Common Surgeries Used to Treat Back Pain

When treating back pain, it is almost always in the best interest of the patient to begin with nonsurgical treatment and only use surgical treatments if there is no response to the nonsurgical methods.

The reason that nonsurgical treatment options should be explored first is because even though there are several common operations that can be preformed on the spine that are effective at treating some of the common back problems, all of them carry significant risks to the patient. This is true of almost any type of surgery, but because the spine is so important to our nerve and motor function, even a small complication could be incredibly serious.

There are actually a number of different operations that can be preformed to fix back pain, with most only used to treat specific conditions.

Some of the terminology used, such as a description of the different parts of the spine is explained here.

Types of Spine Surgery

Spinal Decompression Surgery

Spinal decompression surgery is preformed when it is necessary to relieve the pressure on the nerves or the spine. Often, the nerves, which travel into and out of the spine through small openings, will become pinched, leading to a great deal of back pain. Spinal decompression surgery attempts to fix this, by expanding or restoring these small openings.

In most cases, spinal decompression operations are only preformed as elective procedures, however in some cases they are preformed in an emergency. There are actually several types of decompression surgeries used, which differ depending on the specific back problem.

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Laminectomy and Spinal Canal Decompression to Treat Spinal Stenosis

During this type of operation, the surgeon will first take x-rays and use other imaging technologies, such as MRIs and Cat Scans, to determine the exact extent of the problem and how many vertebrae need to be decompressed.

Once a the doctor has a clear picture of the problem, they will make an incision along the back and move the back muscles aside, which will expose the spine. Then, the part of the spine that is causing the pinched nerves is removed. Often this could be a bone spur or a ligament, as well as disc matter. Usually, the patient must remain at the hospital for several days.

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Removal of Disc Fragments and Lumbar Hemilaminotomy

During this type of operation, an incision is made in the lower back, exposing the ligaments and laminae. By removing a small amount of bone and opening the ligamentum flavum(yellow ligament), the doctor is able to move the pinched nerve and the part of the disc that is herniated. The entire disc is not removed, however, and only the portion that is herniated.

When the doctor preforms this type of operation with a microscope, it is called a microdiscetomy. Usually, both types of operations require at most one day of hospitalization.

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Anterior Discectomy for Thoracic Disc Herniation

The most common type of disc rupture is the lumbar disc rupture, but sometimes one of the thoracic disc is ruptured. This creates a problem for the surgeon, as it is not possible to move the spine aside to reach the thoracic discs. Instead, the surgeon goes in through the chest, which is an anterior approach.

When an anterior approach is used, it requires that a piece of the rib is removed. Depending on which disc is affected, it is also sometimes possible to preform the surgery using a thorascope. The thorascope allows the surgeon to insert a a very small camera and surgical tools through the chest.

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Lumbar Disc Herniation and Endoscopic Decompression

Endoscopic Decompression uses a narrow tube and very small camera to allow the doctor to remove a portion of the disc that is causing the problem. Unfortunately, the doctor has a very limited field of vision, which often means that not enough of the herniated disc is removed. Typically, endoscopic decompression is preformed as an outpatient surgery.

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Spinal Fusion Surgeries

Fusion surgeries are used to address a variety of conditions, such as fractures, acute back pain, deformities, and instability. The goal of a fusion operation is to fuse(weld) together one or more portions of the spine, specifically the portions of the spine that are responsible for motion.

Typically, fusion surgeries are classified by whether the operation is preformed from the back, posterior, or from the chest, anterior. In some cases, both types of fusion surgery will be preformed at the same time, depending on the location of the problem.

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Bone Grafts and Anterior Lumbar Interbody Fusion

During this type of surgery, the doctor will make an incision in the abdomen, usually in the lower left hand portion. The number of fusions that are being preformed determines how long the incision is. The physician then removes a significant portion of the disc, usually between 90% and 95%. After removing the disc, the area is filled back in with a bone graft.

There are two types of bone grafts used, either bone chips or solid pieces of bone, depending on the overall goal of the surgery. It is also possible for the patient to use their own bone, which is called an autograft or someone else's bone, which is called a allograft.

Usually, an Anterior Lumbar Interbody Fusion is preformed at the same time as a posterior fusion, although this depends on the individual situation.

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Anterior Lumbar Interbody Fusions Using a Stand-Alone Cage

Starting in the 1990's, physicians began preforming an anterior lumbar interbody fusion and instead of using a bone graft, they screwed in a stand-alone cage. A stand-alone cage is basically a cylinder shaped object, filled with bone grafts.

These types of surgeries quickly became popular and are still preformed today. However, due to a high rate of failure, they are becoming much less common. Usually, a hospital stay of around three days is required.

