Back Surgery

Doctors will almost always try non-surgical back pain treatments before recommending back surgery. People with chronic (recurring) back pain are often good candidates for back surgery, as are people who have lower back pain without leg pain. Some of the diagnoses that may need back surgery include herniated discs, spinal stenosis, spondylolisthesis, vertebral fractures, and discogenic low back pain.

 

Back Surgery: An Introduction

Depending on the diagnosis, back surgery is sometimes used when other non-surgical treatments have failed. People who may be candidates for back surgery:
 
  • Have constant pain
  • Have pain that recurs frequently and interferes with their ability to sleep
  • Have pain that prevents them from functioning at their job
  • Have pain that makes it difficult to perform daily activities.
 
In general, there are two groups of people who may require back surgery to treat their spinal problems. People in the first group may have:
 
  • Chronic low back pain
  • Sciatica (see Sciatica)
  • A herniated disc
  • Spinal stenosis (see Spinal Stenosis)
  • Spondylolisthesis
  • Vertebral fractures with nerve involvement.
 
People in the second group may have predominant lower back pain (without leg pain). These are people with discogenic low back pain (also called degenerative disc disease), in which discs wear out with age. In most cases, the outcome of spine surgery is much more predictable in people with sciatica than in those with predominant low back pain.
 
(Click Lower Back Pain for more information about lower back pain.)
 
Some of the diagnoses that may require back surgery include:
 
  • Herniated discs
  • Spinal stenosis
  • Spondylolisthesis
  • Vertebral fractures
  • Discogenic low back pain.
 

Back Surgery for Herniated Discs

Herniated discs are 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.
 
Back surgery options for a herniated disc include:
 
  • Laminectomy/discectomy
  • Microdiscectomy
  • Laser surgery.
 
Laminectomy/Discectomy
In this type of back surgery, 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 back surgery 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 will use a magnifying microscope or lens to locate the disc through the incision. The smaller incision may reduce pain and the disruption of tissues, and it will reduce 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 will insert a needle into the disc that will deliver a few bursts of laser energy to vaporize the tissue in the disc. This will reduce its size and relieve pressure on the nerves. Although many patients return to daily activities within 3 to 5 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.
 

Back Surgery for Spinal Stenosis

Spinal stenosis is the narrowing of the spinal canal, through which the spinal cord and spinal nerves run. Spinal stenosis is often caused by the overgrowth of bone resulting from osteoarthritis of the spine. Compression of the nerves caused by spinal stenosis can lead to:
 
  • Pain
  • Numbness in the legs
  • Loss of bladder and/or bowel control.
 
Patients may have difficulty walking any distances and may also have severe pain in their legs, as well as numbness and tingling.
 
The only back surgery option for spinal stenosis is a laminectomy. In a laminectomy, the doctor will make a large incision down the affected area of the spine and remove the lamina and any bone spurs (overgrowths of bone) which may have formed in the spinal canal as the result of osteoarthritis. A laminectomy is major surgery that requires a short hospital stay and physical therapy afterwards to help regain strength and mobility.
 
(Click Spinal Stenosis Surgery for more information about this type of back surgery.)
 

Back Surgery for Spondylolisthesis

Spondylolisthesis is 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 low back pain and severe sciatica leg pain.
 
The back surgery option for spondylolisthesis is spinal fusion. When a slipped vertebra leads to the enlargement of adjacent facet joints, surgical treatment generally involves both laminectomy 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 that is used for grafting comes from another area of the body, usually the hip or pelvis. In some cases, donor bone is used.
 
Although the back surgery is generally successful, either type of graft has its drawbacks. Using your own bone means surgery at a second site on your body, and with donor bone, there is a slight risk of disease transmission or rejection. In recent years, a new development -- bone morphogenic proteins -- has eliminated these risks for some people undergoing spinal fusion. Bone morphogenic proteins are used to stimulate bone generation, thereby 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.
 

Back Surgery for Vertebral Fractures

Vertebral fractures are 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 may also put pressure on the nerves, creating leg pain. Back surgery options for osteoporotic fractures include:
 
  • Vertebroplasty
  • Kyphoplasty.
 
Vertebroplasty
When back pain is caused by a compression fracture of a vertebra due to osteoporosis or trauma, a doctor generally makes a small incision in the skin over the affected area. The doctor will then 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.
 
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 will insert a balloon device to help restore the height and shape of the spine. In the second step, the doctor will inject polymethyacrylate to repair the fractured vertebra. This procedure is done under anesthesia, and in some cases it is performed on an outpatient basis.
 

Back Surgery for Discogenic Low Back Pain

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. Back surgery options for discogenic low back pain (also called degenerative disc disease) include:
 
  • Intradiscal electrothermal therapy
  • Spinal fusion
  • Disc replacement.
 
Intradiscal Electrothermal Therapy (IDET)
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. This procedure is done on an outpatient basis, often under local anesthesia. The usefulness of IDET, however, is debatable and further studies on its effectiveness are needed.
 
Spinal Fusion
When the degenerated disc is extremely painful, the surgeon may recommend removing it and fusing the disc to help with the pain. This fusion can be done through the abdomen in a procedure known as anterior lumbar interbody fusion, or through the back in a procedure called posterior fusion. Theoretically, fusion surgery should eliminate the source of pain. This procedure is successful in about 60 percent to 70 percent of cases, and 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 or artificial 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 have performed disc replacement surgery for more than a decade, the procedure had only been experimental in the United States until the Food and Drug Administration (FDA) approved the Charité artificial disc.

(Click Artificial Discs and Back Surgery for more information about back surgery to insert artificial discs.)
 
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Written by/reviewed by: Arthur Schoenstadt, MD
Last reviewed by: Arthur Schoenstadt, MD