At some point, acute back pain affects 85% of adults and is severe enough for them to seek medical attention. Fortunately, in most cases the pain subsides in a few days to a week without requiring major treatment. Typically, activity modification, NSAIDs, and pain medication will have most people back on their feet quickly. If the pain persists for more than a week, a thorough evaluation with a spine specialist is recommended. If your acute back pain is initially debilitating and/or includes radiating pain in one or both legs, you should seek immediate attention from a spine specialist. In these circumstances, be aware that you may also experience associated weakness or numbness. In rare cases, loss of bowel or bladder function may occur with severe back pain. This could indicate a surgical emergency and an MRI should be performed ASAP. If you experience unresolved or recurrent episodes of back pain, you should seek medical attention. Remember, in many cases the result of an evaluation with a spine specialist ends with reassurance that no major problems exist and the emphasis is placed on avoiding the recurrence of symptoms.
What exactly is “Laser Spine surgery”? Can Spine surgery be performed more effectively and with less complications using a Laser? Why is the word Laser almost synonymous with Spine surgery? Well of those three questions the last one is the easiest to answer. And that answer is marketing. Google anything regarding disc or spine surgery and you will immediately see advertisements about laser spine surgery. Watch much daytime television and you will see countless advertisements about laser spine surgery. So what about the first two questions? What is Laser Spine surgery and does it make Spine surgery more effective or safer? Let’s discuss.
First of all, Laser spine surgery is NOT a defined surgical procedure and subsequently it is not recognized specifically as a procedure by Medicare or private insurance companies. Microdiscectomy, Decompressive Laminotomy or Laminectomy are examples of defined surgical spine procedures accepted by insurers and Medicare. The confusion really comes from associating, through marketing, the word Laser with the concept of Minimally Invasive surgery. With out a doubt, microdiscectomy surgery and decompressive laminectomy or laminotomy surgery can be done successfully with minimally or least invasive techniques. So the real question is-does the Laser make spine surgery less invasive or safer than using a scalpel or electrocautery? The answer is absolutely unequivocally NO! For a sobering assessment about the subject, search Laser surgery criticisms or complications and read the articles by Bloomberg or Business Week. There is a reason why the Laser is not routinely used as a tool for spine surgery in Peer reviewed institutions like the Mayo Clinic or UAB Hospital and that also includes our local institutions Huntsville Hospital and Crestwood Hospital, and that reason is that a laser does not make spine surgery better or safer.
Let’s reset the discussion. New technology and advancing surgical procedures is one of the pillars of modern medicine. No better example of that is surgery for gall bladder disease. In the early 1980’s, cholecystectomy surgery was done with a large abdominal incision. I have some painful memories as a medical student holding a Dever retractor with two hands while the attending surgeon removed the gallbladder with an open technique. In just a matter of a few years with the development of minimally invasive laparoscopic techniques the paradigm completely changed and the laparoscopic technique became the standard of care.
In Spine surgery, there has been a tremendous amount of new technology in the last few decades. Kyphoplasty, Artificial Disc technology, advances in fusion techniques with better instrumentation are all examples of peer reviewed technology that has been proven safe and effective and therefore incorporated into mainstream spine surgery throughput the world. You may have read recently about the Mazor robot or the O-arm which are a couple of new technologies recently introduced into the Huntsville spine market. The laser as a surgical tool is not one of them. A laser is essentially a cutting tool that can be used to cut soft tissue. As a spine application it can be used to perform a procedure called facet or dorsal rhizotomy which is a non surgical pain management procedure to treat back pain, but the laser has not been shown to perform that procedure any better than radio frequency or electrocautery.
Using a laser as a surgical tool to treat nerve pain related to disc herniations or spinal stenosis has not been proven safer or more effective than a scalpel or electrocautery and further does not make disc or spinal stenosis surgery anymore mimimally invasive. Let’s keep it simple, if the laser was a great tool that made spine surgery better, spine surgeons all over the country and that includes the local spine surgical community here in Huntsville would be using it.
