Anterior Cervical Discectomy with Fusion (ACDF)
Anterior cervical discectomy and fusion (ACDF) is a type of neck surgery that involves removing a damaged disc to relieve pressure on the spinal cord or nerve roots and alleviate associated pain, weakness, numbness, or tingling. A discectomy is a form of surgical decompression, so it may also be called an anterior cervical decompression.
The surgery, which is done under general anesthesia with the patient lying on their back, has two phases:
Anterior cervical discectomy:
The cervical spine is accessed by making an incision in the anterior, or front, of the cervical spine (neck). The damaged disc is then extracted from between the two vertebral bones encasing it on each side.
A fusion surgery is performed immediately following the discectomy operation in order to stabilize the cervical segment. It involves placing a bone graft and metal implants in the space left by the removed disc in order to allow the restructured area to heal correctly and to provide it with stability and strength.
While ACDF is most commonly indicated for treating a symptomatic cervical herniated disc, it may also be done to resolve cervical degenerative disc disease, remove bone spurs (osteophytes) caused by arthritis, or alleviate symptoms associated with cervical spinal stenosis. In addition, it may be done for only one level or for multiple levels of the cervical spine.
Anterior Lumbar Interbody Fusion (ALIF)
Anterior lumbar interbody fusion (ALIF) is a type of back surgery that involves removing a damaged or degenerated disc to relieve pressure on the spinal cord or nerve roots and associated lower back pain, muscle weakness, or numbness. It is similar to posterior lumbar interbody fusion (PLIF), except that in the former the disc space is fused by approaching the spine through the front of the torso instead of through the lower back.
This type of procedure is ideal in cases where only one level of the lumbar spine needs to be operated; for multiple levels or for more complex cases, it is often combined with PLIF.
In the ALIF approach, a three-to-five-inch incision is made on the left side of the abdomen and the abdominal muscles are retracted to the side. The abdominal contents, which lay inside a large sack (peritoneum), are also retracted, allowing the spine surgeon access to the front of the spine without entering the abdomen. As the body´s large blood vessels (aorta and vena cava) lay on top of the spine, at Legacy Brain & Spine our surgeons often perform this procedure together with a vascular surgeon, who manipulates and monitors those vessels. Once they too have been moved to the side, the spinal surgeon removes the disc from the intervertebral space and inserts a bone graft along with any necessary metal implants to help the restructured area heal correctly.
The anterior fusion approach is more sparing to patients compared to posterior fusion because both the back muscles and nerves remain undisturbed, which lowers the risk of neurologic injury. It also allows placing the graft through the front of the spine, which facilitates better fusion and faster recovery.
Lastly, a much larger implant can be inserted through an anterior approach, which provides for better overall stability of the fused vertebrae.
Balloon Kyphoplasty for Compression Fracture
Balloon kyphoplasty is a minimally invasive procedure used to repair vertebral compression fractures (VCFs) by ”reversing” them and stabilizing the affected area. VCFs are a common type of osteoporotic fractures that can lead to pervasive pain, spinal deformity, and reduced quality of life. In some cases, such fractures can also be due to cancer or benign tumors, and they typically affect people over 50 years of age.
The goal of balloon kyphoplasty is to relieve VCF-associated pain, restore vertebral body height that has been lost due to compression, and stabilize the fracture. The procedure involves the insertion of two inflatable bone tamps (IBTs), or balloons, into the collapsed vertebral space. Once inside, the IBTs are carefully inflated under volumetric control so as to push the vertebral endplates apart, restoring vertebral height and correcting angular deformity. The balloons are then deflated and removed, and the newly expanded cavity is filled with bone cement, which functions as an “internal cast” to prevent future collapse.
The balloon kyphoplasty procedure lasts about one hour per fracture and can be performed in an outpatient setting. It can be done under either local or general anesthesia; your anesthesiologist will determine the most appropriate method, based on your overall condition.
Brain Tumor Surgery, Radiation, and Chemotherapy
The standard treatment for most brain tumors is surgery. To remove a brain tumor, a neurosurgeon makes an opening in the skull, an operation called craniotomy. Whenever possible, the surgeon attempts to remove the entire tumor, but if that is not feasible without damaging neighboring healthy brain tissue, they will remove as much of it as it is safe to. Partial removal helps to relieve symptoms by reducing pressure and shrinking the size of the remaining tumor, which is treated further by radiation therapy or chemotherapy.
