Spine Surgery in New York

SPINE SURGERY
A Patient’s Guide
-An illustrated guide to spine
diseases and treatments

By
Carl J. Spivak, MD

Illustrated By Ginger
Weatherford

Library of Congress Control Number:

ISBN

First printing : 1,000 copies : January 2007

Published by Carl Spivak

Copyright © 2007
Carl J. Spivak
All Rights Reserved.

All rights reserved. No part of this book may be reproduced in any form,
except for the inclusion of brief quotations in a review, without permission
in writing from the author or publisher..

Important Note: Medical knowledge is ever-changing. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy may be required. The author of
the material herein have consulted sources believed to be reliable in their efforts to provide
information that is complete and in accord with the standards accepted at the time of publica-
tion. However, in the view of the possibility of human error by the author, of the work herein, or
changes in medical knowledge, the author, or any other party that has been involved in the
preparation of this work, warrants that the information contained herein is in every respect accu-
rate or complete, and they are not responsible for any errors or omissions or for the results ob-
tained from use of such information. Readers are encouraged to confirmed herein with other
sources. For example, readers are advised to check the product information sheet included in the
package of each drug they plan to administer or use to be certain that the information contained
in this publication is accurate and that changes have not been made in the recommended dose or
in the contraindications for administration. Some of the product names, patents and registered
designs referred to in this book are in fact registered trademarks or proprietary names even
though specific reference to this fact is not always made in the text. Therefore, the appearance
of a name without designation as proprietary is not to be construed as a representation by the
author that it is in the public domain.

Dedication

This book is dedicated to my wife Bridgette and three children
Chanelle, Luke and Nicholas, who are a constant source of
blessing, inspiration, encouragement and joy to my life.

TABLE OF CONTENTS

INTRODUCTION

1.Preface……………………………………………….i.

2.Introduction…………………………………………..ii

NECK DISEASE

3.Cervical disk herniation. (slipped disk neck)..………1

4.Cervical spine stenosis (tightness)……..…………….14

MIIDLE BACK DISEASE

5.Spinal compression fractures (broken back bone)……28

LOW BACK DISEASE

6. Lumbar disk herniation (slipped disk) ……………….40

7. Lumbar spinal stenosis (tightness)…………………....52

8..Lumbar spondylolithesis (slipped spine)……..……….64

9. Glossary……………………………………………….79

PREFACE
Today there is an enormous amount of medical information
available in textbooks, medical journals and on the internet.
This information ranges from simple to very complex. Most
information is written for medical specialists and may be
wordy, full of medical jargon, difficult to understand and ex-
pensive to obtain. These obstacles are difficult for patients to
overcome when trying to understand their disease and treatment
options. This book was written to help fill that gap.
This book contains valuable medical information, diagrams,
X-rays, CT and MRI images to help understand neck and back
problems. It is comprehensive, yet easy to understand. It re-
views anatomy (the structure of the spine), pathology (spine
disease), treatments and outcomes of treatments.
This book is best used to educate yourself about a medical
disease. It will give you greater breadth of understanding of the
problem and will help you make an informed decision. The
more information you have the better decision you will make!

i

INTRODUCTION

Neck and back problems are very common medical problems
in North American society. Most people will be troubled by
neck and back pain during their lifetime. The pain may range
from mild to severe. Many times this pain may resolve with
rest, activity modification or anti-inflammatory medications and
the passage of time.
Neck and back problems may become more severe and be
associated with dysfunction of the nervous system. This nerv-
ous system dysfunction may present itself with pain, numbness,
tingling or weakness of the arms or legs. It may also present
with problems controlling bowel and bladder function with in-
continence or severe constipation.
In the following chapters I provide detailed, but easy to un-
derstand information about spine disease. Each chapter de-
scribes the relevant spinal anatomy, disease process, clinical
and radiological investigations, treatments, outcomes and com-
plications. I have also included many drawings, X-Rays, CT
and MRI scans to help increase your understanding of this
complex subject.
I hope you find this book interesting and useful to you.

ii

Chapter 1: Cervical Disk Herniation and
Anterior Cervical Diskectomy, Fusion
and Plating

What is the spine?
The neck is made up of seven bones called cervical vertebrae
(figure 1). These vertebrae surround and protect the spinal cord
from damage. The front of the vertebrae is made up of a square
shaped vertebral body and the back of the vertebrae is made up
of pedicles, facet joints, lateral mass and lamina, called the pos-
terior elements. The vertebrae are held together by a spongy
disk in the front and strong ligaments in the front and back. The
disk helps cushion the neck bones.

C3
Disk
C4
Vertebrae
C5
Nerve
Disk Root
C6
Spinal
Spinal
Cord
Cord C7

A. B.

Figure 1. Normal cervical spine. A) Side view of cervical ver-
tebrae C3-C7. B) Top view of a vertebrae on the right.

1

Chapter 1: Cervical Disk Herniation

What is a cervical disk?
Cervical disks are located in between the spinal vertebrae and
are made up of a tough outer shell (annulus fibrosis) and a soft
gel-like center (nucleus pulposus). Their structure is similar to
a jelly donut.

Why do cervical disks pinch the spinal
cord and nerves?
As people age the spine slowly wears out through a process
called degeneration. Degeneration is first seen in the nucleus
pulposus (“jelly center”) and annulus fibrosis (“donut”) in
adults. The annulus may weaken and bulge outward or tear, al-
lowing the nucleus pulposus to squeeze (herniate) out of the
annulus into the spinal canal (figure 2)1.
This disease is referred to by many names including slipped
disk, bulging disk, ruptured disk, pinched nerve, herniated nu-
cleus pulposus and disk herniation.
The herniated disk may compress or “pinch off” the spinal
nerves resulting in neck and arm pain, numbness, tingling and
weakness. This pain may be worsened or maintained by inflam-
mation around the nerve roots2,3. Compression of the spinal
cord may cause myelopathy (spinal cord injury) producing elec-
trical shocks down the spine, weakness, numbness and bladder
incontinence.
Possible risk factors for ruptured disks are hereditary, smok-
ing, heavy work, injury to head or neck, heavy lifting or opera-
tion of vehicles4,5,6. Sometimes the process begins after a
memorable accident.

2

Spinal cord
swelling

A. B.

Figure 2. Herniated cervical disk compressing the spinal cord
with evidence of spinal cord compression and swelling. A) Side
view of the herniated disk highlighted in black. B) top view of
the herniated disk (large black arrow) compressing the spinal
cord.

How do I know I have a ruptured disk?
The ruptured disk usually begins with neck and shoulder pain
followed later with the development of arm pain1. This arm
pain may be associated with numbness (loss of feeling in the
arm or hand), tingling, burning and weakness. The neck and
arm pain may be worsened by neck movements and relieved by
placing their hand on their head. Rarely, a herniated disk may
cause electrical shocks running down the back or clumsiness,
weakness or paralysis in the arms or legs or loss of bowel and-
bladder control. These changes may come on quickly or gradu-
ally over time, with slow transition to using cane, walker and
finally wheelchair. If any of these symptoms occur the patient
should seek emergency medical care.

3


What should I do?
If you are experiencing neck pain associated with pain,
numbness or weakness in your arm, unsteadiness on your feet
or have bowel and bladder difficulties you should see your doc-
tor. You will require a history and physical examination, which
may include an examination of you neck, gait, strength, sensa-
tions and reflexes.
After an initial assessment, you may require radiological in-
vestigations, including x-rays and magnetic resonance imaging
(MRI) of the spine. MRI is the best test for looking for herni-

Spinal
cord

Herniated
disk
Herni-
ated disk

Spinal
cord
A. B.

Figure 3. MRI (T2WI) of the neck showing a C4/5 herniated
disk compressing the spinal cord and exiting nerve root. A) The
side view. The white fluid (cerebral spinal fluid) at the level of
the disk. B) top view of the herniated disk.

4

Patients with pacemakers, spinal cord stimulators or other
metal within their body are unable to have an MRI. These pa-
tients should undergo a computer tomogram (CT) with or with-
out a myelogram. The CT myelogram produces better images
then the CT alone. A myelogram is the injection of contrast
medium (dye) into spinal canal to improve the visibility of the
nerves on the CT (figure 4).

Disk herniation

Contrast
(Dye)

Spinal cord

Figure 4. CT myelogram of the neck showing a herniated disk
(arrows) top view on the right. Compliments Dr. A. Eisenberg.

Should I have surgery?
Many patients with neck and arm pain secondary to a rup-
tured disk may improve with non-operative treatments includ-
ing bed rest, physical therapy, head traction, neck collar, non
steroidal anti-inflammatory drugs (NSAIDS), steroids (Medrol
dose pack), muscle relaxants, antidepressants and steroid injec-
tions7,8.

5


Patients should consider surgery if they fail to improve with
conservative therapy, have severe pain or significant neurologi-
cal dysfunction (table 1). Additionally, patients with significant
spinal cord compression and swelling on MRI scan may require
surgery.

Table 1 Indications for Surgery
1. Failure of conservative treatment
2. Severe pain
3. Weakness
4. Loss of bowel & bladder control
5. Compression and swelling of spinal cord

What are the surgical treatment op-
tions?
Neck and arm pain are a result of the herniated disk com-
pressing the spinal nerve. To relieve the pain surgery must re-
move the herniated disk and take pressure off the nerve. The
removal of disk is called a discectomy. Today most cervical
herniated disks are removed through the front of the neck by an
operation called an anterior cervical discectomy, fusion and
plating (ACDFP). Cervical herniated disks are less commonly
removed through the back of the neck by a posterior lami-
notomy (parial removal of the lamina which is part of the back
of the spine) and diskectomy.