To conclude, most spine surgery for leg or arm pain caused by a disc herniation or spinal stenosis can be performed with a small incision and as an outpatient procedure. In our community, spine surgeons perform these procedures and send people home the same day every day. Just remember that in most cases, is not the surgeon that makes the procedure large or small, it is the diagnosis that makes the procedure necessary to fix it large or small.
The most common spine problem that a patient will seek medical attention involves the lumbar disc. Diagnostic problems involving the lumbar disc are complex in presentation and therefore each patient’s symptoms are somewhat unique. Some patients have back pain and some have pain in one leg or perhaps in both legs. Numbness, weakness, back spasm, leg pain with no back pain, sudden onset or slow in developing, pain may be severe or subtle. Every patient is different and a good history is fundamental to figuring out the specific disc problem and how to treat it. Patients can be really confused and certainly anxious because disc problems can cause some serious pain and dysfunction. But rest assured, if you are having some of the symptoms listed above, an experienced Spine specialist can usually figure out the problem by just listening to you and examining you.
Doctor, “Is my disc ruptured or slipped”? “Do I have a herniated or a bulged disc”? “My Mom had sciatica, and got better with some emu oil”. Most patients have already received some free advice from a relative or friend before they seek a professional opinion. And that’s okay, heck I would too! So let’s talk about the subtleties of the lumbar disc.
As I said before, it is all about the history. Lumbar disc problems rarely are the result of trauma like a fall or a car wreck. Those types of injuries are more likely associated with a fracture if severe or perhaps a muscle strain if less severe. Most disc problems are the result of wear and tear and genetics. Most patients just kind of notice a little stiffness for a few days and then suddenly they wake up in severe pain looking for some help. The most distinguishing feature that your spine specialist will look for is leg pain known as radiculitis or radiculopathy and commonly known as sciatica. If that is the case then you are more likely to have a herniated or ruptured disc pinching a nerve rootlet in your back and causing the leg pain. Numbness, weakness difficulty standing and walking and even difficulty with your bowel and bladder can be present. In these instances, a more urgent approach may be recommended. X-rays and an MRI of your lumbar spine are important and surgery may be necessary if the symptoms are severe and associated with nerve dysfunction. Other options like an epidural injection, or physical therapy and oral medications may be the initial recommendation and can get often settle things down without surgery.
If the patient presents with symptoms limited to back pain without leg pain, then a simple back strain may be the cause and the treatment is more cautious. Often times the problem may not be a back problem at all. Diagnostic studies can be delayed to see if the symptoms will settle down over a week or two. If symptoms persist or worsen, then more aggressive options may be necessary. A degenerative disc or bulged disc that is not putting pressure on a nerve may be the diagnosis. Even these conditions can lead to surgery if they persist for many months and don’t improve with non surgical treatment.
Lumbar disc problems can truly be painful and getting some expert advice and just understanding the problem helps out tremendously. Your Spine Specialist will look for the simplest and least invasive way to get you better. Just remember it all starts with a good history and examination from an experienced professional.
So you want a robot to do your spine surgery? You can now sign up…well at least for robot assisted surgery! Huntsville Hospital has recently purchased the Mazor robot for spine surgery and it is ready for action. I am sorry to diappoint you or perhaps I am happy to reassure you that a robot is not going to roll into the operating room, scrub in and replace your humanoid spine surgeon at the OR table.
So exactly how does a robot help in spine surgery? Let’s describe the Mazor’s role as a very sophisticated assistant. Spine surgery involves two fundamental tasks: Decompression and Stabilization. Decompression involves the delicate process of relieving abnormal and painful pressure on compressed neural structures namely the spinal cord or spinal nerves. This abnormal pressure can be the result of a disc herniation or arthritic bone spurs that result in spinal stenosis. Even tumors, infection or trauma can cause painful pressure on neural structures. Pain, weakness or even paralysis can occur from compression on neural structures. Well the robot is not ready to replace the experienced hands of your spine surgeon to perform decompression techniques…at least not yet!
