David L. Kramer, M.D.
David A. Bomback, M.D.


20 Germantown Road Danbury, CT 06810 TEL: (203) 744-9700

     
  

Back Surgery


 

My doctor told me that I have arthritis of my spine and that I should learn to live with the pain.  Is this true?

 

Arthritis is a general term applied to degenerative conditions of any joint throughout the body.  Degeneration of our joints is actually a natural phenomenon that occurs in virtually all individuals.  Studies have shown that significant degenerative changes begin in the spinal column by the age of 30.  By this age, the water content within the lumbar discs begins to decrease, and there is an associated loss of disc height with bulging of the discs.  This is a natural phenomenon.  The joints in the spine respond by forming bone spurs as the body's defense mechanism in an attempt to reestablish stability of an otherwise aging spine.  The loss of disc height and the associated development of bone spur formation in the spine is commonly referred to as arthritis.  It is important to note, however, that the existence of back pain does not necessary correspond with the extent of degeneration seen.  Typically, back pain related to spinal degeneration can be treated with conservative maneuvers, including anti-inflammatory medications, physical therapy, rest, and, at times, various injection modalities.  If back pain persists beyond several weeks, an individual should seek evaluation from a spine specialist to interpret the degree of "arthritis" seen on routine spinal imaging, and its contribution to the patient’s particular symptoms.       

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When is surgery necessary for patients with spine problems?

 

Spine surgery ought to be considered as a last resort when addressing pathology localized to the spine.  All attempts at application of conservative measures, including rest, physical therapy, simple anti-inflammatory medications, various injection techniques, and even simply the passage of time, should be allowed before pursuing a surgical discussion.  If neck or back pain is associated with significant new neurologic deterioration, including radiating numbness, tingling, or weakness in either or both legs, medical attention ought to be sought, and the work up ought to be pursued.  Even when these symptoms are present, conservative care is usually the mainstay of treatment.

 

 

What is a laminectomy?

 

A laminectomy is a surgical procedure that involves the removal of the bony arch in the back of the spine.  By removing the bony arch, the compressed spinal cord and nerve roots can expand and float more freely within the spinal canal.  This is a common procedure performed for patients with narrowing of the diameter of the spinal canal related to degenerative changes resulting in lumbar spinal stenosis.

 

 

 When do I need a fusion?

 

A fusion is a procedure that connects one vertebra to the next.  Typically, a fusion procedure will be performed if there is instability in the relationship between two vertebrae.  The most common fusion performed in the cervical spine occurs when your surgeon recommends an anterior cervical discectomy.  Once the disc material is removed and the spinal cord and/or nerve root is freed up, the space that remains will typically be filled with a structural bone graft.  This anterior cervical fusion that follows an anterior cervical discectomy results in reestablishment of more normal cervical alignment and prevents collapse across the disc space that can often become painful with the passage of time.

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 What effect does a fusion have on the rest of the cervical spine?

 

A cervical fusion is a procedure that involves the biological connection of one vertebra to the next.  Each time two vertebrae are "fused" together, there is some loss of cervical range of motion.  It is thought that between five and ten percent of one's cervical flexion and extension or side-to-side rotation may be restricted as the result of a one-level fusion.  It is important to note, however, that the vast majority of one's cervical flexion and extension occurs at the joint between the skull and the first cervical vertebra.  Also, fifty percent of one's side-to-side rotation occurs at the specialized joint between the first and second cervical vertebrae.  The remainder of one's cervical range of motion is distributed equally from C2 through T1.  It has also been shown that with each additional vertebra fused, there exists increased lever-arm forces at the adjacent discs.  As such, the longer the fusion, the more likely that a patient may experience degeneration of adjacent discs above or below the fusion.  One should note, however, that the observation of radiographic disc degeneration adjacent to a solid fusion does not always correlate with the development of neck pain.

 

 

If I have a fusion, does that mean I will never be able to bend?

 

A fusion is a procedure that results in the connection of one bony vertebra to the next.  Typically, the fusion of one vertebra to the next will result in approximately five to ten percent reduction in the lumbar spine's ability to flex and extend.  Patients should keep in mind, however, that the majority of forward flexion at the waist as one attempts to reach the floor occurs as a result of flexion occurring at the hips.  Certainly, the more levels of lumbar vertebrae that are fused, the more restriction in low back range of motion may occur.  Experience in adolescent individuals who have undergone lengthy spinal fusions for scoliosis have shown that even with an extensive fusion of multiple lumbar vertebrae, the majority of individuals can flex forward at the waist due to the preservation of hip flexion, with the added flexion provided at the level of the knees, the individual can reach the floor in a fluid and spontaneous manner.

 

 

Does it matter what screws and rods my surgeon uses?

 

Most manufacturers of spinal implants today make use of well-established biomechanical principles in the design and production of their implants.  Typically, the metal rods and screws are made out of titanium alloys and/or stainless steel.  Most spinal instrumentation manufacturers offer a wide variety of modular adaptations that allow the standard screw-and-rod technology to be applied to a specific individual's needs.