6

How is a discectomy done?
The patient is given antibiotics prior to surgery. They are
then taken to the operating room and are put to sleep under a
general anesthetic. A tube is placed down their throat to help
them breath. They lie down on their back looking up at the ceil-
ing. Their neck is washed and sterile drapes are placed around
the operative site.
An incision is made just off midline, usually on the right side.
The skin is separated, the esophagus (food “pipe”), larynx and
trachea (voice box and breathing “tube”) and carotid artery
(supplies the brain with blood) are retracted to the side. This
opens up a tunnel to the front of the spine. The level of the her-
niated disk is found with the x-ray machine.
The operating room microscope is used to magnify and light
the disk space (figure 5). The disk is incised with a knife and
removed with a variety of biting and scraping instruments. Af-
ter the disk is removed, the posterior longitudinal ligament is
opened up. This ligament separates the disk from the spinal
canal. Removal of this ligament provides direct visualization of
the thecal sac (with contains the spinal cord), the exiting nerve
roots and herniated disk. The disk is then carefully removed re-
lieving pressure off of the spinal cord and/or nerve roots.
After the disk is removed, the ends of the vertebrae are clean
and prepared for the bone fusion. A bone fusion is when two
bone heal solidly together. A graft is placed into the empty disk
space (figure 5). The graft holds the vertebrae apart and the ver-
tebrae eventually fuse together through the graft. This de-
creases movement across the abnormal vertebrae and helps re-
duce pain. This graft may be made from the patient’s bone
(autograft) and is usually taken from the hip, or may be taken
from the bone bank (allograft). Recently cages made out of
plastic (polyetheretherkeytone, PEEK), metal (titanium) and

7


A. B.

C. D.

Figure 5. Anterior cervical diskectomy, fusion and plate sur-
gery (ACDF). A&B) The disk is removed through the front of
the spine relieving pressure off the spinal cord. C) After the disk
is removed, the vertebrae are prepared for the fusion and the
bone graft is inserted. D) The bone graft is held into position by
the metal plate and screws.

8

carbon fiber have become available. These cages are presently
filled with autograft or allograft but bone morphogenic protein
(BMP) , a bone hormone which promotes bone growth in the
body, will soon be available.
After the graft or cage has been placed into the disk space, the
spine is stabilized with a metal plate and screws (figure 5&6).
The size of the plate and screws depends on the number of disks
removed and the size of the patient’s vertebrae. The metal plate
is made of titanium which produces minimal interference on
MRI. The titanium plate does not trigger airport metal detectors.
Plastic plated may soon be available. After the plate is secured,
bleeding is stopped and the muscle and skin are brought to-
gether with sutures. Sometimes a drain may be temporary
placed to remove blood over night. Patients are woke up and

A. B.

Figure 6. An x-ray of the cervical spine with plate and screws
placed after an anterior cervical discectomy and fusion of C5/6
disk in (A) and C4-5-6-7 in (B). Cervical plates are labeled by
white arrows.

9


Does surgery work?
Surgery is very effective for treatment of neck and arm
pain9,10,11. Approximately 75-90% of patients will have good
pain relief after surgery. The resolution of numbness, weak-
ness and bowel and bladder function is less consistent. After
surgery there is a 3% chance of developing another disk herni-
ation per year12. There is a low risk of complications (2%)11 but
complications may potentially include: death, stroke, heart at-
tack, weakness/paralysis, loss of bowel and bladder function,
infection, clots in legs (deep venous thrombosis), clots in the
lungs (pulmonary embolus), blood vessel injury, failure of fu-
sion, breakage of screws and plates, movement of cage/graft,
difficulty swallowing, hoarse voice, but not limited to these
complications. Neck pain, numbness and difficulty swallowing
or speaking are the most common complaints after surgery and
they usually resolve.

When can I go home?
Most people are discharged home after surgery. Some patients
are kept over night. Dissolvable stitches are used to close the
wound and do not require removal. Sometimes non-dissolvable
stitches or staples are used and must be removed. Please ask
your doctor prior to discharge.

What if I have neck pain or arm pain af-
ter surgery?
It is normal to have neck pain and soreness from the operation
for few weeks. It is also normal to have pain, numbness and
tingling that comes and goes after surgery. You should contact
your doctor right away if you develop difficulty breathing, neck

10

What are my limitations after surgery?
Please remove the dressing over your incision the day after
surgery and wash your incision in the shower. You may use
soap and water. Do not rub your incision. Please do not sub-
merge your incision in the bath tub for 2 weeks after surgery.
Soaking in dirty bath water may increase your risk of infection.
Get plenty of rest after surgery. Avoid driving, bending, ex-
tending and twisting of your neck. Most people can return to
work 3 to 12 weeks after surgery. Please discuss your specific
limitations with your doctor.

Should I use a bone stimulator?
Bone stimulators have been found to improve bone healing
rates by stimulation of bone cells by electrical fields. They are
especially useful in patients who are at high risk of malunion
(the bones not healing together). Patients who should consider a
bone stimulator include multi-level fusion surgery, revision sur-
gery for failed bone fusion, smokers and patients with osteopo-
rosis, diabetes and metabolic bone disease. If the fusion does
not heal this may result in multiple neurological and medial
problems and may require further surgery. The Orthofix, Inc.
bone stimulator has been found to improve fusion rates by 15%,
from 69% to 84% in high risk patients13.

11


Discharge Instructions

1. Strict control of sugar levels in patients with diabetes. Poorly
controlled sugar levels may increase risk of infection.
2. Do not smoke or use non-steroidal anti-inflammatory drugs.
They may interfere with bone fusion.
3. Keep wound clean and dry. Please shower the day after sur-
gery. Do not submerge your wound in the bath for 2 weeks.
4. Use neck collar or bone stimulator as directed by your doc-
tor.
5. No driving, twisting, bending neck for up to 1 month after
surgery.
6. Watch for the development neck swelling, difficult breath-
ing, problems swallowing, change in your voice, fever, red-
ness or drainage from the wound.
7. Pain, numbness and weakness often require days to months
to resolve.
8. Call your doctor if you have any concerns.

12

References
1. Connell Md, Wiesel SW. Natural history and pathogenesis of cervical
disk disease. Orthop Clin North Am. 1992 Aug;13(4):345-9.
2. Omarker K, Meyers RR. Pathogenesis of sciatic pain: role of herniated
nucleus pulposus and deformation of spinal nerve root and dorsal root
ganglion. Pain 1998 Nov; 78(2):99-105.
3. Hou SX, Tang JG, Chen HS, Chen J. Chronic inflammation and com-
pression of the dorsal root contributing to sciatica induced by the in-
tervertebral disc herniation in rats. Pain 2003 Sep;105(1-2):255-64.
4. Sambrook PN, MacGregor AJ, Spector TD. Genetic influences on cervi-
cal and lumber disk degeneration: a magnetic resonance study in twins.
Arthritis Rheum. 1999; 42(2):366-72.
5. Irvine DH, Foster JB, Newel DJ, et al. Prevalence of cervical spondylo-
sis in a general practice. Lancet 1965; 1: 1089-1092.
6. Kelsey JL, Githens PB, Walter SD et al. An epidemiological study of
acute prolapsed cervical intervertebral disc. J Bone Joint Surg AM. 1984
Jul; 66(6):907-14.
7. Tan JC, Nordin M: Role of physical therapy in the treatment of cervical
disk disease. Orthop Clin N AM 23:435-449, 1992.
8. Rexhtine GR: Nonsurgical treatment of cervical degenerative disease.
Inst Course Lect. 1999; 48:433-5.
9. Whitecloud TS, Werner J. Cervical spondylosis and disk herniation: The
anterior approach. In Frymoyer J, (ed): The Adult Spine: Principles and
Practice, 2nd ed. Philadelphia, Lippincott-Raven, 1997, pp 1357-1379.
10. Sampath P, Bendebba M, Davis JD, Ducker T: Outcome in patients with
cervical radiculopathy: Prospective, multicenter study with independent
clinical review. Spine 24:591-597, 1999.
11. Bruneau M, Nisolle JF, Gillard C, Gustin T. Anterior cervical interbody
fusion with hyroxyapatite graft and plate system. Neurosurg Focus 10
(4): Article 8, 2001.
12. Hillibrand AS, Carlson GD, Palumbo MA, et al: Radiculopathy and
myelopathy at segments adjacent to the site of a previous anterior cervi-
cal arthrodesis. J Bone Joint Surg Am 81:519-528, 1999.
13. Orthofix, Inc. PMA Randomized, Prospective Clinical Trial of Pulsed
Electromagnetic Field Stimulation for Cervical Fusion, 2004
(unpublished).

13

Chapter 2: Cervical Stenosis

Chapter 2: Cervical Stenosis, Myelopa-
thy and Cervical Laminectomy, Instru-
mentation and Fusion

What is the spine?
The spine is made up of many bones called vertebrae. The
cervical spine or neck is made up of seven vertebrae (figure 1).
These vertebrae surround and protect the spinal cord from
damage. The front of the vertebrae is made up of a square
shaped vertebral body and the back of the vertebrae forms a
protective shield made up of pedicles, lamina and facet joints,
called the posterior elements. The vertebrae are held together
by a spongy disk in the front and strong ligaments in the front
and back. The disk helps cushion the neck.

C3
Disk

C4
Verte-
brae

C5
Disk Nerve
Root
C6

Spinal
Spinal Cord
Cord C7 B.
A
.
Figure 1. Normal cervical spine. A) Side view of cervical
vertebrae C3-C7. B) Top view of a vertebrae on the right.