Stabilization involves strengthening weak areas in the spine. In addition to causing abnormal pressure on nerves, degenerative disc disease, fractures, tumors and infection can destabilize the spine. Stabilizing a weak area of the spinal column involves fusing the weak area to relieve pain and prevent further danger to the spinal cord and spinal nerves. Fusing a weak, degenerative or unstable segment of the spinal column can also allow the spine to support the body for ambulation.
Modern spinal fusion techniques utilize spinal instrumentation. Instrumenting two or more vertebrae together is accomplished by using screws and rods. Screws placed in the spine are typically placed in a narrow tubular structure called the pedicle. This is where the Mazor robot asssists the surgeon. Using preoperative imaging from a CT scan, the Mazor robot can map out the exact trajectory to safely place the pedicle screw in the best location even with a very small incision. In some cases this allows the surgeon to become more efficient and use smaller incisions to instrument the spine. Patients can mobilize quicker and sometimes go home from the hospital sooner.
I expect robotic techniques will continue to evolve and assist the spine surgeon in the operating room. But I assure you that a robot is no where close to replacing your spine surgeon. So if you need a spine surgery go with the advice of your surgeon. He or she may want to leave the robot in the hallway!
So you have severe back pain or severe leg pain or perhaps a combination of both. Very likely you have tried to get better with physical therapy and spinal injections. Perhaps you have had a previous back surgery to repair a disc herniation and the pain has returned. Your spine surgeon has recommended a spinal fusion. You have heard that some people have it done from the front, others from the back. You have researched spinal fusion on the internet and have seen that there are different approaches to do the surgery. So how does your surgeon decide the best approach for you? Let’s discuss.
Your spine surgeon may recommend a spinal fusion as a part of your surgical plan if you have certain conditions. Recurrent disc herniation, spondylolisthesis, scoliosis, and severe degenerative disc disease are common reasons to consider a fusion to correct your condition. In the modern fusion era, spinal fusion surgery offers different techniques that are designed to limit exposure and reduce recovery time. Most patients stand and walk the day of surgery. Some patients can even go home the same day and very few patients need more than a day or two in the hospital.
The most common spinal fusion is done posteriorly or through the back. This method seems logical. After all, the spine is in the back. Posterior approaches allow the surgeon to perform spinal nerve decompression for disc herniations and spinal stenosis. Typically pedicle screws are placed for a posterior lumbar fusion (PLF). An interbody fusion can also be done to allow fusion to occur in the disc space. Transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are well established techniques. The bottom line is a posterior approach is best if you need direct nerve decompression for conditions like severe spinal stenosis.
An anterior approach or ALIF allows for direct access to the disc space without having to displace the nerves. Usually the approach is assisted by a general surgeon or vascular surgeon to expose the front of the spine. Degenerative disc disease, especially at L5-S1 and L4-5, can be addressed through the anterior approach. Restoration of disc height and placement of large surface area implant devices are advantages of the anterior approach. As a general rule, anterior approaches are less painful and easier to recover from. Anterior approaches are a good option for single level degenerative disc disease or in cases where restoration of disc space height is necessary.
A newer technique known as extreme lateral lumbar interbody fusion or XLIF requires an incision on the flank. This technique offers similar advantages and has similar indications as an ALIF but can be an easier way to access the upper lumbar areas like L3-4 and above. Finally, in some cases an anterior and a posterior approach is recommended. In cases that require multi level fusion or in patients with more complex problems a combination anterior/posterior approach may be the best choice to address the problem.
An experienced spine surgeon will employ all these different techniques and provide a good opinion on what is the best choice for your case. Remember the goal is to fix the problem with the least invasive technique that allows the fastest recovery time. Animations of all these techiniques are on my website.