Surgery can provide dramatic relief for painful spinal conditions with restoration of quality lifestyle for years—even for the remainder of a patient’s life. In many cases of disc herniations or stenosis causing back and leg or neck and arm pain, surgery may bring tremendous relief. In one large review of 81 academic studies, 65-85% of patients undergoing lumbar or low back discectomy—removal of a herniated disc pressing on a spinal nerve—had no sciatica one year post operatively. In contrast, only 36% of patients treated without surgery—reduced activity, medication, epidural injections, physical therapy–were without sciatica at one year. In another major review of several studies, surgical removal of herniated lumbar discs has over a 90% success rate. Less than 1% of operated patients had serious complications. However, 10% of those operated eventually underwent further surgery.
Cervical disc herniation is often treated with fusion (see below) of the cervical spine, with nearly comparable outcome as lumbar disc surgery without fusion. Thoracic disc herniation causing complaints leading to surgery is rare but requires major surgery, through the chest and followed by fusion, to be treated.
Surgery is not a cure for further degeneration of the spine. Nor is pain management. Both have a role in treating spinal disorders. The key in deciding to opt for surgery, as opposed to a more conservative approach, is based on:
Nature and time heals many disc herniations. Seventy to eighty percent of disc herniations causing pain in the lumbar spine and legs and neck and arms, respectively, improve spontaneously over 6-8 weeks. A disc is approximately 90% water and herniated discs may dessicate and shrink over time—in a manner analogous to a large grape becoming a small raisin. As the disc shrinks, it eventually no longer compresses the spinal nerve, and pain, muscle spasm, weakness, and numbness disappear.
Oral medication with strong analgesics—including narcotics—and oral steroids should be used as well as medication to reduce nerve related pain. These drugs include older antidepressants such a nortriptyline and the anti-epileptic gabapentin. Physical therapy should be avoided until the pain has resolved and used only to recondition muscles that may have become weak or stiff following prolonged pressure on the nerves making them function. Unfortunately, all too many patients are sent to physical therapy early, causing increased irritation of the compressed nerve, resulting in prolonged pain, weakness, and numbness—and possibly a sojourn in the operating room that could have been otherwise avoided.
Although epidural steroids have no benefit on sciatica due to disc herniation at 3 or 12 months after injection, they do often have a short term benefit lasting less than 6 weeks. That may be enough to make the healing process in those discs, which will shrink (the vast majority) less painful. The steroids do not eliminate the compression of the nerves. However, nerves under pressure retain water and swell, making the pressure on them worse. Steroids reduce the swelling significantly, with improvement of pain and even weakness and numbness for months. However, the medication must surround the compressed, swollen nerves in a high concentration to work properly.
In the long run, for herniated discs which continue to cause pain, weakness, or significant numbness, after a trial of conservative therapy for 6-8 weeks, surgical treatment is superior to prolonged conservative therapy—pain medication, physical therapy, acupuncture, massage, chiropractic manipulations, lifestyle modification, and injections.
Unlike disc hernations, other spinal conditions such as narrowing of the spine due to arthritis (stenosis), spinal slippage, and scoliosis never resolve spontaneously. Stenosis is narrowing of the spinal canal and foramena. As the spine ages, the discs separating the vertebra desiccate and become brittle. Discs are composed mostly of water in youth. As we age the dessicating discs lose height, bringing the vertebra separated by the discs closer together. This results in narrowing of foramenal stenosis with pressure on the nerve roots. The brittle discs may also protrude into the canal, compressing nerves within it. Moreover, as the discs dessicate and lose volume, the vertebra begin to slip one over another. The ligaments inside the spine are attached to the vertebra so as to stabilize them. Once the vertebra begin to slip, the ligaments are strained and become thicker, contributing to pressure on the nerves. The facets also become worn and arthritic, contributing to back pain, stiffness, and narrowing of the spinal canal and foramena.
The discs and ligaments may calcify over time and become hard like bone. These structures act like pliers, squeezing the nerves within the canal and foramena, causing back and leg pain and leg weakness, numbness or tingling. A similar phenomenon occurs in the neck, causing the same problems in the neck and arms as seen in the legs.
