Spine surgery: types, indications for intervention and rehabilitation

In the modern era of high technology, with a predominantly sedentary lifestyle and work, a total lack of movement and an unfavorable ecological state of the external environment, spinal diseases are significantly common among almost all age groups of the population.

Unfortunately, not all spinal pathologies and their stages can be resolved with conservative treatment methods alone. In many cases, surgery remains the only chance to gain health, restore an active lifestyle, or get rid of pain. Despite the fact that spine surgery is considered one of the most complex and risky areas of orthopedics and traumatology, today innovative and microinvasive techniques of spinal surgery have brought it to a completely new level of development. Modern technologies and surgical techniques make it possible to solve the problem as safely as possible for the patient, significantly reducing intraoperative risks and shortening the postoperative recovery period.

Indications for surgical interventions

Most spinal diseases without treatment lead to severe consequences, a significant decrease in quality of life, chronic pain and even disability. Main indications for spinal surgery:

• compression (squeezing) of the spinal cord or its roots with a clinical picture of neurological impairment (for example, impaired sensitivity or motor functions), or a high risk of such complications, severe pain. Most often this happens with herniated intervertebral discs, spinal canal stenosis;
• scoliosis , with a curvature of more than 40 degrees;
• spinal deformities of various etiologies, which rapidly progress or disrupt the functioning of internal organs;
• neoplasms of the spinal cord and its membranes, vertebrae, vessels and nerves in the spinal canal area;
• spinal deformities with significant defects in appearance;
• injuries , the most common are compression fractures (occur when falling from a height);
• instability of individual segments of the spine due to various reasons;
• pain syndrome that cannot be relieved by alternative methods;
• ineffectiveness of conservative treatment within 6 months from its start;
• dysfunction of the pelvic organs;
• cauda equina syndrome;
• sequestration of intervertebral hernia and prolapse of the nucleus pulposus.

Operations and complications, removal of disc herniation

The essence of surgery for intervertebral hernia or protrusion lies solely in the mechanical elimination of the cause of pain and dystrophic syndromes that occur with this disease. This is a general principle of surgery, which provides for instrumental penetration of the pathogenic focus with the shortest access with the least possible tissue trauma and removal of the formation that determines the course of the disease, in this case a protrusion or herniated disc. And then, in theory, the forced and short surgical stage should end and the patient moves into the sphere of activity of neurologists and physiotherapists.

But this, unfortunately, does not always happen and the surgical stage is delayed for an indefinite period due to complications arising after the operation and recurrence of disc herniation. Both parties, the doctor and the patient, participate in the decision-making about planned surgical intervention. And these parties absolutely agree that it is necessary to treat radically and eliminate the cause of the disease, and not fight its manifestations.

Absolutely correct message. But serious doubts arise about the “radicality” of the operation to remove a spinal hernia or disc protrusion. At first glance, removal of an intervertebral hernia solves the issue radically. But recurrences of the hernia and the syndrome of the operated spine that occurs in the long term indicate the opposite. Opponents who claim that recurrence of intervertebral hernia can be avoided by completely removing the disc with subsequent prosthetics or stabilization of the segment should ask the question whether the surgeon who made the decision on the operation could have assumed that in the long-term postoperative period in the adjacent spinal motion segment, even in the absence of there, due to the instability that developed after the operation, the protrusion results in a disc herniation.

It should be noted that cicatricial ischemic radiculopathy, which occurs with compression damage to the nerve root due to its compression by scar connective tissue in the postoperative period, does not go away over time and requires repeated surgical intervention. Moreover, with a diagnosis of intervertebral disc herniation, surgery does not radically solve the issue, but new problems arise, but only of a surgical nature.

It is clear that not everything can be foreseen during surgery and in the early postoperative period; it is quite obvious that surgery always involves a high degree of risk. But the doctor is obliged to explain to a patient who is simply tired of pain and ineffective treatment in clinics and “handymen” that surgery for a herniated disc is not a radical method of treatment. The patient must remember that a surgeon who stands at the operating table for several hours every day naturally dulls his sense of risk, otherwise it is difficult for the doctor to withstand the colossal mental stress and he would not be able to work.

Therefore, assessing the degree of risk of a planned operation and the degree of responsibility lies with the patient no less than with the surgeon. You need to know that surgery for a disc herniation has strictly limited indications, and even the occurrence of pelvic disorders with lumbar hernias, described as cauda equina compression syndrome, is not an absolute indication for surgery.