Some tumors cannot be surgically removed. In such cases, the doctor may perform a biopsy, whereby a specimen of the lesion is collected so that a pathologist can examine it under a microscope to determine the type of cells it contains. This helps the treating physician decide which treatment to use.
A brain biopsy is typically done with a needle. To determine the exact location of the tumor and guide the needle to it, patients are fitted with a lightweight aluminum halo-like “head frame” designed to restrict head movement and have CT or MRI scans taken that project a three-dimensional coordinate system of their brain and pinpoint precise target coordinates. The surgeon then makes a small pinhole in the skull and steers the needle to that location to obtain a tissue specimen. This technique, which is used for both brain biopsy and brain surgery, is called stereotaxis.
Radiation therapy, also called radiotherapy, is a type of cancer treatment that uses high-powered energy beams to destroy cancer cells and stop them from growing. It is often used when tumor tissue cannot be safely removed with surgery or when surgery alone cannot eliminate all cancer cells. Radiation therapy is also used when surgery is not advisable due to other factors, such as the patient´s age, immune status, or attending comorbidities.
Radiation therapy may be given in two ways: externally or internally. External radiation comes from a large machine and sessions are typically scheduled five days a week over several weeks, depending on each patient´s tumor specificity and personal treatment plan. External radiation may be directed just to the tumor, to the surrounding tissue, or to the entire brain, and sometimes it may also be directed to the spinal cord. Spreading the total dose of radiation over an extended period helps to protect healthy tissue in the area of the tumor.
Gamma Knife stereotactic radiosurgery is yet another way to treat brain tumors. The Gamma Knife is not actually a knife, but rather a radiation therapy technique that delivers a single, finely focused, high dose of radiation from multiple angles aimed precisely to its target. In this way, the radiation reaches the tumor without damaging other brain tissue. Like surgery, it is a “one-and-done” treatment modality and requires only one session.
Chemotherapy is a cancer treatment approach that uses drugs to kill fast-growing cancer cells. Depending on the tumor characteristics, it may involve just one drug or a combination of drugs, usually administered orally or by injection into a blood vessel or muscle. Intrathecal chemotherapy is a type of chemotherapy specific to brain tumors, which involves injecting the drugs into the cerebrospinal fluid.
Chemotherapy is usually given in cycles of treatment periods and recovery periods. As most chemotherapy drugs are given on-site at the doctor´s office or clinic, patients don't need to stay in the hospital. However, depending on the drugs used, the way they are administered, and the patient's general health, a short hospital stay may occasionally be necessary.
Cervical Artificial Disc Replacement (Arthroplasty)
Cervical artificial disc replacement (ADR) surgery is a procedure designed to replace a damaged disc in the cervical spine (neck), relieve associated chronic neck or arm pain, and maintain motion.
The natural cervical intervertebral disc can withstand a large compressive load while maintaining a range of motion between the bones in the neck. Although duplicating this form and function with an artificial disc is challenging, several artificial cervical discs have been developed and are available as a surgical option to treat cervical disc problems.
Before deciding whether to have cervical ADR surgery, also called cervical disc arthroplasty, it is important to understand what the surgery aims to accomplish. The main indications for cervical ADR are to:
Relieve nerve compression
When a disc herniates or begins to degenerate and collapse, there is less room for the nerve roots (and sometimes the spinal cord) to function. This causes compression that can be a source of chronic pain, tingling, numbness, or weakness radiating from the neck out into the arm. Removing the damaged disc and replacing it with an artificial one aims to relieve such pressure and give spinal nerves the space to heal and function normally. If the spinal cord has been compressed, artificial disc replacement usually resolves or prevents the development of other symptoms, such as trouble with coordination, walking, or incontinence.
Maintain motion at the repaired spinal level
Cervical ADR surgery enables patients with cervical degenerative disc disease or otherwise damaged cervical discs to regain natural biomechanics in the neck. While an artificial disc cannot create or improve motion per se, it does help to maintain it.
Most neck pain is due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints around each vertebra. The vast majority of patients who experience neck pain can be successfully treated with non-surgical measures and will not require any type of operation. However, in some cases disc and joint deterioration in the cervical spine can lead to too much pressure on the spinal cord, which is a serious condition that may require surgical intervention.