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Anterior Thoracic or Lumbar Fusion Using Strut Grafts or Cylindrical Cages

This type of operation is not very common and is only used to treat very serious conditions, such as a fracture, spinal infection, or tumor. The surgeon will first decompress the spine and then use a strut bone graph or a metallic cylinder filled with pieces of bone in its place. In many cases, the surgeon will also provide supports anteriorly.

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Lumbar Posterolateral Fusion

During this type of operation, the doctor will first expose the spine, using a mid-line incision. Then, any small bits of bone, muscle, and soft tissue is removed. The exposed bone surfaces are then ruffed up and a bone graft is added. In most cases, the graft is from the patient, a autograft, commonly taken from the pelvis. The hospital stay for this type of operation is usually between 4 and 5 days.

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Lumbar Posterolateral Fusion using Instrumentation

This type of operation is similar to a posterolateral fusion, except in addition to adding a bone graft, small screws and rods are also used, holding the pedicles together. By using the screws and rods, the healing time is usually reduced and there is a much greater level of stability. Sometimes, translaminar screw fixation is used, but this is not as common, as it is less effective.

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Posterior Lumbar Interbody Fusion

During a Posterior Lumbar Interbody Fusion(PLIF,) a laminectomy is preformed, allowing the doctor to move the nerves aside. Then, the majority of the disc is removed, including the annulus. A bone graft is inserted into the space left by the disc and it is common to use posterior fixation, to hold the graft in place.

Due to the risks associated with this type of operation, it is not very common and usually only preformed in very serious situations. One of the most common complications is nerve scarring. Usually a hospital stay of at least four days is required.

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Transforaminal Lumbar Interbody Fusion

A Transforaminal Lumbar Interbody Fusion, or TLIF, is a relatively new procedure, which removes the disc and inserts the graft posteriorly. Since the incision is made in the back, it is possible to avoid many of the nerves and bleeding problems associated with the Posterior Lumbar Interbody Fusion. This is in large part, because unlike the PLIF, it is not necessary to preform a laminectomy.

Small screws are used to hold the bones together and a graft is then added. The hospital stay is often a little less with a TLIF, usually less than four days.

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Spinal Deformities and Posterior Instrumentation and Fusion

Scoliosis is a back problem, which causes the spine to curve and twist. To fix this type of spinal deformity, doctors have been preforming Posterior Instrumentation and Fusion for close to fifty years. After making a posterior incicsion towards the middle of the back, the nerves are moved out of the way and if there are any tight ligaments, they are relased. The physcian then uses a combination of screws, rods, wire, and hooks to help correct the deformity. After the screws and hooks are in place, bone grafts are used to fill in any space.

The hospital stay required for this type of operation is a little longer, usually between five and seven days, but today, the surgery rarely requires the patient to wear a back brace afterward.

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Anterior and Posterior Interbody Fusion with Instrumentation

During this type of operation, bone grafts are added anteriorly and small screws are used posteriorly. This is one of the more common types of surgeries and usually requires about five to seven days of recovery at the hospital.

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Posterior Fusion using Mass Osteotomy and Refusion

An osteotomy is where the doctor cuts a bone that has healed crookedly and puts it back together in a manner that attempts to mimic the natural alignment of the bone. When preformed on a leg bone or arm bone, osteotomy is not a very complicated procedure, but whenever you are dealing with the spine, you must also take into account the nerves, so a spinal osteotomy is significantly more complicated.

Often, spinal osteotomies are preformed after a patient has already had a fusion, often to address a deformity or acute back pain. The surgeon will reopen the old inscion and remove part of the fusion and secure the spine back together using some sort of metal instrumentation.

These types of surgeries are very risky and often require a significantly longer hospital stay.

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Pedicle Subtraction Osteotomy and Refusion

This type of osteotomy is also usually preformed on patients who have already had a previous back surgery, usually to treat some type of spondylitis. The doctor will remove a significant portion of the previous fusion, as well as a pair of pedicles, removing a wedge of bone by the dural sac. The space is filled back in using metal instrumentation, in an effort to improve alignment.

This is an incredibly complicated operation and very risky, but usually only requires between a 5 and 7 day hospitalization.

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Fusion Using Bone Morphogenetic Protein

Bone morphogenetic protein(BMP) is a substance that occurs naturally in the body, but can also be created artificially. It is still being tested and has not been fully approved by the FDA, but it looks very promising. This is because the protein actually helps facilitate spinal fusion.

Since using BMP is so new, the operation is very expensive and is often not covered by insurance. However, it is an incredibly promising technology.

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