14

What is cervical stenosis?
The spine contains a central cavity called the spinal canal.
The spinal cord and spinal nerves are found inside this canal.
Normally the spinal canal is wide open and does not impinge
upon the cord. Degenerative (“wear and tear arthritis”) may
cause narrowing or tightening of the canal. This small canal is
called cervical stenosis. This often affects people who were al-
ready born with a small canal (congenital spinal stenosis).

How does cervical stenosis form?
As people age, the neck begins to “wear out”. This begins
with the drying out and collapse of the cervical disks1,2. This
collapsed disk changes the forces across the spine and results in
abnormal motion. To stop this motion the body strengthens the
neck by thickening the spinal ligaments and stabilizing the mo-
bile joints with bone spurs. This is especially seen behind the
vertebral bodies, around the facet joints located at the side of
the spine and in the ligamentum flavum at the back of the spinal
canal. These changes lead to decrease in the size of the spinal
canal and may result in spinal cord compression (figure 2).
Spinal stenosis may result in spinal cord injury and dysfunc-
tion. This may be due to compression from the thickened liga-
ments and bone spurs, abnormal spinal motion or from interrup-
tion of the blood supply1,3,4. Spinal cord dysfunction
(myelopathy) commonly presents in middle-age or elderly peo-
ple with clumsy hands and difficulty walking.

15


Bone spurs

Thickened
ligaments

Thickened
ligaments
Bone spur &
disk bulge

A. B.

Figure 2. Cervical stenosis is caused by bone spurs and thick-
ened ligmaments. It may cause nerve root and spinal cord com-
pression. A) Side view and B) top view.

Do I have spinal cord dysfunction?
Spinal cord dysfunction secondary to spinal stenosis in the
neck is called cervical spondylotic myelopathy. This is the
most common cause of spinal cord dysfunction in people over
55 years old in North America5. Spinal cord dysfunction usually
begins in middle-age to elderly people. It usually progresses
slowly over many years, but may have a rapid progression with
disabling neurological dysfunction..
Spinal cord compression (cervical myelopathy) may be diffi-
cult to diagnose because of the variable symptomatology. It
may range from mild dysfunction with numbness in the hands
to complete paralysis of the arms and legs. The symptoms de-
pend upon the level of spinal cord affected, the location in the
spinal cord and involvement of spinal nerves. The spinal cord
begins at the brain and runs down to the middle of the back to

16

approximately the first lumbar vertebrae (L1). Each part of the
spinal cord has specific functions. Injury to the spinal cord af-
fects the function of the spinal cord below it. Injury to the spinal
cord in the neck may cause weakness or paralysis of the arms
and legs. While injury in the upper back only affects the legs.
Similarly to the vertical arrangement of function, there is also
right to left and front to back arrangement of function. Injury to
the right side of the spinal cord may cause weakness on the
right side of the body and numbness of the left side of the body
(called the Brown Secord Syndrome). Lastly, the involvement
of spinal nerves cause characteristic syndromes of pain, numb-
ness and weakness and are clinically distinct from spinal cord
compression6.
Cervical spinal cord compression most commonly presents
with poor hand coordination and a stiff, unsteady gait. Patients
may or may not have neck pain. The spinal cord compression
may increase with head movements (particularly bending the
head forward) resulting in electrical sensations shooting down
the back (Lhermite’s sign) or weakness or paralysis of an ex-
tremity. The patient may notice numbness, tingling, weakness
in their arms and occasionally pain. It maybe difficult to per-
form activities of daily living like buttoning a shirts latching a
bra or using fork and knife or chopsticks6. Walking may be-
come difficult secondary to weakness, numbness or stiffness in
the legs. At times people may decline in a step wise course
from walking independently to using a cane, walker and finally
require a wheelchair. Bowel and bladder function are less often
affected. Bladder urgency is the most common presentation of
bladder dysfunction. Patients who experience bladder urgency
develop a sudden need to empty their bladder. If they can not
immediately void they may wet their pants.

17


What should I do?
If you are experiencing neck or arm pain, numbness, weak-
ness or bowel and bladder dysfunction you should see your doc-
tor. You will require a thorough history and physical examina-
tion, which may include examination of your neck, gait,
strength, sensations and reflexes.
(MRI) of the cervical spine. MRI is the best test for looking for
spinal cord compression (figure 3).
tients

A. B.

Figure 3. MRI scan of the neck demonstrating severe cervical
stenosis (tightness), spinal cord compression and spinal cord
swelling (arrow). Spinal cord swelling is white on T2WI MRI.
A) Side view and B) top view.

18

should undergo a computer tomogram (CT) with or without a
myelogram. The CT myelogram produces better images then
the CT alone. A myelogram is the injection of contrast medium
(dye) into spinal canal to improve the visibility of the nerves on
the CT (figure 4).

Kyphoisis &
slipping of
spine

Spinal stenosis
Small spinal
canal
A B.

Figure 4. CT of the neck showing severe spinal stenosis, abnor-
mal bending (kyphosis) and slipping of the C4 on C5 vertebral
bodies. A) Side view and B) top view.

Should I have surgery?
Most patients with spinal cord dysfunction should consider
surgery, especially if it is new or progressively worsening. A
small amount of people may improve without surgery7,8. This
is presently an area of research. Other indications for surgery
may include pain or severe spinal stenosis with evidence of spi-
nal cord injury on MRI.

19


tions?
Surgery for spinal stenosis may be done through the front of
the neck (anterior) or the back of the neck (posterior) or a com-
bination of both (anterior-posterior or 360 degree operation).
There are many factors considered when deciding if surgery is
the best treatment and what type of surgery would best treat the
patient. These include the location of the disease in the spine
(front, back or both), the stability of the spine (the ability of the
spine to keep the spine aligned and prevent abnormal move-
ments) and the extent of spinal disease. The patient’s age,
medical health and neurological disability are also taken into
consideration.
Anterior surgery is done through an incision in the front of
the neck. It usually involves removal of one or more cervical
disks to take pressure off of the spinal cord or nerves.
After the disk is removed the disk space is filled with a bone
graft. The spine is then held together with a plate and screws as
described in chapter 1. More extensive spinal cord compres-
sion may require the removal of the spinal vertebra in addition
to disks (figure 5). This removes bony pressure from the verte-
bral bodies. This area is then reconstructed with a plastic or
metal cage filled with bone graft and is stabilized with a plate
and screws.
Posterior decompressive surgery is done through the back of
the neck. There are many ways to remove pressure from the
back of the neck. The treatment options include laminoplasty,
laminectomy and laminectomy and lateral mass instrumenta-
tion.
Laminoplasty is more commonly done in children then adults.
The lamina at the back of the spine is removed in one large

20

piece, the spinal cord is decompressed and the lamina is re-
placed with small metal plates and screws.
Laminectomy is the removal of the lamina to take pressure
off of the nervous structures. This is usually done in adults and
is similar to a laminoplasty except the lamina are not replaced.
This is similar to a lumbar laminectomy discussed in chapter 5.
Laminectomy and lateral mass screw-rod instrumentation is
needed in patients with posterior spinal cord compression and
instability of the spine. This procedure combines decompres-
sion with stabilization similar to lumbar spondylolithesis in
chapter 6. The lamina are first removed to decompress the spi-
nal cord and then small screws and rods are inserted into the
lateral mass (the part of the spine beside the lamina which
makes up part of the facet joints) of the spine to hold it to-
gether. Bone graft is also laid onto the lateral mass to promote
long term stabilization through bone fusion. Front and back
(anterior and posterior surgery) is sometimes needed for severe
spinal cord compression or instability. Since similar topics are
covered in other areas of the book, I will discuss the surgery for
laminectomy and lateral mass instrumentation in detail in this
chapter.

How is a laminectomy and lateral mass
instrumentation done?
them breath. The patient’s head is secured by a clamp. The
patient is positioned face down on the operating table. Her

21


Cage

A. B.
Figure 5. Before (A) and after (B) CT scan of a patient with se-
vere cervical stenosis and angulation treated with removal of
cervical vertebral body compression, correction of abnormal
angle and placement of plastic cage filled with bone graft and
stabilization with plate and screws.
head and clamp are secured to the table. The back of her neck is
shaved, washed and draped around the operative site.
An x-ray machine is used to find the level of the spinal steno-
sis. After the correct levels are found, a midline incision is
made. The skin and muscle are retracted from the spine and the
spinous process and lamina are exposed (figure 6). The spinous
processes, lamina and thickened ligaments are removed with a
drill and bone biting punches instruments. This removes the
pressure off of the spinal cord and spinal nerves. After the neu-
ral elements have been decompressed, efforts are then directed
at strengthening the spine through the placement of instrumen-
tation and fusion. This is done by using short screws placed
into the lateral mass (facet joints). These are usually placed with
the aid of an X-ray machine. After the screws have been suc-
cessfully placed they are connected together with rods. This
same processes is then repeated on the other side of the spine.
The bone surfaces are then prepared for fusion by removal of all

22

Spinous
process

Lateral
Lamina
Mass /
facet
joints

A. B.

Lateral mass
screws, rod Thecal sac and
and bone spinal cord
fusion

C.

Figure 6. A) The spinous process, lamia and facet joints of the
neck were exposed by retraction of the skin and muscles. B)
The spinous process and lamina were removed to decompress
the thecal sac containing the spinal cord. C) The spine was sta-
bilized by screws, rods and bone fusion

23


soft tissues and outer bony surfaces from the facet joints/lateral
mass with the high speed drill. This promotes strong bony heal-
ing at the surgery site. Bone previously removed from the
laminectomy and Infuse ™ sponges (Medtronic, Inc, Memphis,
TN) are placed over top of the prepared bone surfaces for fu-
sion. Infuse™ is a bone morphogenic protein
(BMP) which greatly increases bone healing. The bleeding is
stopped and the muscle and skin are brought together with su-
tures. Patients are then taken to recovery room.