When this condition occurs, the entire spinal cord is in danger because the pressure affecting it can lead to the formation of bone spurs, a narrowing of the spinal canal (spinal stenosis), or another degenerative condition called cervical myelopathy. One surgical option is to relieve the pressure by removing both the degenerative vertebrae and the attached discs, and replacing them with an implant. This procedure is called a corpectomy and the implant is referred to as a strut graft.
How is the procedure performed?
Cervical corpectomy is performed under general anesthesia. Once the patient is asleep, the problem vertebrae and discs are usually removed from the front, through an incision in the neck right beside the trachea (windpipe). The muscles, arteries, and nerves are then moved to the side and each disc and vertebra are identified using an X-ray to make sure that the right vertebrae and discs are being removed.
When this is confirmed, the damaged vertebrae and the discs both above and below them are removed as a means of “decompressing” that section of the spine. Any bone spurs that may be found sticking off the back of the vertebrae are removed as well.
Once the problem-causing vertebral segments have been removed, the space is filled with an implant. That implant is usually a strut graft that can be either an autograft that is taken from the patient´s own body (usually the small bone in their leg), or an allograft taken from a bone bank. On occasion, an artificial implant known as a “cage” may also be used, in which case it is affixed to the adjacent healthy vertebrae using bone fragments from the removed vertebrae.
Cervical foraminotomy is a minimally invasive surgical technique designed to relieve pressure on one or more spinal nerves resulting from age-related wear and tear affecting the spinal discs (cervical spondylosis), a narrowing of the cervical disc space (foraminal stenosis), or an intervertebral disc prolapse (bulge). It is performed from the back of the neck and involves carefully removing a small portion of bone and joint which overlie the affected spinal nerve, as well as any soft tissue which may also be causing compression. In some cases, portions of a herniated disc are also removed (microdiscectomy).
This procedure is generally indicated when the main problem is arm pain rather than neck pain. Its leading advantage is that it avoids fusing vertebrae in the neck, thereby preserving as much motion as possible. Still, it is usually recommended only when conservative treatment options, including physical therapy, pain medication, and nerve sheath injections, have failed. In cases of significant instability or neurological problems, it may be appropriate as a first treatment option.
Generally, the symptoms that cervical foraminotomy resolves most reliably are arm pain and weakness resulting from nerve root compression. Neck pain and headaches may or may not improve (very occasionally they can get worse). Patients can expect to resume normal activities within six weeks from the date of surgery.
Cervical laminectomy is a minimally invasive surgical technique designed to relieve pressure on the spinal cord and nerves caused by a damaged vertebra. It is performed from the back of the neck and involves carefully removing the back part of the problem vertebra, known as the lamina, which covers and sometimes overgrows into the spinal canal. Soft tissue which may also be causing compression can also be removed.
The procedure, a form of decompression surgery, is generally indicated when arthritis, bone spurs, or age-related wear and tear are causing a narrowing of the space in the spinal canal. This often leads to symptoms such as radiating pain, weakness, numbness in the arms, difficulty standing or walking, and loss of bladder or bowel control.
Still, cervical laminectomy is usually recommended only when conservative treatment options, including physical therapy, pain medication, or epidural steroid injections have failed to improve symptoms.
Cervical laminectomy is tolerated well by most patients and leads to significant improvements of their symptoms, particularly radiating pain. Patients can expect to resume normal activities within a few weeks from the date of surgery.
Cervical laminoplasty is a minimally invasive surgical procedure that reshapes or repositions bone to relieve stress on the spinal nerves in the cervical spine. Its etymology comes from the anatomical term lamina, referring to the roof of a bone over the back of the spinal cord, and from the Green word plastos, meaning to “mold.”
It is different from a laminectomy in that it opens up space in the spinal canal by correcting the vertebral lamina without removing it, but rather by repositioning or reshaping it, using metal plates and hardware.
Who needs cervical laminoplasty?
This procedure is indicated for patients who have cervical stenosis. Spinal stenosis occurs when the spinal canal narrows, putting pressure on the spinal cord and nerve roots. The spinal canal may narrow due to age-related degeneration of the cervical joints and intervertebral discs, formation of bone spurs in the spinal canal, or thickening of connecting ligaments.
Most patients who undergo laminoplasty are able to be back on their feet within one or two hours after surgery. The surgeon may recommend the use of a soft neck collar and will provide instructions on how to avoid sudden or jerky neck movements.
