When should I consider surgery?

Surgery should always be the last resort when it comes to treating spinal conditions in the neck and back. However, if various non-operative treatments have been attempted without improvement or worsening over a 6-12 month period, then surgical treatment seems reasonable for certain specific conditions such as spinal stenosis, sciatica, spondylolisthesis or degenerative scoliosis. The decision for surgery should be individualized to the patient and the patient's symptoms, along with their level of function.

Am I a candidate for minimally invasive spine surgery?

The field of minimally invasive spine surgery continues to grow. Most surgeries today can be treated with some aspect of minimally invasive surgery. However, there are certain conditions that require standard open treatment, such as high-degree scoliosis, tumors and some infections.

The best options should be individualized to the patient's diagnosis and overall patient condition. At UCSD we perform both minimally invasive spine surgery, as well as open-surgery, and choose the type of treatment that is best suited for the individual patient.

Why do I need to get an MRI, CAT Scan and an XRay before I have surgery?

The integration of our newest technolgies that assist in MISS surgery often require that radiologic procedures be tailored to fit each operation and will often require a new scan.

How long will I be in the hospital?

In general, minimally invasive spine surgery decreases the hospital stay by one-half. In a typical endoscopic discectomy, the surgeries are performed in the same day, and the patients go home shortly after surgery on the same day.

For various types of lumbar fusion surgery, the patient typically goes home in 2-3 days, where previously they stayed in the hospital 5-7 days. Furthermore, the immediate post-operative period is marked by much less pain when using minimally invasive techniques.

When can I go back to work after minimally invasive back surgery?

The decision to return to work should be individualized to the patient, as well as the patient's occupation. For patients with sedentary jobs, such as office work, a minimally invasive discectomy would allow that patient to begin part-time work within 1-2 weeks. For a larger surgery such as a fusion, this may take 4-6 weeks. Again, return to work is much faster using minimally invasive surgery vs. standard open surgery but this decision is individualized to special needs of each patient.

How long is the recovery?

Most patients are able to get up out of bed and start walking shortly after surgery, usually on the same or following day. For the first 6 weeks, the activity level is limited to walking and normal daily activities.

Most patients are encouraged to avoid heavy lifting, frequent bending, twisting or turning or climbing during the first 6 week period. After 6 weeks, patients begin a physical therapy and exercise program to achieve rapid recovery and strength. By 3 months a gradual increase in normal activities as well as the institution of low impact sporting activities can be started. At 6 weeks, all activities are begun, including sports.

After surgery, how long will my pain last?

On average, patients who have had minimally invasive spine surgery are discharged in half the time of traditional surgery and the pain usually follows this rule. Each procedure will have a differnent rate of recovery.

Will I have to take pain medication after my surgery? Will I become dependant?

There is no evidence that post-operation pain treatment leads to addiction.

Do I have to wear a brace?

Although most patients are provided a brace, this is for comfort only. The use of minimally invasive techniques that preserve muscle function, along with specialized implants that act as an internal brace, allows one to avoid having to wear a brace. Most patients find that the brace improves their pain for about 1-2 weeks, and thereafter it is only worn occasionally.

Will I need physical therapy after I get minially invasive spine surgery?

Physical therapy is an important component of a rapid recovery. This is individualized to the patient, but in most cases, physical therapy started 2-6 weeks after surgery, depending on the surgery performed and the patient's overall condition.

Do you use lasers for minimally invasive back surgery?

Minimally invasive spine surgery utilizes a wide variety of advanced techniques, including lasers, endoscopes, operating microscopes, as well as computer-assisted navigation systems, so that procedures typically done with a large, open decision can be done through small openings.

By necessity, advanced technologies are needed to accomplish the same task that we would otherwise do with an open procedure using more basic equipment. The decision to use one or other types of advanced technologies depends on the individual condition and the surgery performed.

What are the disadvantages of MISS compared to traditional, open surgery?

Minimally invasive spine surgery holds significant promise, in terms of less pain and more rapid recovery. However, it is important to keep in mind that this is relatively new technology, and all new techniques are associated with some degree of uncertainty.

Furthermore, certain minimally invasive techniques are highly technical and require significant training, and in cases where there is a lack of training, complications may occur. Such complications can include inadequate decompression, nerve injury, infection or persistent pain.

However, these are all risks that are associated with open surgery as well. Occasionally, due to the complexity and technical challenges of minimally invasive surgery, the surgeries may take a longer period of time to complete.

Which type of surgery has a greater success rate?

At present, the long-term results of minimally invasive surgery are not well studied. These assessments are ongoing. The short term success of minimally invasive spine surgery is well established. It is clear that minimally invasive surgery allows more rapid recovery and return to work/sports. There is less post-operative pain and shorter hospital stay.

Is minimally invasive spine surgery experimental?

No. MISS has been used sucessfully for many years. However, the scope, complexity and procedures available continue to evolve at a rapid rate.

Why aren't more hospitals and surgeons performing MIS surgeries?

Minimally invasive surgery is highly technical. This requires significant training of the surgeon as well as the OR staff. Furthermore, the equipment needed to perform these procedures safely and effectively can be very expensive.

What causes neck pain?

Neck pain has a variety of causes. Poor body mechanics, herniated discs, spinal fracture, muscle spasms, spinal deformity, and osteoarthritis are a few reasons. Your physician will determine if the pain is mechanical, (coming from the joint or the disc); radicular, (coming from a nerve or nerve root); or myelopathic, (coming from the spinal cord) and determine a treatment plan.

What is a herniated disc?