Does surgery work?
Surgery is effective treatment for cervical myelopathy. The ma-
jority of people see some improvements in their symptoms, but
this maybe small. Patients are rarely cured. Anterior
(corpectomy and fusion), posterior (laminectomy, instrumenta-
tion and fusion) or combination produced some improvement in
approximately 65-100% of people after surgery depending upon
which study is reviewed9,10,11,12,13,14. Rates of complications vary
between studies but they may be as high as 8-38%9,10,11,12,14.
Complications vary between studies but may include: death,
stroke, heart attack, weakness/paralysis, loss of bowel and blad-
der function, infection, clots in legs (deep venous thrombosis),
clots in the lungs (pulmonary embolus), blood vessel injury,
failure of fusion, breakage instrumentation, movement of cage/
graft, difficulty swallowing, hoarse voice, but not limited to
these complications.

When can I go home?
Most people are discharged home 1 to 3 days after surgery. Sta-
ples or stitches are removed 10 to 14 days after surgery. Please
ask your doctor prior to discharge.

24

What if I have pain, numbness or weak-
ness after surgery?
These symptoms may require several weeks or months to im-
prove. It is normal for the symptoms to vary over time. You
should contact your doctor right away if you develop fever, dif-
ficulty breathing, neck swelling, horse voice, severe pain or
weakness.

What are my limitations after neck sur-
gery?
You may remove your neck dressing 1 to 2 days after sur-
gery. You may shower but do not scrub or submerge your inci-
sion in the bath tub for 2 weeks to decrease risk of infection.
Get plenty of rest after surgery. Avoid driving, bending, ex-
tending and twisting of your neck. Most people can return to
work 3 to 12 weeks after surgery. Please discuss your specific
limitations with your doctor.

Should I use a bone stimulator?
Bone stimulators have been found to improve bone healing
rates by stimulation of bone cells by electrical fields. They are
especially useful in patients who are at high risk of the bone
not healing. Patients who are typically suggested to wear stimu-
lators include multi-level fusion surgery, smokers, osteoporosis,
diabetes, revision (second) surgery and patients with metabolic
bone disease. If the cervical fusion does not heal you may re-
quire further surgery. The Orthofix, Inc. bone stimulator has
been found to improve fusion rates by 15%, from 69% to 84%
in high risk patients15. This data has not yet been peer re-
viewed.

25



1. Strict control of sugar levels in patients with diabetes.
Poorly controlled sugar levels may increase risk of infec-
tion.
2. Do not smoke or use non-steroidal anti-inflammatory drugs.
They may interfere with bone fusion.
3. Keep wound clean and dry. Please shower the day after sur-
gery. Do not submerge your wound in the bath for 2 weeks.
4. Use neck collar or bone stimulator as directed by your doc-
tor.
5. No driving, twisting, bending neck for up to 1 month after
surgery.
6. Watch for the development neck swelling, difficult breath-
ing, problems swallowing, change in your voice, fever,
redness or drainage from the wound.
to resolve.

26

References
1. Parke WW: Correlative anatomy of cervical spondylotic myelopathy. Spine
1988; 13:831-837.
2. Connell Md, Wiesel SW. Natural history and pathogenesis of cervical disk
disease. Orthop Clin North Am. 1992 Aug;13(4):345-9.
3. Nurick S: The pathogenesis of the spinal cord disorder associated with cer-
vical spondylosis. Brain 1972; 95:87-100.
4. Panjabi MM, White AA: Biomechanics of nonacute cervical spinal cord
trauma. Spine 1988; 13:838-842.
5. Cooper P R: Cervical Spondylotic Myelopathy. Contemp Neurosurge 1997;
19 (25): 1-7.
6. Kumar VGR, Madden C, Rea GL: Cervical spondylotic myelopathy. In
Winn HR (ed): Youmans Neurological Surgery 5th Ed. USA, Saunders,
2004, p 4448.
7. Epstein N, Epstein J, Carras R, et al. Coexisting cervical and lumbar steno-
sis: Diagnosis and management. Neurosurgery 1984; 15: 489-496.
8. Kadanka Z, Mares M, Bednarik J et al.: Approaches to spondylotic cervical
myelopathy conservative versus surgical results in a 3-year follow-up study.
Spine 2002; 20:2205-2211.
9. Rajshekhar V, Kumar GS: Functional outcome after central corpectomy in
poor-grade patients with cervical spondulotic myelopathy or ossified poste-
rior longitudinal ligament. Neurosurgery 2005 Jun; 56(6):1279-84.
10. Chagas H, Domingues F, Aversa A, Vidal Fonseca Al, de Souza JM. Cervi-
cal spondylotic myelopathy: 10 years of prospective outcome analysis of
anterior decompression and fusion. Surg Neurol 2005; 64 Suppl 1:S1:30-5.
11. Kumar VG, Rea GL, Mervis LJ, McGregor JM. Cervical spondylotic mye-
lopathy: functional and radiographic long-term outcome after laminectomy
and posterior fusion. Neurosurgery 1999 Apr; 44(4):771-7.
12. Houten JK, Cooper PR. Laminectomy and posterior cervical plating for
multilevel cervical spondylotic myelopathy and ossification of the posterior
longitudinal ligament: effects on cervical alignment, spinal cord compres-
sion and neurological outcome. Neurosurgery 2003 May; 52(5): 1081-7.
13. Chibbo S, Benvenuti L, Carnesecchi S et al. Anterior cervical corpectomy
for cervical spondylotic myelopathy: experience and surgical results in a
series of 70 consecutive patients. J Clin Neurosci. 2006 Feb; 13(2):233-8.
14. Kabok S, Mehmet T, Ufuk T et al. Results of surgical treatment for degen-
erative cervical myelopathy. Spine 2004; 29:2493-2500.
15. Orthofix, Inc. PMA Randomized, Prospective Clinical Trial of Pulsed Elec-
tromagnetic Field Stimulation for Cervical Fusion, 2004 (unpublished)..

27

Chapter 3: Spinal Compression Fractures

Chapter 3: Spinal Compression Frac-
tures

What is the spine?
The spine or backbone is made
up of many bones called vertebrae T1

(figure 1). There are 7 cervical ver-
tebrae in the neck, 12 thoracic ver-
tebrae in the upper back (thorax)
and 5 lumbar vertebrae in the lower T6
back.
The front of the vertebrae is
made up of the vertebral body. The
normal vertebral bodies have a
square to rectangular shape. The
back of the spine is made up of ped-
icles, lamina and facet joints, T12
named the posterior elements. The
vertebrae are held together by a
spongy disk in the front and strong
ligaments in the front and back. The
disk helps cushion the spine and
support the body’s weight when
L5
upright.

Figure 1. A side view
Figure 1. The side view of the of the spine.
spine.

28

Why does the spine break?
In young, healthy individuals the verterae are very strong and
require substantial forces to break them, such as a fall from a
high height or car accident. Spinal bones may weaken from
osteoporosis, infection or cancer and break from very little
trauma, such as sitting down on a chair, heavy lifting, rolling
over in bed, swinging a golf club and falls (figure 2).
Osteoporosis is a disease that affects the whole body and is
characterized by thinning and weakening of the bones. Osteo-
porosis affects approximately 10 million Americans and occurs
in as much as 30% of woman older then the age of 651. Risk
factors for osteoporosis include female sex, increased age,
white race, family history of osteoporosis, prior fracture, low
estrogen and low body weight. Other secondary causes include
low estrogen, alcoholism, overactive thyroid or parathyroid
glands, poor absorption of nutrients from the gut, anorexia, glu-
cocorticoid (“steroid”) and seizure medications1. In the United
States, 700, 000 vertebral compression fractures occur each
year, more than the number of hip and wrist fractures com-
bined2,3. Infection and cancer is a less common, but important
cause of spinal fractures.

How do I know my spine is broken?
Spinal compression fractures may present with severe pain,
weakness, loss of bowel and bladder control or initially may
have no symptoms at all.
Pain is the most common symptom of vertebral body com-
pression fractures; it may range from mild to severe. It may be
improved with lying down and worsened by moving, especially
walking. Approximately 150,000 people per year are hospital-
ized in the United States for compression fractures. Fortu-
nately, the pain often improves the first month after the frac-
ture4.

29


A. B.

Figure 2. A) Normal square shaped vertebral body on the left.
B) Broken squished wedge shaped vertebral body on right
(arrow).

Fractures resulting in compression of the spinal nerves or spi-
nal cord may result in mild to extreme weakness in the legs, and
sometimes paralysis (Figure 3). It may also compress the nerves
to the bowel and bladder producing urinary retention or inconti-
nence.

What should I do?
If you are experiencing back pain, weakness or bowel and
bladder difficulties you should urgently see your doctor. You
will require a thorough history and physical examination, which
may include feeling your back for tenderness, checking your
strength, sensations and reflexes in your legs.
vestigations, including x-ray and magnetic resonance imaging
(MRI) of the spine. MRI is best for finding spinal compression

30

Fractured Compressed
vertebral spinal cord
body

Figure 3. MRI scan of T12 compression fracture with collapse
of vertebral body compressing the spinal cord causing leg
weakness (white arrow)

fractures and for determining the age of the fractures (figure 4).
All MRI tests should include STIR (Short T1 Inversion Recov-
ery) imaging, a sequence very sensitive for edema (swelling) in
the vertebral body. Spinal compression fractures with swelling
respond well to treatment5. Patients who are unable to have
MRI scans due to pacemakers, brain aneurysm clips or other
conditions should undergo a CT scan to look at the anatomy of
the spine and bone scan to look at the age and activity of the
fracture.
After a vertebral body fracture or any spine disease is diag-
nosed, the patient should be referred to a spine surgeon to deter-
mine the best treatment for the problem.