Returning to work depends on how quickly the patient's body heals and the type of work they do, but most people can expect to resume normal activities within a couple of weeks.
Craniotomy for Brain Bleeds
Craniotomy is a minimally invasive surgery performed to stop bleeding in the brain, remove blood clots from a leaking blood vessel, or relieve intracranial pressure and swelling that may be caused by a head injury or stroke.
What happens during a craniotomy?
A craniotomy is performed under general anesthesia. The surgeon makes an incision in the person's head, pulls apart part of the skull using special tools, and makes another incision in the tissue that surrounds the brain (the dura) to access the brain. The second incision allows extra fluid or blood to flow out of the brain, which helps decrease pressure and prevent injury during the procedure.
The surgeon then inserts microsurgical instruments through the incision to stop the bleeding or remove the blood clot. They may place a device in the brain tissue to monitor pressure while the operation is completed. The surgeon then closes the incision in the brain tissue with sutures, reattaches the bone flap with metal plates, closes the scalp incision with stitches or staples, and applies a sterile bandage over the treated area.
What happens after a craniotomy?
After the procedure, the patient will be taken to our on-site intensive care unit (ICU) for close monitoring while they recover. They may be given medicine to control pain and decrease brain swelling, which is normal after a craniotomy, and their vital and neurological signs will be frequently checked by nursing and medical staff. Their pupils will be checked to see how they react to light and they will be asked to follow basic commands and answer orientation questions to assess brain function. Hand grasp, arms and leg strength, and balance will also be tested.
Some swelling and bruising of the face or around his eyes, headache, fatigue, or temporary memory difficulties are all common symptoms after this type of surgery and get better over time. Recovery time varies from patient to patient, depending on their injury or other conditions, but usually does not last beyond 3 or 4 weeks.
Craniotomy for Brain Tumors
Craniotomy is the most common procedure used to remove brain tumors. During the operation, the surgeon makes an opening in the skull in order to access the tumor and, whenever possible, tries to remove all of it or as much of it as it is safe to. (Some tumors cannot be operated on if they are too close to a sensitive area of the brain, such as the areas that that control breathing or sight.)
What is an awake craniotomy?
A craniotomy is usually performed under general anesthesia, with the patient being asleep, but in some cases it requires them to be awake for at least part of the procedure in order to assess their brain function in real time. In the latter case, the surgical area is treated with local anesthesia so that no pain is felt.
An awake craniotomy is indicated if a brain tumor is close to segments of the brain that control important functions, such as speech, vision, and movement. Keeping the patient alert allows the neurosurgeon to check with them during surgery and monitor brain activity as they respond, as well as to minimize the risk of damage to those functional areas.
Although awake brain surgery can sound scary, it can actually reduce the risk of inadvertently damaging critical and healthy brain tissue. If you are a candidate for craniotomy, the highly specialised healthcare team at Legacy Brain & Spine will discuss all relevant details, explaining step by step what happens during the procedure and how to mentally prepare for it.
On average, a craniotomy takes between 4-6 hours, depending on the part of the brain being operated on. After the surgery, patients spend a few hours in the intensive care unit (ICU), where their vital signs are brain function are actively monitored, followed by 2-3 days in the hospital. They can expect to resume normal activities within 6-12 weeks.
CyberKnife radiosurgery is a form of advanced, highly targeted radiation technique that delivers with laser-like precision a high dose of radiation to tumors in the brain or elsewhere in the body. Despite its name, it does not involve a scalpel or a knife and is completely painless and non-invasive. It is a variant of stereotactic radiosurgery and has “surgery” in its name because of its precision.
CyberKnife radiosurgery is typically indicated for complex cancerous and noncancerous tumors, including primary, metastatic, and rare brain tumors, as well as for large brain tumors where a single radiotherapy session is not sufficient and for vertebra tumors. It does not require the use of anesthesia and is performed as an outpatient procedure, but can sometimes be combined with conventional surgery for optimal results in especially aggressive or hard-to-treat tumors.
The CyberKnife device comprises a linear accelerator connected to a computer-guided robotic arm that emits a narrowly targeted beam of radiation while rotating around the patient’s body to attack the tumor from multiple angles.
Using dynamic brain scans taken before and during the procedure, the robotic arm automatically detects small movements that may cause the tumor to shift, such as breathing, and adapts the radiation beam accordingly.
