Indications for surgery:
Spinal instability – traumatic, malignant or degenerative
Spondylolisthesis causing back or radicular leg pain
Recurrent disc prolapse
Lateral foraminal stenosis with disc degeneration
Evidence for surgery:
Multiple studies including poor quality randomised controlled trials support the use of decompression and fusion to treat stenosis and spondylolisthesis. It is clear that significant instability must be treated with some form of spinal stabilization. The treatment of recurrent disc prolapse and radicular pain associated with degenerative stenosis is considered to be an option with insufficient evidence to support a treatment guideline.
Benefits of surgery:
Improvement in back and leg pain associated with instability and compression.
Recurrent disc prolapse should be negated by complete discectomy and stabilisation.
Brief description of surgery:
X rays are used to place needles, and then over the needles, screws into the vertebral bodies via the pedicles. A small tube retractor is then passed through the muscle so that using a microscope the facet joint may be removed and the nerve freed so no pressure remains on the nerve. The disc is then removed and a cage placed in the disc space. Rods are connected to the screws, which are then fixed in place. Bone from the decompression is used in the disc space to promote fusion.
Risks of surgery:
Death, paraplegia, significant weakness, numbness or bladder and bowel dysfunction <1% risk
Worsened back or leg pain ~ 5% risk; Infection 2-5%; Screw or cage misplacement requiring revision surgery 2-5%; Injury to nerve causing localised weakness / numbness / increased pain 2-5%; failure of fusion or hardware ~5%, bleeding and blood transfusion 5-10%, medical and anaesthetic risks.
You will be transferred back to the ward where you will be closely looked after. You may have a special ‘push button’ pain relief system called a PCA. Depending on your comfort levels the ward nurses and physiotherapists may help you get up on the day of surgery or the first day after the operation. Over the following few days you will increase your activities with the physiotherapists until you are comfortable and safe to return to home. Some patients may require rehabilitation following the procedure.
After a few days pain is typically well controlled with paracetamol and with occasional morphine based tablets.
Mobility restrictions are designed to limit discomfort and promote spinal fusion. Smoking should be avoided as this reduces the chances of spinal fusion. Activities will be restricted and focus should be made on walking and increasing walking distances. You should not lift anything heavier than a full kettle of water.
Driving should be avoided for the first 4 weeks post op. After this period driving should only be undertaken if there is no weakness and good range of movement without discomfort to allow the driver to easily be in full control in an emergency situation. If this is not the case the patient is legally bound to avoid driving.
Return to work is variable between different types of jobs and dependent upon your quality of function. We will discuss return to work at your 6 week follow up appointment.
Multiple types of spinal fusion can be performed. I will discuss the most appropriate type of fusion with you prior to the surgery. The different options include: