Nedal Hejazi, MD
 

 

  
 

 

 

Axial CT demonstrates transpedicular screwfixation.

 

 

 

 

{short description of image}

Animation demonstrates the steps of lumbar stabilizations

 

 

 

 

 

Figures demonstrate the situation after artificial disc surgery of the cervical spine.

 

 

 

 

 

MRI of cervical Myelopathy preoperatively.

 

 

 

 

 

This  figure demonstrates the situation after the cervical decompression with open-door-laminoplasty (3D-reconstructed cervical CT postoperatively)

 

 

 

 

 

Cervical Corpectomy of C5 and C6 after traumatic fracture

 

 

 

 

 

 

 

 

 

 

 

                     

 

 

Spinal Fusion and Stabilization

What is Spinal Fusion?

The spine is made up of a series of bones called "vertebrae"; between each vertebra are strong connective tissues which hold one vertebra to the next, and acts as a cushion between the vertebrae. The disc allows for movements of the vertebrae and lets people bend and rotate their neck and back. The type and degree of motion varies between the different levels of the spine: cervical (neck), thoracic (chest) or lumbar (low back). The cervical spine is a highly mobile region that permits movement in all directions. The thoracic spine is much more rigid due to the presence of ribs and is designed to protect the heart and lungs. The lumbar spine allows mostly forward and backward bending movements (flexion and extension).

Indications for spinal fusion and stabilization

  • degenerative segmental instability and Failed-back-Syndrome
  • postoperative segmental instability
  • Spondylolisthesis (vera or degenerative)
  • after Spondylitis/Spondylodiscitis
  • after spinal or spinal cord tumors

Fusion is a surgical technique in which one or more of the vertebrae of the spine are united together ("fused") so that motion no longer occurs between them. The concept of fusion is similar to that of welding in industry. Spinal fusion surgery, however, does not weld the vertebrae during surgery. Rather, bone grafts are placed around the spine during surgery. The body then heals the grafts over several months - similar to healing a fracture - which joins, or "welds," the vertebrae together.

When Is Fusion Needed?

There are many potential reasons for a surgeon to consider fusing the vertebrae. These include: treatment of a fractured (broken) vertebra; correction of deformity (spinal curves or slippages); elimination of pain from painful motion; treatment of instability; and treatment of some cervical disc herniations. One of the less controversial reasons to do spinal fusion is vertebral fracture. Although not all spinal fractures need surgery, some fractures - particularly those associated with spinal cord or nerve injury - generally require fusion as part of the surgical treatment. Certain types of spinal deformity, such as scoliosis, are commonly treated with spinal fusion. Scoliosis is an "S" shaped curvature of the spine that sometimes occurs in children and adolescents. Fusion is indicated for very large curves or for smaller curves that are getting worse. Sometimes a hairline fracture allows vertebrae to slip forward on top of each other. This condition is called spondylolisthesis (see North American Spine Society patient education brochure on Adult Isthmic Spondylolisthesis), and can be treated by fusion surgery. Another condition that is treated by fusion surgery is actual or potential instability. Instability refers to abnormal or excessive motion between two or more vertebrae. It is commonly believed that instability can either be a source of back or neck pain or cause potential irritation or damage to adjacent nerves. Although there is some disagreement on the precise definition of instability, many surgeons agree that definite instability of one or more segments of the spine is an indication for fusion. Cervical disc herniations that require surgery usually need not only removal of the herniated disc (discectomy), but also fusion.

With this procedure, the disc is removed through an incision in the front of the neck (anteriorly) and a small piece of bone is inserted in place of the disc. Although disc removal is commonly combined with fusion in the neck, this is not generally true in the low back (lumbar spine). Spinal fusion is sometimes considered in the treatment of a painful spinal condition without clear instability. A major obstacle to the successful treatment of spine pain by fusion is the difficulty in accurately identifying the source of a patient's pain. The theory is that pain can originate from painful spinal motion, and fusing the vertebrae together to eliminate the motion will get rid of the pain.

Unfortunately, current techniques to precisely identify which of the many structures in the spine could be the source of a patient's back or neck pain are not perfect. Because it can be so hard to locate the source of pain, treatment of back or neck pain alone by spinal fusion is somewhat controversial. Fusion under these conditions is usually viewed as a last resort and should be considered only after other conservative (nonsurgical) measures have failed.

How Is Fusion Done?