A disc is the fibrous cartilage pads that lie between the spinal vertebrae; each is made up of two parts: a jelly-like center (the nucleus pulposus) that loses moisture with age, and a tough outer ring (the annulus fibrosus) that can split with age or injury A herniated disc occurs when the disc's jelly-like center (the nucleus pulposus) ruptures the tough, fibrous outer ring (the annulus fibrosus) oozing through small openings in the vertebrae where nerves enter the spinal column.

What is the difference between a herniated disc and a bulging disc?

A bulging disc is a slight protrusion of the center of the disc (nucleus pulposus) into the spinal canal. In a bulging disc, the annulus fibrosus (outer ring) has not been ruptured.
A disc herniation is a large protrusion of the nucleus pulposus (center of the disc), which has burst through the annulus fiborsus (outer ring of the disc) into the spinal canal, invading the surrounding nerves and causing pain in the neck, shoulders or arms.

Are bulging or herniated discs normal?

No, they are not "normal" in that we are not born with herniated or bulging discs. They are very common and occur with age and natural dehydration and degeneration of the disc. MRI studies of asymptomatic patients showed that approximately 40% of the population has herniated or bulging discs.

Does whiplash cause herniated discs?

Whiplash refers to a sprain or strain of the muscles in the neck. This occurs when there is a sudden flexion and extension of the neck. A disc that is bulging or predisposed to herniation may become herniated at the time of trauma.

Should I have a MRI if I have pain?

Your physician will determine is an MRI is necessary. Generally, an MRI is ordered for patients that have failed conservative therapy, or have persistent pain in the neck, shoulder, or arms, or exhibit weakness in the arms.

What can I do to avoid surgery?

The best way to avoid surgery is to keep physically fit, maintain a healthy weight, avoid smoking, avoid repetitive motion, and use proper body mechanics. Alternative therapies may relieve the symptoms and allow patients to avoid or delay surgical intervention.

Are there alternative therapies available to help me deal with my pain?

Alternative therapies such as light traction, acupuncture, Pilates, anti-inflammatory medication, a short course of steroids, or trigger point injections are often treatment options for neck pain. While these may relieve some symptoms, there is not a "cure" for herniated discs.

When do I need surgery?

Surgery is only indicated if conservative therapy fails, the patient becomes dysfunctional, or the patient should experience progressive neurological problems.

Will I have irreversible damage if I delay surgery?

Your physician will advise you based on your condition. In general, if there is severe spinal cord compression or a nerve is compressed over a period of time there may be irreversible damage. If a patient experiences an increase in weakness, weakness in the legs, loss of balance, or loss of bladder or bowel control, they should be reevaluated by their spine specialist immediately.

When do I need a fusion?

The treatment plan is individualized for each patient. A fusion becomes necessary when there is instability in the spine. This may occur because of degeneration of the disc, a spinal deformity such as spondylosis, or during as a result of removing a disc during surgery. A fusion is performed to reconstruct the spine's natural balance and lordosis (curvature). Instrumentation such as screws and plates may be used to stabilize the spine while the boney fusion grows.

Why is surgery often done through the front of the neck?

The anterior (front) approach is preferred because the muscles in the front of the neck naturally part and offer direct access to the disc while the spinal cord is protected by the vertebra. Because the muscles naturally part rather than being cut, there is less trauma and a faster recovery.

What effect does a fusion have on the rest of the cervical spine?

That is an excellent question. In a one level fusion, there is little impact on the spine. In a multilevel fusion, the major concern about performing a fusion is adjacent segment degeneration. The discs act as shock absorbers between the vertebras. When the spine is fused, the levels above or below the fusion may absorb the sheer force from every day motion, and thus wear out the discs. When the fusion is performed with the appropriate size bone graft, the balance of the spine is maintained and the adjacent segments are at less risk of degeneration.

Should I have allograft or autograft bone?

This is decided on an individualized basis. In general, I use an allograft (donor bone) and BMP in single level fusions, and autograft (bone graft taken from the patient's hip) for multilevel fusions. Under some circumstances in a single level fusion, and in multilevel fusions, using bone harvested from the patient's hip may have a higher fusion success rate.

Will the surgery lessen my mobility?

A one level fusion does not greatly limit a patient's mobility, possibly 5-7%. Most of the yes/no motion is from C1/C2 area. If a patient is experiencing extreme muscle stiffness, they may experience greater motion following surgery when the muscles relax.

In a multilevel fusion, a patient may have some decreased motion.

Will I have pain after my surgery?

Most patients have minimal pain following an anterior fusion surgery. The first few days following surgery are the most uncomfortable, and patients often experience a sore throat. The pain is well tolerated, and easily managed with pain medication.

What are my chances for success?

The success of the surgery is determined by the reconstruction of the balance of the spine and the reduction/elimination of the patient's symptoms. The outcome is dependent on the condition of the spine and surgeon performing the surgery.

What are my risks?

There are risks associated with any surgical procedure. The risks for a cervical surgery include but are not limited to: inter operative complications, infection, bleeding, hardware failure, hoarseness, paralysis, and death.

Will my surgery be photographed or video taped? Occasionally Dr. Pashman will take interoperative pictures for educational purposes. The photos or video do not show any identifying features (such as name or your face). This is covered in your surgical consent form. If you have a preference about being photographed, please let Dr. Pashman know when you sign the consent form.

Will I have to wear a collar after surgery?

In the majority of cases, a collar is not necessary.

When will I be back to my normal activities? Driving?

Patients resume normal activities when they have recovered full coordination and experiencing minimal pain.

Source: smiss.org; orthopedics.about.com