The spinal cord lies withn the cervical, thoracic, and upper lumbar canal and can be compressed as well, causing weakness, bowel and bladder dysfunction, and an alteration of gait. Stenosis rarely affects the thoracic spine, however.
In some cases, the vertebra slip and eventually become fixed in a slipped position, narrowing the canal and foramena, and compressing nerves. If the slippage is unstable—the vertebra slip and slide back and forth with changes in body position—the nerves inside the narrowed canal and foramena are intermittently irritated, depending on the position of the sliding vertebra surrounding them.
Operations to open the narrowed spine in stenosis are usually also quite successful in at least 65% of patients. The major reason for failure of this surgery to improve symptoms is inadequate opening of the narrowed spine—the nerves remain squeezed by arthritic overgrowth of the spine following unsuccessful surgery. Stenosis surgery, performed by a skilled surgeon helps restore function and reduce pain significantly. The surgery is not a cure for the aging process with its associated stiffness, muscular weakness, and arthritic pains—or the risk of stenosis occurring at other parts of the spine, above or below the operated area. However, a good surgical result will help a motivated patient engage in a more active life, including enhanced participation in rehabilitation and an ongoing fitness program .Unfortunately, the complicated anatomy of some cases of stenosis—those with co-existant scoliosis, spinal slippage, or severe foramenal stenosis–requires surgical fusions to truly decompress squeezed nerves. (see below). Simple stenosis surgery may be an enormous undertaking for some older patients. Fusion surgery and recovery from it is an even more daunting undertaking.
It is not surprising that not all patients with stenosis are good candidates for surgery for medical reasons. For these patients, the operation and recovery from it are worse than the pain and disability caused by the stenosis itself. Moreover, complications following the surgery, or inability to participate in extensive rehabilitation following surgery, may even shorten the lives of these patients. For these patients, good pain management is the only reasonable option. Many elderly patients tolerate powerful pain medication poorly. However, taking some analgesics should be attempted—a process requiring patience and trial and error. However, employing judicious use of epidurals and root blocks, performed under CT guidance with mild intravenous sedation, may give months of tremendous relief and can be repeated. Using these injections, I have helped patients who were too ill to undergo any surgery, intolerant of anything more than Tylenol (which was not effective), and living a hellish life of chronic pain. Some were even unable to walk across the living room due to pain.
Unfortunately, steroids taken by mouth may relieve sciatica due to disc herniations but do not reliably relieve pain from stenosis. Obviously, not all compressive situations are identical. Apparently, treatment of pain emanating from nerves compressed by long-standing stenosis requires a higher local concentration of steroid surrounding the swollen, pain-inducing nerve, than practically can be achieved orally.
The same type of injections administered in the office, or with the aid of fluoroscopy, do not work. It is all too often impossible to cover the compressed, pain-inducing nerves with steroids without the use of a CT scanner. Furthermore, if all the pain causing areas are not treated at the same time, the patient remains in pain. Failure to adequately cover all the pain-inducing nerves simultaneously is a major reason than injection therapy often is ineffective in relieving pain from multi-level spinal stenosis.
Once patients are considerably better through good pain management, reconditioning weak muscles can be accomplished by home physical therapy, walking as much as possible, and where feasible, going two times a week for active physical therapy.
The benefit of injections wanes with time but they may be repeated (with good results) two-to-three times annually, as needed.
In a fusion, compressed nerves are often decompressed and the vertebra surrounding the compressed nerves are fused together using various techniques. The bones to be fused are exposed and the surface of the bone is removed. Bone chips harvested from a graft site on your hip or sacrum are placed over the exposed vertebra to be fused. Metallic hardware drilled into the spine, attached to metallic rods or plates, is used to allow the fused bones to heal, in a manner analogous to an internal cast. The hardware screws (at times) cause local pain following surgery when a thin patient leans backwards in a chair. At times, pain-inducing parts of the hardware may be surgically removed once the fusion is solidly healed. Unfortunately, not all fusions heal solidy and a decision must be made to reoperate and try the fusion again.