The flexibility of the robotic arm also makes it possible to treat areas of the body, such as the spine and spinal cord, that cannot be treated by other radiosurgery techniques.
Generally, CyberKnife radiosurgery treatments are split across 1-5 daily sessions, each lasting between 30-90 minutes, with the exact number of sessions and dose of radiation therapy determined by the size, location, and shape of the tumor.
Endoscopic Transsphenoidal Surgery
Endoscopic transsphenoidal surgery is the most common minimally invasive surgery used to remove pituitary tumors. The pituitary gland, which is located at the base of the skull (at the bottom of the brain) and above the inside of the nose, is responsible for regulating the body's hormones. Tumors located in that area are associated with hormone problems and vision loss.
This surgery is typically performed as a transnasal procedure, whereby a thin surgical instrument called an endoscope is inserted through the nostril and alongside the nasal septum to access the pituitary tumor.
The endoscope is equipped with a tiny light and camera that are wirelessly connected to an external monitor, from which the surgeon can watch and guides the handling of additional instruments and maneuvers associated with removing the tumor.
Endoscopic pituitary surgery is indicated as treatment for several types of pituitary tumors, including:
Hormone-secreting tumors. These growths secrete chemical messengers that travel through the blood.
Nonhormone-secreting tumors. These growths, also called endocrine inactive pituitary adenomas, may cause headache and visual disturbances as they increase in size.
Cancerous tumors. These growths may be treated with a combination of surgery, cancer drugs, and radiotherapy.
Endoscopic pituitary surgery is done under general anesthesia and patients are asked to stop eating and drinking after midnight on the night before surgery. They may also be asked to stop taking medications that increase the likelihood of bleeding during surgery and are advised not to take any over-the-counter medications without an explicit approval by their doctor. Prior to surgery, they will have had blood tests, a heart rhythm test, and a chest X-ray to discard any issues that may give rise to complications.
After endoscopic transsphenoidal surgery patients need to stay in the hospital for a day or two. During this time, nurses actively monitor their recovery and help with any dressings and bathroom needs. Patients are encouraged to get out of bed and walk as soon as they are able to and can expect full recovery within 4 weeks after the date of surgery.
Extreme Lateral Interbody Fusion - (XLIF)
Extreme lateral interbody fusion (XLIF) is a versatile surgical technique used to treat a number of degenerative conditions, spinal instability, and deformities that require fusion of the lumbar spine. It can be performed at multiple lumbar levels, although in most cases it is performed only at one or two levels.
Most surgeons limit the procedure to upper and mid lumbar levels because of the elevated risk of injury to sensory nerves in the legs when it is performed at lower levels. While the XLIF may be performed as a standalone procedure, it is often combined with a posterior decompression or stabilization surgery with metal screws and rods.
An XLIF is done under general anesthesia through a minimally invasive or mini-open approach. Its main advantage compared to other types of spinal surgery is that it is performed from the patient´s side rather than from the front or back, thus minimizing impact on major back muscles, bones, and joints.
What happens during XLIF surgery?
During XLIF, a 1-2 inch incision is made on the patient’s side and the abdominal muscles are shifted to allow the surgeon access to the space behind the abdomen. The front of the spine and the disc to be removed are then identified and special instruments called tubular dilators are introduced to enlarge the space, so that another surgical tool called a retractor can remove the problem-causing disc.
Once the disc is removed, a bone graft or interbody fusion device is placed into the empty space, the retractor is removed, and the lateral incision is closed with stiches and a sterile dressing.
XLIF is tolerated well by the vast majority of patients are most of them are able to walk the same day.
Intraoperative Nerve Monitoring
Intraoperative nerve monitoring (IONM), also referred to as intraoperative neurophysiological monitoring or intraoperative neuromonitoring, is a technique used during surgery to monitor the condition of a patient's nervous system in order to prevent damage to it. Its purpose is to reduce the risk of surgery-related nerve damage by identifying and ensuring the functional integrity of nerves that are near the organ or tissue being operated on. IONM is often used during spine or brain surgery, where surgical complications may cause a loss of neurological function.
How it is set up
Prior to beginning the surgery, the operating team places electrodes on or beneath the patient´s skin at several locations along the nerve pathway. The electrodes are connected to a computer and send information to it about the nerves being monitored, which it analyses in real time.