There are many surgical approaches and methods to fuse the spine, and they all involve placement of a bone graft between the vertebrae. The spine may be approached and the graft placed either from the back (posterior approach), from the front (anterior approach) or by a combination of both. In the neck, the anterior approach is more common; lumbar and thoracic fusion is usually performed posteriorly. The ultimate goal of fusion is to obtain a solid union between two or more vertebrae. Fusion may or may not involve use of supplemental hardware (instrumentation) such as plates, screws and cages. Instrumentation is sometimes used to correct a deformity, but usually is just used as an internal splint to hold the vertebrae together to while the bone grafts heal. Whether or not hardware is used, it is important that bone or bone substitutes be used to get the vertebrae to fuse together. The bone may be taken either from another bone in the patient (autograft) or from a bone bank (allograft). Fusion using bone taken from the patient has a long history of use and results in predictable healing. Autograft is currently the "gold standard" source of bone for a fusion. Allograft (bone bank) bone may be used as an alternative to the patient's own bone. Although healing and fusion is not as predictable as with the patient's own bone, allograft does not require a separate incision to take the patient's own bone for grafting, and therefore is associated with less pain. Smoking, medications you are taking for other conditions, and your overall health can affect the rate of healing and fusion, too. Currently, there is promising research being done involving the use of synthetic bone as a substitute for either autograft or allograft. It is likely that synthetic bone substitutes will eventually replace the routine use of autograft or allograft bone. With some of the newer "minimally invasive" surgical techniques currently available, fusion may sometimes be done through smaller incisions. The indications for minimally invasive surgery (MIS) are identical to those for traditional large incision surgery; however, it is important to realize that a smaller incision does not necessarily mean less risk involved in the surgery.

How Long Will It Take To Recover?

The immediate discomfort following spinal fusion is generally greater than with other types of spinal surgeries. Fortunately, there are excellent methods of postoperative pain control available, including oral pain medications and intravenous injections. Another option is a patient-controlled postoperative pain control pump. With this technique, the patient presses a button that delivers a predetermined amount of narcotic pain medication through an intravenous line. This device is frequently used for the first few days following surgery. Recovery following fusion surgery is generally longer than for other types of spinal surgery. Patients generally stay in the hospital for three or four days, but a longer stay after more extensive surgery is not uncommon. A short stay in a rehabilitation unit after release from the hospital is often recommended for patients who had extensive surgery, or for elderly or debilitated patients. It also takes longer to return to a normal active lifestyle after spinal fusion than many other types of surgery. This is because you must wait until your surgeon sees evidence of bone healing. The fusion process varies in each patient as the body heals and incorporates the bone graft to solidly fuse the vertebrae together. The healing process after fusion surgery is very similar to that after a bone fracture. In general, the earliest evidence of bone healing is not apparent on X-ray until at least six weeks following surgery. During this time, the patient's activity is generally restricted. Substantial bone healing does not usually take place until three or four months after surgery. At that time activities may be increased, although continued evidence of bone healing and remodeling may continue for up to a year after surgery. The length of time required you must be off of work will depend upon both the type of surgery and the kind of job you have. It can vary anywhere from approximately 4-6 weeks for a single level fusion in a young, healthy patient with a sedentary job to as much as 4-6 months for more extensive surgery in an older patient with a more physically demanding occupation. In addition to some restrictions in activity, a brace is sometimes used for the early post-operative period. There are many types of braces that might be used. Some are very restrictive and are designed to severely limit motion, while others are intended mainly for comfort and to provide some support. The decision to use a brace or not, and the optimal type of brace, depends upon your surgeon's preference and other factors related to the type of surgery. Following spinal fusion surgery, a postoperative rehabilitation program may be recommended by your surgeon. The rehabilitation program may include back strengthening exercises and possibly a cardiovascular (aerobic) conditioning program, and a comprehensive program custom-designed for the patient's work environment in order to safely get the patient back to work . The decision to proceed with a postoperative rehabilitation program depends upon many factors. These include factors related to the surgery (such as the type and extent of the surgery) as well as factors related to the patient (age, health and anticipated activity level.) Active rehabilitation may begin as early as 4 weeks postoperatively for a young patient with a single level fusion.

What Can I Expect in the Long Run?

Although fusion can be a very good treatment for some spinal conditions, it does not return your spine to "normal." The normal spine has some degree of motion between vertebrae. Fusion surgery eliminates the ability to move between the fused vertebrae, which can put added strain on the vertebrae above and below the fusion. Fortunately, once a fusion has healed it rarely, if ever, breaks down. However, it does place more stress on the vertebrae next to the fusion. This has some potential to accelerate degeneration of those segments, but this risk varies between individuals. Many surgeons therefore recommend that spinal fusion patients avoid repetitive strenuous activities that involve combined lifting and twisting maneuvers to minimize the stress on the areas around the fusion. The decision whether or not to undergo spinal fusion is complex and involves many factors related to the condition being treated, the age and health of the patient, and the patient's anticipated level of function following surgery. This decision must therefore be made carefully and should be discussed thoroughly with your surgeon

Surgery of Cervical Instability & Instrumentation

There are several operations that may be used to treat cervical disc disease. The selection of which operation and the determination of when to perform the operation depend on many factors, which obviously differ for each patient and doctor combination. However, some general factors include the kind of disc disease you have (herniated disc or bone spurs), whether there is pressure on the spinal cord or spinal nerve, the presence of one or more areas of disease within the cervical spine, and if the spine is dislocated in addition to pressure on the cord or nerves. Other factors are determined by your age, how long you have had the disease, other medical problems, previous operations on the neck, and so on. The particular combination of these and other factors will determine the choice of surgical treatment.