These operations are performed from the back of the spine, the side of the thoracic and lumbar spine, or the front of the lumbar spine and neck. In this manner pressure is taken off the nerves by opening the tight areas of the spine before the fusion is carried out or, alternatively, simply making the spine rigid so bodily movement will no longer cause the vertebra to shift positions and squeeze nerves within or exiting the spine.
Why are fusions necessary at all? The spine is stabilized by the disc between the vertebral bodies and the two facet joints, one on each side, connecting two vertebra together. As noted above, once the discs begin to dry out, they become a source of spinal decline. Simple spinal operations in the lumbar spine are usually performed from the back .Opening up the spine and relieving pressure on nerves within it usually is sufficient for a gratifying surgical result. This is how simple disc surgery and stenosis surgery is performed. However, there is always a delicate balance in removing disc, ligaments and facets—insufficient removal results in surgical failure and continued symptoms, Excessive decompression invites spinal instability resulting in pain, possible weakness and sensory complaints, with the likelihood of further surgery to stabilize the spine with a fusion.
Lumbar (low back) or lumbar-thoracic fusions are designed to treat pain and at times extremity weakness and sensory complaints (numbness or tingling) which exist in five conditions. The first are certain cases (not all) of severe foramenal stenosis which cannot be adequately decompressed without removing so much supporting facet so as to render the spine unstable. Second, following the rational in fusing select patients with foramenal stenosis, fusions may be used prophylactically when operating on slipped but stable spines that are predictably going to become unstable—slipping more—after routine spinal decompression. In cases where the spine is slipped but stable before surgery, it may become unstable after routine surgery for the reasons discussed above. Third, fusions may be necessary to treat pain—which cannot be otherwise controlled– and other symptoms in cases of slipped vertebra in unstable spines (Pain control includes medication, including narcotics and radiofrequency lesions to the nerves to the painful facets, for example). Fourth, fusions are needed to correct cases of scoliosis in which pain cannot be adequately controlled using medication and, where needed, radiofrequency lesions, progressive scoliosis, or scoliosis which compromises the ability to breathe. Fifth, fusions are needed to correct deformed spines or damaged vertebra pressing on nerves within the spine following vertebral fractures from accidents, cancer, or cases of osteoporosis. As you will read below, thoraco-lumbar fusions are not a panacea for spine related pain.
Cervical fusions are commonly used to decompress the spinal canal following disc protrusions, stenosis, and vertebral fracture or slippage pressing on the spinal cord.
Unfortunately 50% of fusions in the US—possibly more– may be performed for the relief of back pain in stable spines (see the website sections covering facetal pain and discogenic pain –defined by a positive discogram–and “Goodbye To Back Pain.”). Patients in this category include those with degenerated painful disc and facet pain. Fusions are totally inappropriate for either condition. Most discogenic pain can be managed through other, less invasive means, including medication and some procedures. Facetal pain is well controlled with medication, weight loss, lesioning of the nerves to the painful facets, and judicious use of physical therapy following the lesions, as needed.
Fusions of the thoracic-lumbar spine have been shown to have satisfactory outcomes in 68% overall, with success rates ranging from approximately 15%-95%, depending on the study quoted. Over 85% of cervical fusions may have good outcomes. The stresses on the neck are less than those on the weight bearing lower spine. Consequently, treatment of cervical disc disease and stenosis with fusion carries with it better results and less complications.
Fusions are not always successful. Not all fusions heal properly and some patients may have to be fused more than once. In lumbar fusion about 14% fail and most go on to refusion. In thoracic-lumbar fusions for scoliosis, approximately 17% fail, requiring re-fusion. In the neck 10% or less – to as high as 25% – fail, but only about 17% require refusion.
Most patients with fusions require further surgery, above and below the fusion, within five years of the first surgery. Fusion creates increased stress on the spine above and below it, causing painful facets, disc herniation, stenosis, slippage and instability of the vertebra. These conditions result in increased pain, weakness, and numbness—often leading to surgery—extension of the fusion to previously unfused parts of the spine. The process continues through several surgeries over years before it ends.