How it works
Periodically throughout the surgery the electrodes send electrical impulses to stimulate nerves and evoke a neurological response. The impulses are brief and contain very weak electrical current.
How it is interpreted
Following the stimulation, the nerves' activity is assessed by measuring the speed and intensity of the signal between the stimulating and receiving electrodes. The speed of the signal is calculated using the distance between electrodes and the time it takes the impulses to travel between them.
Using the Information
The baseline information about the patient´s nerve function is compared to that obtained throughout the surgical procedure. If the signal detected is slower and weaker, it may be a sign of a problem with the nerve, such as compression. This real-time intraoperative feedback allows the surgeon to quickly identify potential problems before completing the procedure and take corrective action before nerve damage becomes permanent.
Lumbar Corpectomy and Fusion
Lumbar corpectomy and fusion is a minimally invasive surgical technique designed to alleviate pain caused by damaged vertebrae that compress the spinal cord or nerve roots. It involves the excision and removal of the diseased bone or discs, followed by a fusion of the neighboring vertebrae by way of a bone graft to restore spinal stability.
This procedure is generally indicated as a treatment for vertebral fractures or tumors in the lower spine, as well as to correct any other deformities in the spinal column.
What happens after lumbar corpectomy and fusion?
Most patients are able to go home from the hospital within 4-7 days after surgery. A physical therapist or occupational therapist on their care team will give them instructions about walking independently and the proper techniques of getting in and out of bed. In the early days after surgery, it is advised that patients avoid lifting heavy objects, bending at the waist, and twisting in order to avoid strains and injuries.
Lumbar laminectomy is a minimally invasive surgical procedure designed to relieve pain associated with spinal stenosis, a condition caused by a narrowing of the spinal canal. The surgery, also called open decompression, involves removal of all or part of the posterior part of a vertebra (the lamina) to free up space for the compressed spinal cord or nerve roots.
Lumbar laminectomy surgery is generally indicated when arthritis, bone spurs, or age-related wear and tear of a vertebra are causing a narrowing of the spinal canal in the lower back.
This often leads to symptoms such as radiating pain, weakness, numbness in one or both legs, difficulty standing or walking, or loss of bladder or bowel control. Still, lumbar laminectomy is usually recommended only after conservative, nonsurgical treatment options such as physical therapy, pain medication, or epidural steroid injections have been tried for a period of 8-12 weeks and have failed to improve symptoms.
The procedure has two main objectives:
Relieve neural tissue compression
Spinal stenosis in the lumbar region is usually caused by compression of the spinal cord and nerves. This condition commonly results in leg pain while walking or bending the spine backward, and typically affects both legs. Laminectomy helps relieve the compression of these tissues by widening the spinal canal.
Improve leg function
Lumbar stenosis often causes decreased mobility due to radiating pain and weakness in the legs. Because laminectomy helps decompress, or decrease pressure on, the corresponding nerves, it relieves some or most of that pain and improves mobility.
Lumbar laminectomy is tolerated well by most patients and leads to significant improvements of their symptoms, particularly radiating leg pain. It is important to note, however, that it primarily treats leg pain and not lower back pain. Back pain may persist after the surgery due to localized continuing vertebral degeneration or a cause unrelated to nerve or spinal cord compression.
Patients treated with lumbar laminectomy can expect to resume normal activities within a few weeks from the date of surgery.
Lumbar Puncture (Spinal Tap)
A lumbar puncture, also called a spinal tap, is a non-surgical procedure performed in the lower back, during which a needle is inserted between two lumbar bones (vertebrae) to collect a sample of cerebrospinal fluid. This is the fluid that surrounds the brain and spinal cord to isolate and protect them from injury.
A lumbar puncture is primarily used as a diagnostic procedure to help diagnose serious infections and disorders of the central nervous system, such as meningitis, Guillain-Barre syndrome, multiple sclerosis, and spinal cord or brain tumors. Sometimes a lumbar puncture is also used as a drug delivery method to inject anesthetic or chemotherapy drugs into the cerebrospinal fluid. It can also be used to inject contrast dye into the spinal column in order to obtain X-rays or a CT scan, a diagnostic test known as myelography.
Lumbar puncture is performed under local anesthesia and patients do not feel any pain. There is a slight risk that some spinal fluid may leak from the puncture site into surrounding tissue, which may cause headache, but that usually subsides within a couple of days.
