniated intervertebral disc, it is important to LIMIT THE
AMOUNT OF TIME for sitting (except for necessary bathroom
functions) in the first couple of post-operative days. In the
very early post-operative period, the preferred body positions
are standing or lying down. When you leave the hospital it is
preferred that you walk out. When being driven home (or to your
hotel), try to do so in a reclining position (such as in the back
seat of a large car or in a reclining passenger seat).
For those patients who undergo a Minimally Invasive
"decompressive" laminectomy procedure (without removal of a
herniated disc) and/or implantation of a Minimally Invasive
Interspinous Decompression Device and those who undergo
Minimally Invasive Lumbar Fusion procedures, you may
begin sitting as soon as you find it comfortable to do so. In
these situations we advise the patient to sit only in a
straight-back chair, such as a kitchen or dining room chair.
Please avoid recliners, sofas or "soft-back" chairs.
Post-operatively you will, initially, want to sit for short
periods of time and then increase it a little each day. For
example, begin sitting for short meals. Then progressively
increase the length of time that you sit and the frequency of
sitting during the day. In unusual cases you will receive
further instruction either at the time of discharge or at the
time of your first office visit with the surgeon.
For patients undergoing a more extensive operation, such as a
multiple-level laminectomy for decompression of a narrowed
(stenotic) spinal canal, they must anticipate more postoperative
discomfort and, perhaps, a longer postoperative hospital stay
compared to those undergoing a more limited procedure for a
single-level herniated disc. Nevertheless, early mobilization
is just as important, if not more important. There are some
other significant differences in postoperative care, including
wound care that will be discussed with you as needed.
Please try to be aware of any activities or body positions,
which produce pain since pain is your body's attempt to warn
you of potentially harmful circumstances. Where you experience
increasing pain, stop the activity and/or alter your body position.
It is best to lie down for a while.
Walking will be your major form of exercise for several months.
After the first day at home you may begin to walk out of doors
(provided the weather is reasonable and there are no hills to
negotiate). Set a reasonable schedule for pace and distance
recognizing that as a general rule: "IF IT HURTS - DON'T DO IT!"
A reasonable walking schedule should be developed and adhered to.
Generally we find that most patients can walk at least one (1)
mile per day at four (4) weeks postoperative and up to two (2) to
four (4) miles per day after 6-8 weeks postoperative.
Avoid bending, stooping, lifting, pushing and pulling activities
particularly in the first 2-3 postoperative months. Only lift
that which can be easily accomplished with one arm. Do not lift
anything with an outstretched arm. It takes time for tissues to
heal. You can only cause delay in healing or interfere with the
process with these activities.
Avoid aspirin and aspirin-containing compounds as well as
ibuprofen containing drugs (Motrin, Medipren, Nuprin, Advil)
since all of these interfere with the blood's clotting mechanism.
Take as little pain medicine as possible. Tylenol (acetaminophen)
or similar non-aspirin containing drugs should be all that are
necessary. It is better to lie down when you have some pain than
to take pain medicine to blunt the pain that is occurring from
an activity that you are continuing to pursue. In the event
that you need more potent analgesic medication, your physician
will make the appropriate recommendations before you leave
A general and well-balanced diet will provide the necessary
nutrition to promote healing. We suggest that there be an
added amount of protein intake to your diet during the
post-operative months since protein is a primary source for
the building blocks of repair of tissue.
You will have a list of other activities and personal hygiene
given to you at the time of discharge from the hospital. Please
make sure you understand what is expected and ask for
clarifications. Your cooperation and strict adherence will
help us to help you. It is very important to allow your body
to heal itself to the maximum extent possible before stressing
the operative site. Once you return to the office for follow-up
visits you will receive further instructions as your recovery
progresses and your condition warrants.
For those patients who come to us from other countries (or cities
that are at some distance from Dallas), we will make special
arrangements to contact you by telephone to discuss the progress
of your care. In some instances, we will work with your local
physician as required. In all cases, we will provide your local
physician with the information that is relevant to your treatment.
At a minimum, this will include the Operative Report and the
Discharge Summary, both of which provide the technical details
of the care that was provided to you.
Supplementary information, including diagrams, neuroimaging
studies and examples of operations for these conditions can be
found on our website as well as other venues.
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This page last edited on 2/20