31


A. B. C.

Figure 4. A) MRI of subacute T12 compression fracture. B)
Side and C) Front X-rays of the fracture fixed with percutane-
ous balloon kyphoplasty.

What may happen without treatment?
Vertebral compression fractures may result in pain, physical
and psychological dysfunction sometimes leading to death4.
The pain may interfere with mobility and make everyday
tasks more difficult or impossible to complete. People often
require assistance at home, hospitalization or placement in a
nursing home. Without treatment the acute pain may improve,
with a loss of swelling on the MRI scan. Sometimes this acute
pain may be replaced by chronic long term pain due to changes
in spinal shape and mechanics or from pressure of the rib cage
on the pelvis4. Unfortunately, this chronic pain is not relieved
by vertebroplasty or kyphoplasty.
The pain and loss of independence may cause psychological
distress leading to sleep disorders, anxiety and depression.

32

The hunched back deformity from multiple thoracic (upper
back) fractures may compress the lungs preventing the lungs
from properly expanding leading to shortness of breath. The
hunched back may also compress the abdomen causing a loss of
appetite, weight loss and malnutrition.
Vertebral body compression fractures have been associated
with increased risk of death.. Woman over 65 years old appear
to have a 23% higher death rate after a fracture6. These patients
have two to three times more likely to die of lung disease, espe-
cially chronic obstructive pulmonary disease (COPD) and pneu-
monia.

What are the non-surgical treatment op-
tions?
There are many treatments for compression fractures ranging
from bed rest to large spinal instrumentations and fusions4.
Traditionally compression fractures have been treated with bed
rest with progressive mobilization, spinal bracing (a brace is
like a cast for the body), physical therapy, medications (muscle
relaxants, anti-inflammatory drugs and narcotics) and surgery4.
Immobilization of the broken vertebrae may relieve the pain.
This can be accomplished by bed rest, bracing and physical
therapy. Bed rest decreases movement across the broken spine.
Compression fractures are aggravated by standing and walking
and relieved by lying down. Prolonged bed rest is poorly toler-
ated and is associated with significant medical risks. Spinal
bracing restricts spine movements by squeezing the abdomen
and back, but some people find a brace to be uncomfortable.
Physical therapy strengthens the back and abdominal muscles
to reduce back movements and pain.

33


What are the surgical treatment
options?
Vertebral body compression fractures may collapse, angle
forward (kyphosis) or expand into the spinal canal and com-
press the spinal cord or nerves.
Compression of the spinal cord and nerves requires urgent
decompression to prevent permanent damage (figure 5). Unfor-
tunately damage may already be irreversible. Pressure is re-
lieved through surgery from the front and/or back of the spine.
Afterwards the spine is reconstructed with metal cage filled
with bone and held together with screws, rods and plates. Sur-
gery is associated with many risks including death and is rarely
required for osteoporosis compression fractures.
Most osteoporosis fractures result in the collapse of the bone
without compression of the nervous tissue. These fractures can
be fixed by the injection of bone cement through a needle.
There are two common surgical procedures for treating verte-
bral body compression fractures, vertebroplasty and ky-
phoplasty4.
Vertebroplasty involves the placement of a needle through
the back into the broken vertebral body. After the needle is in
the correct position liquid plastic (polymethylmethacrylate) is
injected into the fractured bone. The plastic hardens and stabi-
lizes the bone preventing painful movements of the vertebrae.
Kyphoplasty ™ is similar to vertebroplasty except a balloon is
initially used to expand the vertebral body. Plastic is then in-
jected into the cavity after the balloon is removed. Vertebro-
plasty and kyphoplasty are very effective at relieving back pain.

34

A. B.

Figure 5: Spinal fracture with spinal cord compression on MRI
scan (figure 3) treated with removal of broken vertebral body.
The spine reconstructed with metal cage and strengthened by
metal plates, screws and rods. A) Side view and B) front view.

How is kyphoplasty done?
The patient is sedated or put to sleep in the operating room.
They are positioned face down on the operating table. Their
back is cleaned and draped for the operation. Under x-ray guid-
ance two needles are inserted through the back into the spine
(figure 6). Next a balloon is placed through the needle and is
inflated to make a cavity and expand the flattened vertebral
body. The balloon is then removed and the cavity if filled with
liquid plastic.

35


Normal vertebrae. Broken vertebrae.

Needle & balloon inserted. Balloon expanding bone.

Cement filling cavity. Broken bone fixed with cement.

Figure 6: Fracture reduction and stabilization with balloon kyphoplasty.

36

How do people feel after surgery?
Most people have significant improvement in back pain.
Studies report greater than 80% significant pain relief 4. The
pain relief is usually immediate, but may be delayed due to lo-
cal soreness from the procedure.

What are the possible complications?
The risk of significant complications with vertebroplasty and
kyphoplasty are low, probably less than 1% per fracture treat-
ed4. Complications may include death, stroke, heart attack, pa-
ralysis, bowel and bladder dysfunction, infection, bleeding, al-
lergic reaction and pulmonary embolus, but are not limited to
these complications7. Please discuss these risks with your doc-
tor.

When can I go home?
Most people are discharge home after vertebroplasty. Pa-
tients are often kept overnight after Kyphoplasty. Patients may
start showering the next day after surgery. Sometimes stitches
in the wounds may need to be removed 1 week after surgery.

What are my restrictions?
No heavy lifting, twisting or bending or strenuous activity
the first month after surgery.

How do I prevent future fractures?
Fractures of the wrist, hip or spine increases the risk of future
bone fractures8. Women who developed vertebral body com-
pression fractures are at least 4 times higher risk of developing
subsequent vertebral compression fractures8. Elderly patients
with bone fractures should undergo investigation and treatment
for osteoporosis.
37



1. Keep wound clean and dry.
2. No lifting greater than 10 pounds, strenuous activity, crawl-
ing, stooping, bending or twisting for 1 months after sur-
gery.
3. Watch for the development of fever or redness and drainage
from the wound.
4. Pain may require many days to resolve. Please alert your
doctor of sudden onset of new pain.
6. Evaluation and treatment for osteoporosis.

38

Reference
1. Wei GS, Jackson JL, Hatzigeorgiou C et al. Osteoporosis management
in the new millennium. Prim Care Clin Office Pract 30 (2003): 711-741.
2. Wasnich U. Vertebral fracture epidemiology. Bone 1996; 18:1791-6.
3. Melton LJ. Epidemiology of vertebral fractures in women. Am J Epide-
miol 1989; 129:1000-11.
4. Truumees E, Hilibrand A, Vaccaro AR. Percutaneous vertebral augmen-
tation. Spine J 2004; 4(2):218-229.
5. Tanigawa N, Komemushi A, Kariya S et al. Percutaneous vertebro-
plasty: relationship between vertebral body bone marrow edema pattern on
MR images and initial clinical response. Radiology 2006 Apr; 239(1):195-
200.
6. Kado DM, Browner WS, Palermo L et al. Vertebral fractures and
mortality in older women: a prosepective study. Arch Intern Med 1999;
159:1215-20.
7. Nussbaum D, Gailloud P, Murphey K. A review of complications asso-
ciated with vertebroplasty and kyphoplasty as reported to the Food and Drug
Administration medical device related web site. J Vasc Interv Radiol 2004;
15:1185-1192..
8. Klotzbuecher CM, Ross PD, Landsmann PB et al. Patients with prior
fractures have an increased risk of future fractures: a summary of the
literature and statistical synthesis. J Bone Miner Res, 2000; Apr 15(4):721-
39.

39

Chapter 4: Lumbar Disk Disease

Chapter 4: Lumbar Disk Disease and
Lumbar Diskectomy

What is the lumbar spine?
The spine is made up of many bones called vertebrae. The lum-
bar spine (low back) is made up of five vertebrae (figure 1).
These vertebrae surround and protect the spinal nerves and
lower part of the spinal cord from damage. The front of the ver-
tebrae is made up of a oval shaped vertebral body and the back
of the vertebrae is made up of pedicles, lamina and facet joints,
and back. The disk helps cushion the spine when upright.

Nucleus
L1 pulposus

L2

Disk L3 Annulus
Space Posterior fibrosis
L4 Elements
Vertebral L5
Body
S1 Facet
Spinal Joint
canal
Lamina
Spinous
Process
A. B.
Figure 1. Side view (A) of the lumbar spine on the left and a top
view (B) of a vertebrae with the inner “jelly” core (nucleus
pulposus) and the outer doughnut (annulus fibrosis). on the
right.
40

What is a lumbar disk?
Lumbar disks are located in between the spinal vertebrae and
are made up of a tough outer shell (annulus fibrosis) and a soft
gel-like center (nucleus pulposus). Their structure is similar to
a jelly donut (figure 1).

Why do lumbar disks pinch nerves?
As people age the spine slowly wears out through a process
called degeneration. Degeneration is first seen in the nucleus
pulposus (“jelly center”) and annulus fibrosis (“donut”) in
adults in their thirties to fifties1. With time the annulus may
weaken and allow the nucleus to bulge outward into the spinal
canal forming a bulging disk. If the annulus tears, the nucleus
can squeeze out through the tear into the canal and form a herni-
ated disk (figure 2).
This disease is referred to by many names including slipped
disk, bulging disk, ruptured disk, pinched nerve, herniated nu-
cleus pulposus, disk herniation, disk protrusion, disk extrusion
or disk sequestration. Even though these terms have specific
meanings they are used interchangeably by most health care
providers.
The herniated disk may compress or “pinch off” spinal
nerves resulting in back and leg pain, numbness, tingling and
weakness. This is commonly referred to as sciatica. This pain
may be worsened or maintained by inflammation around the
nerve roots. Possible risk factors for ruptured disks are smok-
ing, pregnancy, jobs with heavy lifting, repetitive lifting and
twisting or operation of vehicles2. Sometimes the process be-
gins after a memorable accident.