Minimally Invasive Lumbar Discectomy
Minimally invasive lumbar discectomy is a type of surgery performed to remove all or part of a herniated or damaged disc in the lower back. It is more sparing to patients than open lumbar discectomy because it is approached through much smaller incisions (usually less than half an inch compared to 5-6 inches), minimizing damage to the low back muscles and reducing postoperative pain, medication use, and recovery time.
This procedure is indicated when a herniated lumbar disc is pressing on the spinal cord or nerve roots and causing pervasive or shooting pain, numbness, or weakness in the legs. It is recommended when conservative treatment options such as physical therapy, pain medication, or epidural steroid injections have failed to relieve those symptoms.
During a minimally invasive lumbar discectomy, the orthopedic surgeon takes out all or part of the problem-causing disc and decompresses the spine, using different methods. They may insert a small tube into the space with the herniated disc, through which they introduce microsurgical instruments and remove the disc, or they may use a laser. In either scenario, the surgeon does not have to remove and reattach any bone or muscle, as it is done in traditional open discectomy.
Minimally invasive lumbar discectomy is typically performed under general anesthesia and does not require an overnight hospital stay.
Minimally Invasive Posterolateral Lumbar Fusion
Minimally invasive posterolateral lumbar fusion is a surgical technique used to treat degenerative scoliosis, spinal instability (spondylolisthesis), and deformities that require fusion of the lumbar spine. It is a “slimmed down” version of posterior lumbar interbody fusion (PLIF), the most commonly performed type of spinal fusion, and involves placing bone graft between adjacent vertebrae (hence “interbody”).
It is often done in combination with lumbar discectomy or laminectomy, in which a damaged disc or part of a damaged vertebra in the lower back spine are removed.
In contrast to open PLIF surgery, in minimally invasive PLIF the bone graft is placed through the side, thus requiring smaller incisions.
What happens during PLIF surgery?
A minimally invasive PLIF is done under general anaesthesia. Typically, the surgeon makes a vertical incision in the middle of the lower back in order to pull apart the back muscles and reach the vertebrae. After performing a decompression of the troubled area, they meld the vertebrae by placing a bone graft or an artificial interbody fusion device into the empty space. To help the newly operated area heal correctly, the doctor uses screws, rods, or other types of medical hardware.
Minimally invasive PLIF is tolerated well by the vast majority of patients and most of them are able to resume normal activities within 4-6 weeks after the date of surgery.
Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF)
Minimally invasive transforaminal lumbar interbody fusion (TLIF) is a type of surgery recommended for some patients suffering from chronic pain associated with serious spondylolisthesis (a form of spinal instability), degenerative disc disease, nerve compression, lumbar stenosis, or recurrent herniated disc.
As with all fusion surgery, it involves fusing or “melding” two or more vertebrae together after decompressing the affected area, usually by removing a herniated disc or bone fragment.
In recent years, many surgeons have begun performing TLIF as a preferred method to posterior lumbar interbody fusion (PLIF), the most common type of spinal fusion. A TLIF can achieve the same effect as a PLIF (both described in detail in other sections on this page), however in minimally invasive TLIF the bone graft is inserted into the vacated disc space from the side. This allows the back muscles and nerve roots to be shifted rather than cut, which in turn reduces the risk of scarring, nerve damage, blood loss, surgical site infection, and postoperative pain, as well as leads to shorter hospital stays and recovery time.
What happens during minimally invasive TLIF surgery?
In minimally invasive TLIF, a 1-2 inch incision is made on the patient´s side for the surgeon to gain access to the spinal column. He or she then inserts a small tube through the skin that creates a “working channel” within the muscle fibers and, using special microsurgical instruments, carries out the TLIF procedure through that tube.
Although average operative time in minimally invasive TLIF is slightly longer compared to traditional “open” TLIF due to the extremely delicate nature of the work involved, it is tolerated well by the vast majority of patients and most of them are able to go home the same day.
Posterior Lumbar Interbody Fusion (PLIF)
Posterior lumbar interbody fusion (PLIF) is a type of spinal surgery that involves adding bone graft to a damaged or degenerated area of the spine. It usually follows decompression surgery, whereby a herniated disc or bone fragment is removed from the vertebra. As such, it is designed to stimulate a biological response that causes the graft to “fuse” the vertebral plates on both ends of the removed disc, reduce motion between them, and regain stability.