In some studies, up to 66% of patients undergoing lumbar fusions live in enough chronic pain so as to become disabled. Fusions may relieve one set of painful symptoms but cause others. The net result is all too often chronic use of pain medication and a life in pain clinics interspersed by surgical procedures, physical therapy, lost work, and a diminished lifestyle. Avoid fusions at all costs unless there is no other choice.
However, for patients who choose to be fused—this operation is elective except in cases of trauma– choose a skilled surgeon, an excellent pain management physician (post operatively) to manage your pain going forward, a well-qualified physiatrist to prescribe a course of rehabilitation, and an actively involved physical therapist, working out of a well equipped therapy center. There is life after fusions and you can rehabilitate yourself with appropriate medical support.
A point to consider when considering any spinal surgery—a bad result may be correctable if recognized and appropriately treated with further surgery. Bad results are not always reversible—fusions resulting in different pain than preoperatively, but pain of similar magnitude as before surgery, can’t be undone. Similarly, in the event nerves are damaged from the surgery, the effects of this damage are often permanent. Badly damages nerves cause chronic pain, weakness, and numbness—and usually do not heal.
Sixty-six percent of Americans in pain clinics suffer from failed back surgery. At least half of these patients have failed surgery due to inadequate decompression or opening of spinal elements pressing on nerves. This inadequate surgery is all too often unrecognized or minimized. “Well, I did my best. Now you must rely on pain management.” Or, “You need more surgery—and that involves a fusion of multiple spinal segments.” These statements may in fact be totally truthful but prompt important questions. How is inadequate surgery documented and why is it missed on occasion? Could another surgeon further decompress the spine without resorting to a fusion? Lifelong pain management is a poor substitute for more definitive surgery. On the other hand, you must realize by now that unnecessary fusions are also outrageously inappropriate, carrying with them a bad marriage to the medical profession.
Inadequate surgery needs excellent radiological studies to document it—all too often absent in today’s world of managed care—are imperative in documenting inadequate surgery. Insurance companies will reimburse for nine fusions but are penny wise and pound foolish in paying for multiple radiological studies in the same area—the lumbar spine—which may be needed to sort out a confusing postoperative picture in a patient clearly in pain following spine surgery or surgeries.
CT scans to better demonstrate bone pressing on nerves, MRIs with contrast dye to differentiate surgical scar from retained or re-herniated disc material, bending X-rays of the spine to demonstrate spinal instability, and myelograms—X-ray studies in which X-ray dye is injected into the spinal fluid and the patient bent in various positions–elucidating compression of nerves during spinal movement simulating every day activity.
Once inadequate surgery is documented, a surgeon must be located who can clean up the mess without resorting to excessive surgery—again not such an easy task in today’s world of managed care. For a surgeon it is far more cost-effective to grossly decompress a patient and fuse them than to laboriously decompress them while preserving spinal stability.
Another all too common cause of failed back surgery is permanent nerve damage. More surgery never ameliorates this problem. Nor do injections. Radiofrequency lesions of these nerves will worsen the situation. Patients with damaged nerves can benefit from medication including narcotics and medication for nerve related pain. Physical therapy can help alleviate muscle pain, bursitis over the hip, and strengthen weakened muscles and correct gait abnormalities due to weakness or pain. Injections and radiofrequency lesions of the nerves supplying painful facets and the sacro-iliac joints often help reduce pain as a result of limping due to weakness or pain. In spite of the potential help of all the treatments outlined above, many failed back surgery patients remain in pain clinics for life.
Surgery can have “miraculous” benefits or disastrous consequences which may result in disability, financial hardship, and psychological torment. Chose a surgeon with an outstanding reputation for judgment, honesty, skill, and an outstanding support team of colleagues to get you through the surgery or help avoid it, deal with the post operative period, including pain management and rehabilitation and, when needed, recognize and treat complications. For more indepth information on this topic, I encourage you to refer to my book, “Say Goodbye To Back Pain.”
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