Particularly indicative in this sense is a hernia of the cervical spine with localization C3C4. With this localization, compression of the nerve root that controls the tone of the dome of the diaphragm occurs, and C4 radiculopathy develops. Due to the loss of tone, the dome of the diaphragm relaxes, the lung on the affected side “collapses”, the intestines are “squeezed out” into the chest cavity. According to all forecasts, two operations are necessary, neurosurgical for a C3C4 disc herniation and on the chest in the thoracic department. The participation of the abdominal surgeon. Practice shows that even in this case you can do without surgery.

Main types of operations

In modern orthopedics, there are many methods of surgical interventions on the spine, as well as methods of surgical access to the affected area. Until recently, in most cases only open access to the vertebrae was used. Depending on the operated segment of the spinal column, there are:

• posterior approach, in which a skin incision is made from the back;
• lateral access, used only for operations on the cervical spine, the surgeon gets to the vertebrae on the right or left side of the neck;
• The anterior approach, where the spine is accessed through the abdominal cavity, is mainly used for the lumbar region.

The orthopedic surgeon chooses which access to use depending on the location and level of damage, as well as the individual characteristics of the patient. Among the many existing methods and techniques for spinal manipulation, the following main types of operations can be identified:

Discectomy is an operation on the intervertebral disc, in which the part of the disc extending beyond the intervertebral joint is removed (in other words, a protrusion or hernial protrusion). The main goal of the operation is to reduce the pressure of the cartilage tissue of the disc on the nerve roots, which causes their irritation, inflammation and swelling, and leads to significant pain, and if left untreated for a long time, to loss of sensitivity and motor functions.

Laminectomy is an operation on the vertebra and vertebral arch, the purpose of which is to remove a section of bone tissue directly above the spinal root. As a result, more space is formed around the nerve, pressure on the damaged parts of the nerve root is reduced, which improves its blood supply, eliminates swelling of the perineural membrane and thus helps reduce pain. Another name for this operation is open decompression.

Vertebral arthrodesis (or spondylodesis) is an operation in which a fixed connection of several vertebrae is performed. The main goal of the manipulation is to stabilize the affected segment of the spine and prevent spinal cord injury from unstable and too mobile vertebrae. Most often used for spinal injuries/fractures, degenerative diseases of bone tissue and disc cartilage, and deformities.

Vertebroplasty is a surgical intervention with the introduction of special substances from the “bone cement” series into the damaged bone tissue of the vertebra. The procedure is performed through the skin with a special needle and is considered minimally invasive. Therefore, it can also be performed under local anesthesia. The main indications are compression fracture, osteoporosis, hemangiomas, metastatic tumors.

Transplantation and prosthetics of intervertebral discs - in cases of too massive destruction of intervertebral discs, as a rule, the patient is prescribed arthrodesis - an operation of direct and immovable connection of the vertebrae. This significantly affects the biomechanical properties of the spine and limits the patient's movements. Therefore, intervertebral disc replacement transplantation is an excellent modern alternative in such situations. Modern mechanical endoprostheses imitate all the functions of the disc, thereby maintaining mobility in the spine. Also, in our time, clinical trials are being carried out on bioprostheses grown in the laboratory from the patient’s own cartilage tissue.

Surgical treatment of scoliosis . A separate important point in spine surgery is surgical correction of scoliosis. It is indicated for III-IV severity of this disease, or its rapidly progressing course. Currently, the most effective method of correcting scoliosis is the installation of specially designed metal structures on the spine. There are a large number of similar implants in modern orthopedics. Conventionally, these structures can be divided into two types: stable and dynamic. Dynamic implants are used in the treatment of scoliosis in children. Since the child’s spine is constantly growing, the use of static structures a couple of years after surgery can lead to loss of correction with increasing deformity. The dynamic design is an implant that, once installed on the spine, can increase its length as the child grows, thereby not interfering with the development of the spine and without requiring additional invasive interventions or delaying surgical treatment. It is important that such designs are practically invisible in appearance and do not disrupt the usual way of life, do not require wearing a corset and even allow you to play sports.

Degenerative diseases

In degenerative disc disease, the distance between the vertebrae shortens, causing the discs to wear down, which can lead to the formation of a herniated disc.

Degenerative processes can also develop in the joints of the spine (facet joints) or bone tissues with the development of spondyloarthrosis (spondylosis). Degenerative processes in the spine can lead to compression of nerve structures (spinal stenosis or root compression) with the development of symptoms such as pain, numbness, muscle weakness or dysfunction of the pelvic organs.