41


A. B.

Figure 2. Top view (cross section) of the spine. A) Bulging
disk contain within annulus B) Herniated disk ruptured through
the annulus (arrows).

How do you know your disk is ruptured?
The ruptured disk usually begins with back pain and is fol-
lowed with the development of leg pain. The leg pain may take
days, months or years to develop after the back pain. The back
pain often improves after the leg pain begins. This leg pain
may be associated with numbness (loss of feeling), tingling,
pins and needles, burning or cold feelings or weakness. The
pain may be worsened by sitting, standing, walking, coughing,
sneezing or straining. Rarely, a ruptured disk may present with
loss of control of bowel and bladder function with urinary or
bowel incontinence or retention. If this develops the person
must seek medical care emergently.

42

What should you do?
If you are experiencing back pain, leg pain, numbness or
weakness or bowel and bladder difficulties you should urgently
see your doctor. You will require a thorough physical examina-
tion, which may include feeling your back, testing flexibility of
low back and legs, walking and careful testing of strength, sen-
sations and reflexes in your legs.
(MRI) of the spine. MRI is the best test for looking for herni-
ated disk and nerve root compression (figure 3).

A. B.

Figure 3. MRI scan of L4/5 herniated disk on the left side com-
pressing the nerve (arrows). A) Side view and B) top view.
43


A. B.

Figure 4. A) Saggital (side view) CT myelogram and B) axial
(top view) CT myelogram showing a left herniated disk at L5/1
compressing the exiting nerve root (arrows).

Who should have surgery?
Many patients with back and leg pain secondary to a ruptured
disk may improve with non-operative treatments including
physical therapy, bed rest, non steroidal anti-inflammatory
drugs (NSAIDS), steroids (Medrol dose pack) and epidural ster-
oid injections.
Patients who should consider surgery include patients who
fail to improve with 4 to 8 weeks of conservative therapy, pa-
tients with severe pain requiring narcotic medications, like mor-
phine, demoral, codeine, or hydrocodone or who require admis-
sion to the hospital, patients with weakness, or bowel and blad-
der dysfunction (table 1)3.

44

1. Failure of conservative treatment
2. Severe pain
3. Leg weakness

tions?
As discussed previously, back and leg pain are a result of the
herniated disk compressing the spinal nerve. To relieve the
pain surgery must remove the herniated disk and take pressure
off the nerve. The removal of disk is called a discectomy. A
discectomy can be done by many different techniques, the dif-
ference between these procedures is the size of the incision and
the use of a magnification.
Traditionally discectomies were done through a large incision
to visualize the disk and nerves. The skin incision and tissue
disruption decreased with the introduction of the operating mi-
croscope. It provided better visualization of the vital neural
structures through improved lighting and magnification. This
has been further improved with the introduction of tubular re-
tractor systems (METRx by Medtronic, Inc, Memphis, TN).
This tube system provides the same visualization of the opera-
tive site, but reduces incision size, tissue injury, blood loss, in-
flammation, pain and hospital stay4,5 . These procedures may
also be done with an endoscope (which is a snake-like tele-
scope) but this technique has not been widely incorporated into
neurosurgical practice because it sacrifices the surgeon’s depth
of perception.

45


How is a discectomy done?
them breath. They are positioned face down on the operating
table. Their back is washed and sterile drapes are placed around
the operative site. This procedure can be down open or through
a tube. The tube procedure is done similar to a standard micro-
discectomy, except the skin incision is made just off midline,
and the muscle is spread apart instead of stripped off the bone.
The tube provides similar visualization of the bone, ligaments,
nerves and ruptured disk (figure 5).

METRx

Disk

X-RAY
A. B.

Figure 5. (A) X-ray machine used to locate the level of the her-
niated disk (B) METRx tube docked on the spine over the her-
niated disk. Compliments of Medtronics, Inc, Memphis, TN.

46

An x-ray machine is used to find the level of the herniated
disk. After the correct level is found, a small midline incision is
made. The skin and muscle is retracted from the spine and the
back (lamina) of the spine is exposed. A window into the spinal
canal is made by removing a small amount of bone and liga-
ment (figure 6). The nerve sac (thecal sac) and exiting spinal
nerve are identified under the microscope . The sac and nerves
are retracted and the herniated disk is identified and carefully
removed to take pressure off the nerve. After the disk is re-
moved, bleeding is stopped and the muscle and skin are
brought together with sutures. Patients are then taken to recov-
ery room.

Disk
remover

Disk

Nerve

Retractor

A. B.

Figure 6. (A) A window is cut into the bone and ligament illus-
trating the herniated disk compressing the nerve. (B) The nerve
is retracted and the disk is pulled out from underneath.

47


Does surgery work?
Surgery is very effective for relieving back and leg pain from
a ruptured lumbar disk6,7,8. Approximately 90% of patients will
have good pain relief after surgery (table 2). This appears to be
long lasting9. The resolution of numbness, weakness and bowel
and bladder problems is less consistent. There is approximately
6 –10% risk of a recurrent herniated disk7,10 and 4-11% of com-
plications. These complications are usually minor but may in-
clude: death, stroke, heart attack, weakness/paralysis, loss of
bowel and bladder function, infection, clots in legs (deep ve-
nous thrombosis), clots in the lungs (pulmonary embolus), large
blood vessel injury, scar tissue formation (arachnoditis) and in-
stability6,7,8.

Table 2: Outcome after disk surgery
Pain Relief 90%
Recurrent disk 6-10%
Complications 4-11%

When can I go home?
Most people are discharged home the same day after surgery.
The wound is closed with deep sutures and do not need to be
removed. Occasionally external sutures may require removal 1-
2 weeks after surgery. The patients are seen 2 weeks after sur-
gery and are released to return to work if they are doing well.

48

What if I have back pain or leg pain af-
ter surgery?
It is normal to have back pain for few weeks after surgery.
Leg pain, numbness and tingling may come and go after surgery
as the inflammation in the nerve settle. You should contact
your doctor if you develop new pain, weakness or bowel and
bladder problems.

What are my limitations after back sur-
gery?
You may remove your back dressing the next day after sur-
gery and begin to shower. Please return to work, house duties
and recreational activities as soon as you feel able to. Most pa-
tients return to work two weeks after surgery and can return to
full duty by 8 weeks11.

49



1. Strict control of sugar diabetes.
2. STOP SMOKING!
3. Keep wound clean and dry.
4. You may remove your dressing and shower the day after
surgery.
5. Return to work, housework and recreational activities as
soon as you feel your are able to.
6. Watch for the development of fever and redness or drainage
from the wound. Call your doctor if you have any concerns.
to resolve. Call your doctor if you worsen.

50

References
1. Kramer J. Intervertebral disk diseases: causes, diagnosis, treatment and
prophylaxis, 2nd ed. New York, Thieme, Medical, 1990.
2. Hardy R. Extradural cauda equine and nerve root compression from
benign lesions of the lumbar spine. In Youman’s Neurological Surgery.
Philadelphia, WB Saunders Company, 1996, pp.2357-74.
3. Erico TJ, Fardon DF, Lowell TD. Open discectomy as treatment for
herniated nucleus pulposus of the lumbar spine. Spine 20, 16: pp 1829-
1833, 1995.
4. Sasaoka R, Nakamura H et al. Objective assessment of reduced inva-
siveness in MED compared with conventional one-level laminotomy.
Eur Spine J. May 31, 2005.
5. Foley KT, Smith MM. Microendoscopic discectomy. Techn Neurosurg
3:301-307, 1997.
6. Pappas, CT, Harrington T, Sonntag VK.Outcome analysis in 654 surgi-
cal treated lumbar disk herniations. Neurosurgery 30: 862-866, 1992.
7. Davis, RA. Long-term outcome analysis of 984 surgically treated herni-
ated lumbar disks. J Neurosurg 80:415-421, 1994.
8. Sylvain Palmer. Use of a tubular retractor system in microscopic lumbar
discectomy: 1 year prospective results in 135 patients. Neurosurg Focus
13 (2): Article 5, 2002.
9. Findlay GF, Hall BI, Musa S, Oliveira MD, Fear SC. A 10-year follow-
up of the outcome of lumbar microdiscectomy. Spine 23;10:pp 1168-
1171.
10. Connolly ES. Surgery for recurrent lumbar disk herniation. Clin Neuro-
surgery 39:211-216, 1992.
11. Carragee EJ, Han MY, Yang B et al. Activity restrictions after posterior
lumbar discectomy A prospective study of outcomes in 152 cases with
no postoperative restrictions. Spine 24; 22:pp 2346-2351.

51

Chapter 5: Lumbar Spinal Stenosis

Chapter 5: Lumbar Spinal Stenosis &
Lumbar Laminectomy

lumbar spine or low back is made up of five vertebrae (figure
1). These vertebrae surround and protect the spinal nerves and
tebrae is made up of a oval shaped vertebral body and the back
of the vertebrae is made up of pedicles, lamina and facet joints,
and back. The disks help cushion the spine and prevent the ver-
tebral bodies from rubbing together.

Nucleus
L1 pulposus

L2

L3 Annulus
Posterior fibrosis
Disk Space
L4 Elements
Vertebral
Body L5

S1 Nerves to legs,
bowel and
bladder
Lamina
Spinous
process
A. B.

Figure 1. The normal lumbar spine. A) Side view and B) top
view (axial).

52

The spinal vertebrae surround and protect the spinal canal.
The spinal canal contains the spinal nerves (figure 1). These
nerves connect the spinal cord to the legs, bowel and bladder.
They control leg movements and emptying of the bowel and
bladder and receive sensory information about touch, pain, joint
position and bladder fullness.