This procedure is the most common type of spinal surgery and is generally indicated as a treatment for lower back pain associated with degenerative disc disorders or spinal instability (spondylolisthesis). It is recommended when conservative treatment options such as physical therapy, pain medication, or steroid injections have been tried and have failed to resolve the pain.
What happens during PLIF?
A PLIF is performed under general anesthesia and usually in combination with lumbar discectomy or decompression surgery to correct a spinal deformity. The surgeon makes a 3-to-6 inch incision along the midline of the lower back and separates the lumbar muscles from the lamina (the back side of the vertebrae). After the spine is visible, the surgeon lifts off the lamina and similarly cuts through the facet joints covering the spinal nerve roots. The nerve roots are then shifted to the side, the decompression (involving disc removal) is completed, and an organic or artificial bone graft is inserted into the empty disc space.
What happens after PLIF?
Most patients are able to go home from the hospital within 4-7 days after surgery and can expect to resume normal activities within a few weeks. A physical therapist or occupational therapist on their care team will give them instructions about walking independently and the proper techniques of getting in and out of bed. In the early days after surgery, it is advised that they avoid lifting heavy objects, bending at the waist, and twisting in order to avoid strains and injuries.
Spinal Cord Stimulator or (SCS)
A spinal cord stimulator is a patient-controlled device consisting of a pacemaker-like implant (a generator) and a set of thin wires (electrodes) that carry electrical current from the generator to the spinal cord nerves. It is used to alleviate chronic back, leg, or arm pain by sending low-intensity electrical pulses that interrupt pain signals before they reach the brain.
The SCS pulse generator is placed subcutaneously – usually near the buttocks or abdomen – by a specially trained physician guided by an X-ray or ultrasound, while the electrodes are embedded in the epidural space between the spinal cord and the vertebrae. The system comes with a remote control operated by the patient, who can activate stimulation when they feel pain, increase or decrease the intensity of the pulses, or target different pain centers in their body based on pre-set programs.
Standard spinal cord stimulators interrupt an oncoming sensation of pain and “mask” it with a sensation of light tingling, called paresthesia. For patients who find the tingling uncomfortable, some SCS devices offer “sub-perception” stimulation that is even more subtle and practically cannot be felt.
What is spinal cord stimulation used for?
An SCS is indicated for relief from chronic pain after nonsurgical methods such as physical therapy or epidural steroid injections have been tried and have failed, as well as when there is an elevated risk of creating dependency on pain medication. This method of pain control can be used to treat or manage different types of chronic pain, including:
Post-surgical back pain
Arachnoiditis (painful inflammation of the arachnoid, a thin membrane that covers the brain and spinal cord)
Heart pain (angina) untreatable by other means
Spinal cord injury
Nerve-related pain, such as that triggered by severe diabetic neuropathy or cancer-related neuropathy due to radiation, surgery, or chemotherapy)
Peripheral vascular disease
Complex regional pain syndrome
Pain after an amputation
Visceral abdominal pain and perineal pain
The benefits of spinal cord stimulation are improved quality of life and sleep, reduced need for pain medicines, and a greater feeling of control over pain management. It is frequently used in combination with other pain management approaches, including medication, exercise, physical therapy, and relaxation techniques.
Transforaminal Lumbar Interbody Fusion (TLIF)
Transforaminal lumbar interbody fusion (TLIF) is a modern approach to spinal fusion surgery used to relieve chronic back pain by stabilizing dislocated spinal vertebra and introducing a bone graft into the space of a removed disc.
It is a variation of traditional posterior lumbar interbody fusion (PLIF, described in another segment on this page) that takes an alternative trajectory to intervertebral fusion by avoiding aggressive muscle and nerve retraction to access the spine.
TLIF is indicated for a range of spinal disorders, including spinal stenosis, spinal instability (spondylolisthesis), degenerative disc disease, and recurrent disc herniations. As with PLIF, it is recommended when conservative treatment options such as physical therapy, pain medication, or nerve sheath injections have been tried and have failed to resolve the pain.
This procedure is performed under general anesthesia through the posterior (back) part of the spine and involves decompression of the nerves in the lumbar region, removal of the facet joint and intervertebral disc, stabilization of the operated segment of the spine via surgical screws, and fusing of the vertebrae on both ends of the removed disc by introducing a bone graft (also known as a “cage”).
As the bone graft heals, it “melds” the vertebra into one long bone.