When describing surgical options to patients, I often divide procedures into 2 basic concepts. “Unpinch what is pinched” vs “Stop moving parts that hurt from moving.” Apart from tumor or trauma cases, these concepts cover the majority of spine issues that arise.
Surgery is discussed usually after conservative treatment (physical therapy, injections, medications, activity modification) has failed. Generally leg pain arises from pinched nerves and low back pain from degenerative changes in the spine anatomy. Examples include leg pain from a herniated disc (pinched nerves) and lumbar pain from a degenerative disc (worn out shock absorber). The most common areas to experience both of these issues is lumbar 4-5, L5-S1 (low back) and C5-6, C6-7 (neck).
To address “pinched nerves”, surgeons must remove anatomy (bone, ligaments, disc) to open up space surrounding the nerves. This may involve LAMINECTOMY (complete removal of the posterior bony canal) vs LAMINOTOMY (partial removal of the posterior bony canal). For both procedures this includes resection of bone (lamina), ligament (ligamentum flavum) and disc material if required. Interestingly, decompression surgeries have been available since the late 1800’s where the first documented surgery in London took place in 1887 by Dr Haden Horsley.
The second common surgical procedure is called a FUSION. Simply put, this means stopping two moving parts from any further motion. A surprise to most people is that FUSION involves new bone growth in an area that had no prior bone (disc space). The purpose behind permanent immobilization is that no pain can be generated if no motion is present. The growth of new bone takes months and the insertion of screws and rods is used to help the FUSION (much like a cast on a broken bone). Oftentimes, fusion is performed at the same time as a LAMINECTOMY.
Obviously, any procedure that involves altering the spine has drawbacks. These include changing the normal biomechanics of the spine which could potentially lead to premature wear and tear at other non operated spine levels. Aside from a scenario where permanent loss of neurologic function can occur without surgery; the majority of spine surgery is elective. That is the reason why exhausting all conservative options is the usual first step prior to considering Spine Surgery. In selected cases, surgery can be helpful and improve a patient’s quality of life.
-Dr. Paul Saiz, MD