What is spinal stenosis?
Spinal stenosis is the narrowing of the spinal canal. As people
age, the lumbar disks dry out and collapse. The body stiffens
the spine by thickening the spinal ligaments and hardening the
disk and facet joints with bone spurs1. Unfortunately, these
changes result in the narrowing of the spine canal and compres-
sion of the nerves and blood vessels (figure 2). This decreases
the blood supply and oxygen to the nerves producing pain,
numbness, tingling and weakness in the legs2. The brain thinks
the legs are the cause of the pain when it is actually the pressure
in the back. Surgery relieves pain by removal of mechanical
irritation to the nerves and improving blood supply and drain-
age.

A. B.
Figure 2. Spinal stenosis (narrowed spinal canal) from bony
spurs and thickened ligaments. A) Top view and B) Side view.

53


How do I know I have spinal stenosis?
Spinal stenosis usually develops in patients between 50 and
80 years old. It is characterized by slowly worsening back and
leg pain, numbness, tingling and weakness2,3. The pain may be
constant but is usually brought on by walking or certain posi-
tions. It is relieved with sitting, lying down or using a shopping
cart. People sometimes feel like they are walking on a cloud,
cotton wool or that their legs do not belong to them.
Rarely patients may develop urinary and bowel incontinence
with wetting or bowel movement in their pants or retention
with the inability to pee or have bowel movements.

What should I do?
see your doctor. You will require a thorough physical exami-
nation, which may include feeling your back, testing flexibility
of low back and legs, walking and careful testing of strength,
sensations and reflexes in your legs.
After an initial assessment, you may require radiological
investigations including X-rays and Magnetic Resonance Im-
aging (MRI) of the spine. MRI is the best test for looking for
spinal stenosis and nerve root compression (figure 3).

54

A. B.

Figure 3: MRI scan of the lumbar spine with severe spinal
stenosis with loss of white spinal fluid signal (arrows) side view
(A) and top view (B).

A. B.

Figure 4: CT myelogram of the lumbar spine with severe spinal
stenosis with loss of white spinal contrast dye (arrows) side
view (A) and top view (B).

55


Patients with spinal stenosis may improve, stay the same or
worsen over time. If the spinal stenosis is found to be moderate
to severe the pain usually continues to worsen without surgery.
On the bright side, most people will not become paralysed or
loose control of their bowel and bladder function. If you can
tolerate the pain you can continue with normal activities.
Many patients with back and leg pain secondary to spinal
stenosis may improve with non-operative treatments including
physical therapy, bed rest, back brace, non steroidal anti-
inflammatory drugs (NSAIDS), steroids (Medrol dose pack)
and epidural steroid injections. Unfortunately, like surgery the
pain relief from conservative treatment maybe incomplete and
temporary.
Patients who fail to improve with conservative treatment may
consider decompression surgery, especially patients with leg
pain or weakness. Patients with loss of bowel and bladder con-
trol may require urgent surgical treatment (table 1).
Patients with multiple back surgeries, spondylolithesis
(slipping of the spine), scoliosis (abnormal curvature of the
spine) may require realignment and stabilization of their spine
with metal screws, rods and bony fusion. This is called a spinal
fusion (please see chapter 6). A spinal fusion holds the weak-
ened spine together to prevent abnormal movements which may
cause back and leg pain.

1. Severe pain

2. Leg weakness


56

tions?
Bone spurs and thickened ligaments compress spinal nerves
producing back and leg pain. Surgery removes the pressure off
the nerves, improves blood supply and relieves the pain. This
surgery is called a laminectomy since the lamina is removed
(figure 5).

Narrowed
spinal
canal

Thickened
spinous proc-
ess and lamina

Figure 5. The lamina and spinous process (striped area) are re-
moved to decompress the nerves in the spinal canal.

Spinal stenosis may be treated with a laminectomy through a
large midline skin incision or through a tube (METRx MD by
Medtronics Sofamor Danek). Surgery done through a tube re-
quires one or more small skin incisions, sometimes on both
sides of the back. This tube system provides the same visualiza-
tion of the operative site but reduces incision size and tissue in-
jury.

57


How is a laminectomy done?
them breath. They are positioned face down on the operating
table. Their back is washed and sterile drapes are placed around
the operative site.
An x-ray machine is used to find the level of the spinal steno-
sis. After the correct levels are found, a large midline incision
is made. The skin and muscle is retracted from the spine and
the spinous process and lamina of the spine are exposed. The
spinous processes, lamina and thickened ligaments are removed
with a drill and bone biting instruments (figure 6). After the
pressure is removed from the nerves, the bleeding is stopped
and the muscle and skin are brought together with sutures. The
patients is then taken to the recovery room.

Spinal
canal Facet joint

Lamina and
Expanded
ligaments
spinal canal
A. B.

Figure 6. Lumbar spinal stenosis, A) The spinal canal is re-
duced due to overgrowth of lamina, facets and ligaments B) The
expanded spinal canal after removal of posterior elements.

58

This procedure can be down through a tube. Procedures done
through a tube have smaller incision size and are associated
with less blood loss, pain and shorter hospital stay. They pro-
duce less tissue injury and inflammatory response by the
body4,5. The tubular decompression is done similar to a stan-
dard laminectomy once the bony lamina of the spine is reached.
The main difference is the approach to the spine. In a standard
laminectomy the muscle is stripped off the spine and then re-
tracted under high pressure. This may cause permanent muscle
damage and back pain. In a tubular laminectomy the muscle is
dilated with progressively larger tubes. There is no muscle
stripping and probably less muscle retraction pressure since the
pathway to the spine is smaller. The tube provides good visuali-
zation of the bone, ligaments and nerves (figure 7).

Figure 7. Bilateral spinal decompression through the METRx
MD tube (Compliments of Medtronics Sofamor Danek).

59


Does surgery work?
Surgery is effective for improving back and leg pain3,6,7,8,9,10
Approximately 55 to 82% of people have good pain relief after
surgery (see table 1). There is approximately 10-18% risk of
requiring further surgery in the future8,9,11. Surgery for recurrent
spinal stenosis is less successful (usually less than 50%) and are
associated with higher complication rates8. Surgery can be
safely done in people older the 75 years old12.
There is approximately 12% chance of complication for lum-
bar laminectomy surgery7. Most complications are minor, but
possible complications may include: death, stroke, heart attack,
weakness/paralysis, loss of bowel and bladder function, infec-
tion, clots in legs (deep venous thrombosis), clots in the lungs
(pulmonary embolus), large blood vessel injury, scar tissue for-
mation (arachnoditis) and instability, but not limited to these
complications.

Table 2: Outcome after laminectomy
Pain Relief 60-70%
Recurrent (new) stenosis 10%
Complications 10%

When can I go home?
Most people are discharged home the day of surgery, or one
to two days afterwards. Sometimes stitches in the wound may
need to be removed 1-2 weeks after surgery.

60

What if I have back pain or leg pain af-
ter surgery?
It is normal to have back pain related to the surgery for a few
weeks after surgery. Back pain which was present prior to sur-
gery may or may not resolve after surgery. It is also normal to
have pain, numbness and tingling that comes and goes after
surgery as inflammation settles in the nerves. You should con-
tact your doctor if you develop severe leg pain or develop new
weakness or bowel and bladder problems, especially inconti-
nence or inability to urinate.

What are my limitations after back sur-
gery?
You may remove your back dressing the next day after sur-
gery and wash your incision in the shower. Please do not bathe
for 2 weeks after surgery because bathing may increase your
risk of infection.
Please rest after discharge from the hospital. Remember you
have had recent surgery and do not overdo it! Do not lift
greater than 10 pounds or do any strenuous activities like run-
ning, jumping, stooping, crawling, bending and twisting for 4-
6 weeks after surgery. Most people can return to work after
this time. Please discuss your limitations with your doctor
since every person is a little different.

61



1. Strict control of sugar levels in patients with diabetes.
Poorly controlled sugar levels may increase risk of infec-
tion.
2. STOP SMOKING!
3. Keep wound clean and dry. Please shower the next day after
surgery, but no baths for 2 weeks.
4. No lifting greater than 10 pounds, strenuous activity, crawl-
ing, stooping, bending or twisting for 4-6 weeks.
5. Watch for the development of fever and redness or drainage
from the wound. Call your doctor if you have any concerns.

