BACK PAIN: CHRONIC BACK PAIN: SURGICAL TREATMENTS

Depending on the diagnosis, surgery may either be the first treatment of choice — although this is rare — or it is reserved for chronic back pain for which other treatments have failed. If you are in constant pain or if pain reoccurs frequently and interferes with your ability to sleep, to function at your job or to perform daily activities, you may be a candidate for surgery.

In general, there are two groups of people who may require surgery to treat their spinal problems. People in the first group have chronic low back pain and sciatica, and they are often diagnosed with a herniated disc, spinal stenosis, spondylolisthesis or vertebral fractures with nerve involvement. People in the second group are those with only predominant low back pain (without leg pain). These are people with discogenic low back pain (degenerative disc disease), in which discs wear with age. Usually, the outcome of spine surgery is much more predictable in people with sciatica than in those with predominant low back pain.

Some of the diagnoses that may need surgery include:

· Herniated discs. A potentially painful problem in which the hard outer coating of the discs, which are the circular pieces of connective tissue that cushion the bones of the spine, are damaged, allowing the discs' jelly-like center to leak, irritating nearby nerves. This causes severe sciatica and nerve pain down the leg. A herniated disc is sometimes called a ruptured disc.

· Spinal stenosis. The narrowing of the spinal canal, through which the spinal cord and spinal nerves run.

It is often caused by the overgrowth of bone caused by osteoarthritis of the spine. Compression of the nerves caused by spinal stenosis can lead not only to pain, but also to numbness in the legs and the loss of bladder and/or bowel control. Patients may have difficulty walking any distances and also may have severe pain in their legs along with numbness and tingling.

· Spondylolisthesis. A condition in which a vertebra of the lumbar spine slips out of place. As the spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can become enlarged, pinching nerves as they exit the spinal column. Spondylolisthesis may cause not only low back pain but severe sciatica leg pain.

· Vertebral fractures. Fractures caused by trauma to the vertebrae of the spine or by crumbling of the vertebrae resulting from osteoporosis. This causes mostly mechanical back pain, but it also may put pressure on the nerves, creating leg pain.

· Discogenic low back pain (degenerative disc disease). Most people's discs degenerate over a lifetime, but in some, this aging process can become chronically painful, severely interfering with their quality of life.

Following are some of the most commonly performed back surgeries:

For Herniated Discs

· Laminectomy/discectomy. In this operation, part of the lamina, a portion of the bone on the back of the vertebrae, is removed, as well as a portion of a ligament. The herniated disc is then removed through the incision, which may extend two or more inches.

· Microdiscectomy. As with traditional discectomy, this procedure involves removing a herniated disc or damaged portion of a disc through an incision in the back. The difference is that the incision is much smaller and the doctor uses a magnifying microscope or lenses to locate the disc through the incision. The smaller incision may reduce pain and the disruption of tissues, and it reduces the size of the surgical scar. It appears to take about the same time to recuperate from a microdiscectomy as from a traditional discectomy.

· Laser surgery. Technological advances in recent decades have led to the use of lasers for operating on patients with herniated discs accompanied by lower back and leg pain. During this procedure, the surgeon inserts a needle in the disc that delivers a few bursts of laser energy to vaporize the tissue in the disc. This reduces its size and relieves pressure on the nerves. Although many patients return to daily activities within three to five days after laser surgery, pain relief may not be apparent until several weeks or even months after the surgery. The usefulness of laser discectomy is still being debated.

For Spinal Stenosis

· Laminectomy. When narrowing of the spine compresses the nerve roots, causing pain and/or affecting sensation, doctors sometimes open up the spinal column with a procedure called a laminectomy. In a laminectomy, the doctor makes a large incision down the affected area of the spine and removes the lamina and any bone spurs, which are overgrowths of bone, that may have formed in the spinal canal as the result of osteoarthritis. The procedure is major surgery that requires a short hospital stay and physical therapy afterwards to help regain strength and mobility.

For Spondylolisthesis

· Spinal fusion. When a slipped vertebra leads to the enlargement of adjacent facet joints, surgical treatment generally involves both laminectomy (as described above) and spinal fusion. In spinal fusion, two or more vertebrae are joined together using bone grafts, screws and rods to stop slippage of the affected vertebrae. Bone used for grafting comes from another area of the body, usually the hip or pelvis. In some cases, donor bone is used.

Although the surgery is generally successful, either type of graft has its drawbacks. Using your own bone means surgery at a second site on your body. With donor bone, there is a slight risk of disease transmission or rejection. In recent years, a new development has eliminated those risks for some people undergoing spinal fusion: proteins called bone morphogenic proteins are being used to stimulate bone generation, eliminating the need for grafts. The proteins are placed in the affected area of the spine, often in collagen putty or sponges.

Regardless of how spinal fusion is performed, the fused area of the spine becomes immobilized.

For Vertebral Osteoporotic Fractures3

· Vertebroplasty. When back pain is caused by a compression fracture of a vertebra due to osteoporosis or trauma, doctors may make a small incision in the skin over the affected area and inject a cement-like mixture called polymethyacrylate into the fractured vertebra to relieve pain and stabilize the spine. The procedure is generally performed on an outpatient basis under a mild anesthetic.

3 Used only if standard care, rest, corsets/braces, analgesics fail.

· Kyphoplasty. Much like vertebroplasty, kyphoplasty is used to relieve pain and stabilize the spine following fractures due to osteoporosis. Kyphoplasty is a two-step process. In the first step, the doctor inserts a balloon device to help restore the height and shape of the spine. In the second step, he or she injects polymethyacrylate to repair the fractured vertebra. The procedure is done under anesthesia, and in some cases it is performed on an outpatient basis.

For Discogenic Low Back Pain (Degenerative Disc Disease)

· Intradiscal electrothermal therapy (IDT). One of the newest and least invasive therapies for low back pain involves inserting a heating wire through a small incision in the back and into a disc. An electrical current is then passed through the wire to strengthen the collagen fibers that hold the disc together. The procedure is done on an outpatient basis, often under local anesthesia. The usefulness of IDT is debatable.

· Spinal fusion. When the degenerated disc is painful, the surgeon may recommend removing it and fusing the disc to help with the pain. This fusion can be done through the abdomen, a procedure known as anterior lumbar interbody fusion, or through the back, called posterior fusion. Theoretically, fusion surgery should eliminate the source of pain; the procedure is successful in about 60 percent to 70 percent of cases. Fusion for low back pain or any spinal surgeries should only be done as a last resort, and the patient should be fully informed of risks.

· Disc replacement. When a disc is herniated, one alternative to a discectomy — in which the disc is simply removed — is removing it and replacing it with a synthetic disc. Replacing the damaged one with an artificial one restores disc height and movement between the vertebrae. Artificial discs come in several designs. Although doctors in Europe had performed disc replacement for more than a decade, the procedure had been experimental in the United States until the U.S. Food and Drug Administration approved the Charite artificial disc for use.