Surgical Procedures for Low Back Pain and Sciatica
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Surgery may be indicated for persistent back pain that involves an anatomical problem such as a ]]>herniated disc]]> , ]]>spinal stenosis]]> , or ]]>spondylolisthesis.]]> Rarely, surgery may be performed on an emergency basis if there are severe symptoms, such as loss of bowel or bladder control, or if a tumor is present.
The two main surgical options for treating a herniated disc are ]]>laminectomy]]> (with or without ]]>spinal fusion]]> ) and ]]>diskectomy]]> . Spinal decompression may be done to treat spinal stenosis. Spondylolisthesis is treated either with a fusion or with a fusion and a decompression.
Laminectomy (Spinal Decompression)
A laminectomy, also called spinal decompression, is an open surgical procedure that involves removing a small portion of bone in the spine, called the lamina, in order to alleviate pressure on spinal nerves. Along with bone, fragments of a ruptured disc may also be removed during surgery.
The surgeon makes an incision in the back, spreads the overlying muscles, and removes the lamina, which is the small part of the vertebral bone over the area where the nerve is being pinched. Once the bone is removed, the surgeon can see what is compressing the nerve and may remove the offending disc. The incision is closed with stitches or staples.
Spinal fusion is a procedure that joins two bones (vertebrae) in the spinal column together to eliminate pain caused by movement.
Most of the time when a patient has a laminectomy and disc removal, a spinal fusion is not done. If a spinal fusion is to be performed, the adjacent vertebral bones are joined together with bone harvested either from the patient or a bone donor bank. Additional internal devices, such as metal rods and pins, may be used to provide further stability. The actual "fusing" of the vertebral segments occurs as the body stimulates new bone growth between the vertebrae over the course of the healing period, which can last 3 to 6 months or even longer.
Diskectomy is the removal of the protruding disc and part of the backbone. The doctor makes an incision in the back, then a small part of the bone is removed to obtain access to the disc. The disc is then removed to take pressure off the nerve.
In certain cases, the doctor can perform a microdiskectomy to remove a herniated disc. A microdiskectomy is a less invasive procedure. The doctor makes a smaller incision and uses a magnifying instrument to visualize the disc and nerves. It is not always possible to do a microdiskectomy.
In a randomized clinical trial patients with radicular pain and image-confirmed lumbar intervertebral disc herniation were assigned standard diskectomy or a variety of nonoperative treatments. Over two years, both groups showed substantial improvements. Some secondary outcome analyses favored surgical treatment. There were study limitations that could have influenced the outcome.
A clinical trial published in 2007 by Peul, et al., studies early versus delayed microdiskectomy. Patients with severe sciatica were randomly assigned to receive early microdiskectomy (within an average of 2.2 weeks) or conservative treatment (ie, combination of rest, physical therapy, and medications) with delayed surgery if necessary. Although after one year there was no difference in pain or disability between the two groups, those patients receiving early surgery reported significantly faster recovery. However, of the patients who were in the delayed group, only 39% eventually required surgery. ]]>*]]>
Several studies have attempted to look at the effects of surgical diskectomy versus nonoperative treatments. Many of these studies find that patients improve with either surgical or nonoperative care. Over time, results may be similar for either group, and while there is a trend suggesting that patients improve faster with surgery, the studies have imperfections that limit direct comparison of surgery versus nonoperative treatment.
A relatively new procedure, total disc replacement is now available as an alternative to fusion when the cause of the injury is a degenerated disc. In the procedure, an artificial disc is used to replace the damaged disc. In theory, it offers the ability to repair the damaged portion of the spine while still maintaining the mobility of the spine. However, this new procedure remains controversial. It may be appropriate for only a very limited group of patients. Patients with multiple degenerating discs or who have had multiple failed back surgeries may not be candidates for artificial disc replacement. There is also a device to replace only the nucleus pulposus, the soft inner part of the disc. The role of these new technologies is not yet established, and long-term outcome data are lacking.
Nucleoplasty is one of the newer, less-invasive surgical procedures. This procedure typically uses radio waves to treat patients with low back pain caused by a contained or mildly-herniated disc. In nucleoplasty, the surgeon inserts a wand-like transmitter into the disc while the patient is awake but lightly sedated. Guided by x-ray imaging, the surgeon sends radiofrequency pulses into the nucleus or center of the disc. The radiofrequency energy heats and shrinks the gel-like tissue, resulting in less volume and thus relieving pressure on the nerve impacted by the bulging disc. The entire procedure lasts about 30 minutes.
Bhagia SM. Slipman CW. Nirschl M. Isaac Z. El-Abd O. Sharps LS. Garvin C. Side effects and complications after percutaneous disc decompression using coblation technology. American Journal of Physical Medicine & Rehabilitation . 85(1):6-13, 2006 Jan.
Bridwell KH. Anderson PA. Boden SD. Vaccaro AR. Wang JC. What's new in spine surgery. Journal of Bone & Joint Surgery - American Volume. 90(7):1609-19, 2008 Jul.
Cohen SP. Williams S. Kurihara C. Griffith S. Larkin TM. Nucleoplasty with or without intradiscal electrothermal therapy (IDET) as a treatment for lumbar herniated disc. Journal of Spinal Disorders & Techniques . 18 Suppl:S119-24, 2005 Feb.
Conn's Current Therapy 2001. 53rd ed. WB Saunders Company; 2001.
Pain. National Institute of Neurological Disorders and Stroke website. Available at: http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#Spine . Accessed October 27, 2008.
Sciatica. American Academy of Orthopaedic Surgeons website. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00351 . Accessed October 27, 2008.
Textbook of Primary Care Medicine. 3rd ed. Mosby, Inc.; 2001.
Updated Disketomy section on 6/7/2007 according to the following study, as cited by DynaMed's Systematic Literature Surveillance : Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245-2256.
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA . 2006;296:2441–50.
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA . 2006;296:2451–9.
Zindrick MR. Tzermiadianos MN. Voronov LI. Lorenz M. Hadjipavlou A. An evidence-based medicine approach in determining factors that may affect outcome in lumbar total disc replacement. Spine . 33(11):1262-9, 2008 May 15.
Last reviewed October 2008 by ]]>John C. Keel, MD]]>
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