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Will fusing my spine cause damage to adjacent areas?

 

It is commonly believed that attaching one vertebra to an adjacent vertebra results in a stiffened area of the spine that does indeed result in increased lever-arm stresses at the adjacent vertebrae.  Indeed, as spinal instrumentation is applied much more commonly, we are beginning to see the long-term effects of adjacent level disc degeneration brought on by these lever-arm forces.  There is currently debate as to whether or not these adjacent level degenerative disc changes occur as a result of the lever-arm forces or, perhaps, they may relate to the underlying genetic predisposition to disc degeneration that contributed to the patient's initial condition requiring surgery.  Certainly, all attempts ought to be made to limit the length of the spinal fusion to reduce the lever-arm forces as much as possible.

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Do I need to wear a brace after surgery?

 

The need for post-operative bracing depends on many factors.  Standard lumbar spine fusions making use of bone grafting without the use of instrumentation typically require post-operative brace immobilization to provide a semi-rigid environment to encourage the bone fusion to occur.  With the advent of pedicle screw instrumentation, that rigid environment may be provided internally, foregoing the need for brace instrumentation.  The quality of the patient's bone and the length of the spinal fusion may also be factors that contribute to a surgeon's recommendation for post-operative bracing.  For example, osteoporosis is a condition in which the pedicle screw instrumentation may have less purchase in the bone and, accordingly, supplemental support by virtue of a rigid post-operative brace may be advantageous until the body can initiate the healing process.

 

 

Will I have to take medication for pain?  Are there any medications I should be concerned about?

 

Spine surgery is often invasive and requires the dissection through the muscles of the low back.  Additionally, the manipulation of nerves and the mechanical changes in the lumbar spine associated with a spinal fusion can result in post-operative pain.  Typically, oral narcotic medications are prescribed in the post-operative period.  Long-term usage of oral narcotics can result in physiologic addiction.  All attempts ought to be made to wean from the post-operative narcotic medication within the first two to four weeks if at all possible.

 

 

I hear that men should not have fusion surgery.  Is this true?

 

Most often, spinal fusion surgery is done through a posterior approach, meaning that the surgery is done through incisions in the back of the spine.  This type of posterior spinal fusion surgery does not pose any additional risks for men as compared to women.  When anterior spine surgery is performed, that is, surgery performed through an abdominal incision resulting in exposure of the front, or anterior, part of the lumbar spine, there are some additional risks that are more relevant to men.  Specifically, the dissection of the fine latticework of the parasympathetic nerves spanning the anterior disc spaces at L4-L5 and L5-S1 can result in retrograde ejaculation and impotency.

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What are some of the complications associated with fusion surgery?

 

Perhaps the most significant complication associated with spinal fusion surgery is that, with the passage of time, the goal of biological fusion is not obtained.  In the past, traditional spinal fusion surgery involved the application of autogenous bone graft and post-operative brace immobilization.  The literature has reported a 70 percent radiographic fusion rate with this type of surgery.  With the advent of pedicle screw instrumentation, this fusion rate has increased significantly.  Over the past decade, the increased usage of combined anterior and posterior spinal fusion surgery in conjunction with the use of bone morphogenic proteins have resulted in an even higher success rate of biological fusion.  Factors that negatively affect the success rate of the biological fusion include smoking, increasing age, osteoporosis, obesity, diabetes, and prior spinal surgery.  Other potential complications associated with spinal fusion surgery include chronic pain, complications related to malpositioning of the instrumentation, and junctional level disc degeneration and decompensation requiring extension of the fusion.

 

 

How many times will I need to see my surgeon after surgery?

 

Typically, the status of the operative wound needs to be checked frequently within the first two to six weeks.  If a spinal fusion procedure has been performed, radiographic follow up needs to be performed at intervals of two weeks, six weeks, three months, six months, and one year.  Certainly, if there are any unusual concerns or the development of new and unusual symptoms of radiating nerve pain, the patient may need to be seen more frequently.  A patient should have a low threshold to contact his or her surgeon if there are questions pertaining to the rate of recovery from the procedure.

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My doctor said he would be using a bone graft.  What does this mean?  What is a bone graft?

 

When a spinal fusion is to be performed in an attempt to restore stability of the spine, one needs to achieve a solid biological union between at least two vertebrae.  Typically, in order for this to occur, bone material is placed adjacent to the vertebrae to be fused.  This bone material is referred to as "bone graft."  Traditionally, this bone graft material is harvested from a separate incision through the iliac crest (superficial part of the pelvis).  The gold standard for bone grafting to achieve spinal fusion has been with the use of autogenous bone grafting, or application of bone harvested from the same patient.  If autogenous bone is not available, other options include the use of cadaver bone grafts or "allografts."  Cadaver bone carries with it no living biologically-active material (living cells), but rather provides a scaffolding on which the patient's own bone may grow.  More recently, bone graft substitutes, such as bone morphogenic proteins, have been developed.  The FDA has recognized some of these bone morphogenic proteins as true bone graft replacements.  Bone morphogenic proteins are designed to stimulate an individual's own stem cells to differentiate into those cells that form bone.