Anterior Cervical Disectomy & Fusion

This operation is performed on the neck to relieve pressure on one or more nerve roots, or on the spinal cord. The procedure is performed from the front, or anterior, approach. Discectomy means to remove the disc. Surgery for anterior cervical discectomy is performed with the patient under general anesthesia lying on his or her back. The surgeon may place a traction device to pull on the neck. During the course of the operation x-rays may be obtained to assist the surgeon in the surgery. The surgeon will make an incision in the front of your neck; if only one disc is to be removed it will typically be a small horizontal incision in the crease of the skin. If the operation is to be more extensive, the incision may be oblique (slanted) or longer. The soft tissues within the neck are separated to allow the surgeon to reach the front of the spine, following which the intervertebral disc and bone spurs are removed. An operating microscope may be used to better display the area while part of the disc is removed with forceps. Other instruments such as a drill or bone-cutting instruments may be used to enlarge the disc space. This will help the surgeon to relieve any pressure on the nerve or spinal cord due to bone spurs or the ruptured (herniated) disc. Sometimes the space between the vertebrae is refilled with a small piece of bone (fusion). The bone may be yours (for example, from your hip bone) or it may be taken from a bone bank. In time, the vertebrae may fuse, or join together. In addition to the piece of bone, some surgeons may place a metal plate at the fusion site to strengthen it.The neck incision is closed in several layers. Skin suture material may need to be removed or the surgeon may use absorbing sutures and strips of tape which you can later remove by yourself.

Historically and statistically, there are few surgical risks with anterior cervical discectomy; however, some risk is unavoidable and the unexpected may occur resulting in complications. Although every precaution will be taken to avoid complications, common risks possible with surgery are: infection, excessive bleeding (hemorrhage) and an adverse reaction to anesthesia.

Other risks possible with anterior cervical discectomy include: stroke; injury to the recurrent laryngeal nerve, which causes hoarseness and may or may not be permanent; and injury to the involved nerve root(s) or the spinal cord, both of which can cause varying types and degrees of paralysis. The process of informed consent is designed to make you familiar and comfortable with the reasonable expectations and foreseeable risks. Your surgeon and anesthesiologist will discuss these with you and assist you in your decision-making.

Cervical Corpectomy

This operation is an extension of the discectomy procedure. Also using an anterior approach, the surgeon removes a part of the vertebral body to relieve pressure on the spinal cord. One or more vertebral bodies may be removed including the adjoining discs. The incision is generally longer. The space between the vertebrae is filled using a piece of bone (fusion) and maybe a metal plate. Because more bone is removed, the recovery process for the fusion to heal and the neck to become stable again is usually longer than with anterior cervical discectomy.

Cervical Laminectomy and Discectomy

This operation is performed through a vertical incision in the back of the neck, generally in the middle. Through this opening the surgeon will use an instrument (a retractor) to pull aside the strong muscles of the neck and expose the arch of bone (lamina) that forms the spinal canal. A drill and bone cutting instruments are used to remove the bone around the spinal cord (laminotomy) or the bone around the nerve opening (foraminotomy). Once the nerve is located, it is moved gently aside and an incision is made on the outside covering of the disc through which the disc material is then removed.

See also:

References:

Hejazi N. Microsurgical infrapedicular paramedian approach for retrovertebral lumbar disc herniations. Technical note. J Neurosurg Spine. 2005 Jan;2(1):88-91.

Hejazi N, et al: Intraoperative cervical epidurography: a simple modality for assessing the adequacy of decompression during anterior cervical procedures. Technical Note. J Neurosurg (Spine 1) 98:96–99, 2003

Hejazi N, et al. Combined transarticular lateral and medial approach with partial facetectomy for lumbar foraminal stenosis: Technical note. Journal of Neurosurgery (free article) 96:118-121, 2002

Hejazi N, et al. Spinal intramedullary teratoma with exophytic components. Neurosurg Rev (May 2003) 26: 113-116

Witzmann A, Hejazi N. Special neurosurgical paintherapy of the chronic back pain. (German)
J. Neurol. Neurochir. Psychiatr. 2001(4):23-32


Witzmann A, Hejazi N, Krasznai L. Posterior cervical foraminotomy. A follow-up study of 67 surgically treated patients with compressive radiculopathy.
Neurosurg Rev 2000;23(4):213-217.

Hejazi N; Hassler W. Microsurgical treatment of intramedullary spinal cord tumors. Neurol Med Chir (Tokyo) 1998;38(5):266-273.

Hejazi N; Hassler W. Microsurgical treatment of intrameduallry spinal cord tumors. Results of 80 patients and review of the relevant literature. Neurosurgery 1998;43(3):675.

Hejazi N; Hassler W. Nine cases of nontraumatic spinal epidural hematoma. Neurol Med Chir (Tokyo) 1998;38(11):718-724.