62

References
1. Yong-Hing K, Kirkaldy-Willis WH. The pathophysiology of degenera-
tive disease of the lumbar spine. Orthop Clin North Am 14:491-504,
1983.
2. Watanabe R, Park WW: Vascular and neural pathology of lumbosacral ,
spinal stenosis: J Neurosurg 64:64-70, 1986.
3. Lemaire JJ, Sa5r2utreaux JL, Chabannes J, et al: Lumbar canal stenosis:
Retrospective study of 158 operated cases. Neurochirurgie 41:89-97,
1995.
4. Sasaoka R, Nakamura H et al. Objective assessment of reduced inva-
siveness in MED compared with conventional one-level laminotomy.
Eur Spine J. May 31, 2005.
5. Foley KT, Smith MM. Microendoscopic discectomy. Techn Neurosurg
3:301-307, 1997.
6. Herron LD, Mangelsdorf C: Lumbar spinal stenosis: Results of surgical
treatment. J Spinal Disord 4:26-33, 1991.
7. Atlas SJ, Deyo RA, Keller RB, et al: The Main lumbar spine study, Part
III. 1 year outcomes of surgical and non-surgical management of lumbar
spinal stenosis. Spine 21(15): 1787-1794, 1996.
8. Jonsson B, Annertz M, Sjoberg C, et al. A prospective and consecutive
study of surgically treated lumbar spinal stenosis. Part II. Five year fol-
low-up by an independent observer. Spine 22:2938-2944, 1997.
9. Katz JN, Lipson SJ, Larson MG, et al. The outcome of decompressive
laminectomy for degenerative lumbar spinal stenosis. J bone Joint Surg
Am 73:809-813, 1991.
10. Turner JA, Ersek M, Herron L, et al. Surgery for lumbar spinal stenosis:
Attempted meta-analysis of the literature. Spine 17:1-8, 1992.
11. Herno A, Airaksinen O, Saari T: Long-term results of surgical treatment
of lumbar spinal stenosis. Spine 18: 1471-1474, 1993.
12. Vitaz TW, Raque GH, Shields CB, Glassman SD: Surgical treatment of
lumbar spinal stenosis in patients older than 75 years old of age. J Neu-
rosurg 91(2 Suppl): 181-5, 1999.
63

Chapter 5: Lumbar Spondylolisthesis

Chapter 6: Lumbar Spondylolisthesis &
Lumbar Fusion

lumbar spine or low back is made up of five vertebrae (figure
1). These vertebrae surround and protect the spinal nerves and
tebrae is made up of a square shaped vertebral body and the
back of the vertebrae is made up of pedicles, lamina and facet
joints, called the posterior elements. The vertebrae are held to-
gether by a spongy disk in the front and strong ligaments in the
back. The disk helps cushion the spine.

Nucleus
L1 pulposus

L2

L3 Annulus
Posterior fibrosis
Disk Space
L4 Elements
Vertebral
Body L5

S1 Nerves to legs,
bowel and
bladder

A. B.

Figure 1. The normal lumbar spine. A) the side view and B) the
top view (axial).

64

What is lumbar spondylolisthesis?
Lumbar spondylolisthesis is the slipping of the spine. The
vertebral body slips forward over the lower vertebral body
(figure 2).
There are many possible causes of spondylolisthesis. The
spine may slip because the spine was made abnormally from
birth (congenital spondylolithesis), broke in early childhood
(isthmic spondylolithesis), from an injury (traumatic spondylo-
lithesis), infection or tumor (pathologic spondylolithesis) or
“wearing out” from aging (degenerative spondylolithesis). The
spine may also weaken and slip after back surgery. The most
common causes of spondylolithesis are isthmic (the pars of the
posterior elements break in early childhood) and degenerative
(the spine wears out and can no longer hold the bones to-
geather).
Isthmic spondylolithesis usually presents in early adulthood.
It may be caused by repeated injuries to the posterior elements
of the spine by walking, gymnastics or football1. The posterior
elements act as a hook to hold the spine together. If part of this
hook breaks (that is the pars interarticularis) then the spine can
not hold itself together and may result in spinal instability and
the spine slipping apart (figure 2). This instability and slip may
cause back pain. The body forms scar tissue around the broken
pars in attempt to heal the break, unfortunately this scar tissue
may compress spinal nerves and cause leg pain, numbness and
weakness.
Degenerative spondylolithesis presents in later adult hood and
is more common in black females2. It is usually associated with
spinal stenosis (chapter 5) and presents with severe back and leg
pain. The spine is held together by the disk in the front and the
posterior elements in the back. The posterior elements form a
hook (made up of the pars and facet joint) which keeps it

65


A. B.
Figure 2: Isthmic spondylolithesis. The posterior hook holds
the spine together. If the pars interarticularis (arrows) breaks the
spine can no longer hold the vertebrae together and they may
slip apart. Side view (A) and rotated view (B).

attached to the vertebrae above and below. As the spine ages
and becomes worn out the disk and facet joints weaken and al-
low the spine to slip apart (figure 3). This “wear and tear” re-
sults in thickening of ligaments, scar tissue and formation of
bone spurs which may compress nerves causing pain, numbness
and weakness in the legs.

How do you know your back is slipping?
Patients with spondylolithesis present with back pain and leg
pain, numbness and weakness. The back pain may be constant
but usually varies with positon. The pain is worsened by stand-
ing or walking and improved by lying down. Patients with lytic
spondylolithesis may develop disabling deformities of their
body including stiffness, “square” buttock, scoliosis, waddling
gait3. It is uncommon to have problems with bowel and bladder
function with spondylolithesis.

66

What should you do?
see your doctor. You will require a thorough history and physi-
cal examination, which may include feeling your back, testing
flexibility of low back and legs, walking and careful testing of
strength, sensations and reflexes in your legs.
vestigations including X-rays and Magnetic Resonance Imaging
(MRI) of the spine. MRI is the best test for looking for spinal
stenosis and nerve root compression (figure 4).

A. B.

Figure 4. MRI scan of lumbar spondylolithesis of L5 on S1 ver-
tebrae (see arrows). A) Side view and B) top view on the right.

67


nerves on the CT (figure 5). A CT scan may also be ordered in
addition to a MRI scan to look more closely at the bone anat-
omy for planning the placement of the screws.

A. B.

Figure 5. CT Scan of lumbar spondylolithesis of L5 on S1 ver-
tebrae. A) Side view and B) top view.

Some patients with back and leg pain secondary to spinal
spondylolithesis may improve with non-operative treatments
including physical therapy, bed rest, back brace and non ster-
oidal anti-inflammatory drugs (NSAIDS), steroids (Medrol dose
pack) and epidural steroid injections.
Unfortunately, half of the patients fail to improve with con-
servative treatments alone. These patients who fail to improve
may consider surgery (table 1). The treatment for spondylo-
lithesis is spinal decompression, instrumentation and fusion
(table 1). Patients with significant spinal deformity may require
realignment of the spine.
68

1. Severe pain
2. Leg weakness
3. Loss of bowel & bladder control (rare)
4. Slip worsening over time
5. Severe slip

tions?
Surgery for spinal spondylolithesis have significantly ad-
vanced over the years. Initial surgery consisted of a decompres-
sive laminectomy with removal of the back of the spine (see
chapter 5) to decompress the spinal nerves and relieve leg pain.
Unfortunately this did not treat the back pain and resulted in
further slipping of the spine. This lead to development of bony
fusions to make the spine solid and prevent slips. Unfortu-
nately, it takes a long time for the body to fuse the spine and
sometimes fusion did not occur. Most people believe the intro-
duction of metal screws and rods fixed these problems. The
spine is now held rigidly together by screws and rods until the
bones heal (figure 6). The newest advancement in spinal fu-
sions are the discovery of bone morphogenic protein (BMP), a
bone “hormone” which improves fusion rates and minimal inva-
sive surgery which decreases tissue injury and increases patient
level of satisfaction4.

69


A. B.

Figure 6. Post operative X-rays of the lumbar spine after de-
compression, pedicle screw instrumentation and fusion. A) Side
view and B) front view.

How is a fusion done?
The patient is given antibiotics prior to surgery. They are then
taken to the operating room and are put to sleep under a general
anesthetic. A tube is placed down their throat to help them
breath. They are positioned face down on the operating table.
Their back is washed and sterile drapes are placed around the
operative site.
An x-ray machine is used to find the level of the spinal
spondylolithesis. After the correct level is found, a midline in-
cision is made. The skin and muscle is retracted from the spine
and the back of the spine (spinous process and lamina) are ex-
posed. The spinous processes, lamina and thickened ligaments
are removed with a drill and bone biting instruments. After the
laminectomies are completed and the pressure has been

70

removed from the nerve roots and nerve sac, efforts are then
directed towards placing the instrumentation and fusion.
Placement of the pedicle screws requires a detailed three di-
mensional knowledge of the spine. Pedicle screws are usually
placed with the aid of an x-ray machine. The pedicle (which is
part of the posterior elements) is located using bony spinal land-
marks and the x-ray machine. A tunnel is then created through
the pedicles into the vertebral body (figure 7). After verifying
the correct pathway, the screws are placed. Two screws are
placed in each vertebral body. To hold the screws together and
prevent abnormal spinal movement between the vertebral bod-
ies the screws are connected by a rod on each side of the spine
(two rods in total). The rods are sometimes connected to each
other with a cross connector to increase the strength of the in-
strumentation.

Interbody
graft

Figure 7. L4-5 transforaminal interbody fusion (TLIF) with in-
terbody graft in the front and pedicle finding instruments in the
back of the vertebrae.

71


After the placement of the instrumentation, the spine is pre-
pared for fusion and placement of bone graft. There are many
types of fusion procedures (figure 8). The spine may be fused
with placement of bone on the back of the spine beside the
screws and rods (posterolateral fusion, PLF), in the facets (facet
fusion), or between the vertebral bodies (interbody fusion).
There is a variety of interbody fusions, including posterior lum-
bar interbody fusion (PLIF), transforaminal lumbar interbody
fusion (TLIF) and anterior lumbar interbody fusion (ALIF) .
Interbody fusion procedures are all done through the back ex-
cept an ALIF which is done through the abdomen. Each fusion
procedure has its own risks and benefits. These operations can
now be down with minimally invasive techniques. The grafts,
screws and rods can be placed through small incisions.
After completion of the fusion, the bleeding is stopped and a
drain is placed. The muscle and skin are brought together with
sutures. Patients are then taken to recovery room.

72

Posterolateral
A. fusion

Posterior lumbar
B..
interbody fusion

Figure 8. There are many types of spinal fusions, including
posterorlateral fusion (PLF, A), posterior lumbar interbody fu-
sion (PLIF, B), transforaminal interbody fusion (TLIF, C) and
anterior lumbar interbody fusion (ALIF, D). The area of the
spinal fusion are represented by black blocks or ovals.
73


C. Transforaminal lumbar
interbody fusion

Anterior lumbar
D. interbody fusion

74

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