 

 

My spinal specialist said he will take the bone graft from my hip.  How big is that incision compared to the spine surgery?

 

Typically, the incision made over the iliac crest for harvesting bone graft is a small incision.  The incision may range from 1 cm to 8 cm, depending on how much bone needs to be harvested.  The amount of bone needed for the fusion typically reflects the number of levels to be fused.  Oftentimes, it is possible for the surgeon to obtain bone graft from the iliac crest through the midline incision used to perform the spinal decompression.  One's body habitus dictates whether or not this combined approach is possible.

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Are there any alternatives to having a bone graft taken from my hip?

 

Currently, there are many alternatives to using one's own iliac crest bone as bone graft material.  For instance, a common alternative makes use of cadaver bone.  This is bone material harvested from individuals who have died and donated their bone.  This cadaver bone graft material is thoroughly cleansed and sterilized.  The cadaver bone material is screened extensively for communicable diseases, such as hepatitis and HIV.  This bone graft may be crushed into a powder, or it may be partially fragmented into "croutons."  This essentially dead bone material serves as a scaffolding on which one's bone may naturally grow.  There are no active or living bone cells that can initiate bone healing from the cadaver bone graft itself.  More recently, much attention has been placed on the development of genetically-engineered bone morphogenic proteins (BMP).  These proteins occur naturally in our bodies and have been shown to promote the development of bone-forming cells from our body’s stem cells.  These genetically-engineered proteins have been shown to be safe and can serve as a bone graft replacement.

 

 

What are the differences between bone taken from my hip and donor bone?

 

When bone is harvested from the patient's own body, it carries with it those cells that are responsible for bone formation.  The advantage of using your own bone graft is that it serves not only as a scaffolding on which future bone growth may occur, but it also serves as an induction to the formation of bone.  This is not the case when one uses cadaver or donor bone.  The cadaver bone graft has been sterilized and contains no living tissue.    Accordingly, it serves solely as a biological scaffold on which the patient's new bone may grow.

 

 

Are there any potential complications with harvesting bone from my hip?

 

The most common complications of harvesting bone from the iliac crest would include the small risk of infection and the larger risk of potential ongoing pain related to this second incision, dissection of the hip musculature, and the removal of bone.

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Common Spinal Conditions

Understanding Your Spinal Condition

Anatomy of the Spine
Ankylosing Spondylitis
Back and Neck Braces
Biological and Medical Risk Factors
Bone Grafts
Diagnosing Spine Problems
Lifestyle Risk Factors
Osteoporosis
Pain Medications
Possible Complications of Spine Surgery
Post Surgery Rehabilitation
Preventive Treatment Options
Spinal Rehabilitation
Surgical After Care

Neck Pain & Disorders (Cervical)

Anatomy of the Cervical Spine
Anterior Cervical Fusion
Cervical Corpectomy and Strut Graft
Cervical Fusion
Cervical Kyphosis
Cervical Laminectomy
Cervical Radiculopathy
Cervical Spinal Stenosis
Neck Pain (Overview)
Posterior Cervical Fusion
Rehabilitation of the Cervical Spine
Rheumatoid Arthritis of the Cervical Spine

Mid-Back Pain & Disorders (Thoracic)

Adult Kyphosis
Adult Kyphosis - Types and Causes
Compression Fractures
Herniated Thoracic Disc
Possible Complications
Scheuermann's Kyphosis
Scoliosis
Thoracic Spine Anatomy

Low Back Pain & Disorders (Lumbar)

Compression Fractures
Degenerative Adult Scoliosis
Degenerative Disc Disease
Intervertebral Cages
Laminotomy and Discectomy
Low Back Pain (Overview)
Low Back Pain in Athletes
Lumbar Herniated Disc
Lumbar Laminectomy
Lumbar Spinal Fusion
Lumbar Spinal Stenosis
Lumbar Spine Anatomy
Lumbar Spine Surgery
Pedicle Screws and Rods
Possible Complications
Rehabilitation for Low Back Pain
Sacroiliac Joint Syndrome
Scoliosis
Spondylolysis and Spondylolisthesis
Transforaminal Lumbar Interbody Fusion (TLIF)

Scoliosis & Spinal Deformity

Scoliosis
Adult Scoliosis
Adolescent Idiopathic Scoliosis

Radiological Imaging, Tests & Procedures

Bone Scan
CT Scan
Discogram
EMG
Epidural Steroid Injection (ESI)
Facet Joint Block Injection
Lab Tests
MRI Scan
Myelogram
Somatosensory Evoked Potential
Spinal Injections
Spinal Tap
X-ray