Laser vaporization

This surgical minimally invasive intervention is indicated for the early stages of protrusion and herniation of the intervertebral disc before the onset of sequestration. In this case, a conductor needle is inserted into the disk, through which a laser LED is supplied. Laser radiation is supplied through it, which coagulates the inner part of the disc. As a result, the pressure inside the disc decreases, its protrusion and compression of the spinal roots decreases.

The procedure has significant clinical advantages, such as less trauma, surgery lasting no more than an hour, low risk of complications and short recovery period.

Endoscopic discectomy in Germany

Endoscopic resection of the nucleus differs from classical, open discectomy in its low morbidity. Minimally invasive spinal surgery in German clinics provides the following advantages:

• minor damage to surrounding tissue (muscles are peeled away from the spine rather than cut);
• slight blood loss (about 100-150 ml, for comparison with a classic operation 300-500 ml is lost);
• a small, cosmetic incision (approximately 1.5-2 cm long, with a standard intervention 5-10 cm).

Thanks to this, in German clinics it became possible:

• reducing hospital stay to 12-24 hours;
• reducing the intensity of postoperative pain syndrome;
• reduction of the recovery period to 1-3 weeks.

This result allows even professional athletes to avoid unnecessary financial costs and quickly return to everyday life.

Nucleoplasty

The essence of this minimally invasive procedure is to insert a conductor into the intervertebral disc through which the active substance or factor for disc repair is delivered there. Surgeons available may include:

• Cold plasma nucleoplasty - cold plasma is injected into the cartilage tissue of the disc;
• Electrode followed by electrocoagulation of the nucleus pulposus of the disc;
• Chemonnucleolysis - chymopapain, a substance with enzymatic properties in relation to the cartilage tissue of the disc, is injected into the nucleus pulposus.

As a result of each of the impact options, the inner part of the disc is destroyed and, as a result, the protrusion is retracted. Any of the induced types of nucleoplasty is a short-term operation that does not require general anesthesia and a long period of postoperative rehabilitation.

Features of preparation

At the SL Clinic, patients have access to a full range of diagnostic procedures that allow them to accurately assess their health status and predict the possible risks of each type of surgical intervention. As part of the preoperative examination, patients are prescribed:

• UAC and OAM;
• biochemical blood test;
• tests for syphilis, HIV infection, hepatitis A and B;
• coagulogram;
• fluorography;
• ECG;
• MRI;

When choosing a surgical procedure, special attention is paid to MRI results. It is indicated for absolutely all patients as part of preoperative preparation, but its results are extremely important if it is necessary to remove the L5-S1 disc herniation. The MRI image is also supplemented with radiography of the lumbar spine in direct and lateral projections to determine the level of the ilium.

This is because these vertebrae often have enlarged facet joints and a high ilium. They can represent a significant obstacle for the spinal surgeon, especially if removal of the L5-S1 disc herniation is planned using percutaneous nucleoplasty or endoscopy. Therefore, when hypertrophied vertebral processes are detected, removal of the spinal hernia is discussed at a consultation and the decision on the method of removing the disc herniation is chosen depending on the person’s anatomy.

The results of tests and instrumental diagnostic methods are assessed by the therapist. Based on them, he gives a conclusion about the possibility of surgical intervention and the absence of contraindications for this. If, during the examination, deviations from the norm were found that could provoke undesirable complications during the procedure, the patient is prescribed treatment appropriate to the situation, and the planned operation is postponed. If serious contraindications are identified, the patient is recommended another method of treating intervertebral hernia.

If the examination is positive, you should stop taking anticoagulants 2 weeks before the scheduled date. The possibility of using other drugs should be discussed with a therapist.

Epiduroscopy

This is a therapeutic and diagnostic procedure, the essence of which is a direct examination of the epidural space and obtaining images of the main anatomical structures located in the spinal cord: the dura mater of the spinal cord, the yellow ligament, the anterior longitudinal ligament, blood vessels, nerve trunks and adipose tissue. But most importantly, epiduroscopy makes it possible to clearly visualize pathological changes such as adhesions and sequestration, signs of inflammatory, fibrotic and stenotic processes. Therefore, it is an important component of minimally invasive spinal surgery.

Among the important advantages of epiduroscopy: harmless small access, minimal anesthetic load on the body, the possibility of direct transition from diagnostic procedures to therapeutic ones. For example, placement of catheters for long-term chemotherapy for spinal cord tumors, electrodes for coagulation of the nucleus during nucleoplasty procedures, removal of scar tissue, topical administration of medications (for example, painkillers or anti-inflammatory drugs). Also during this procedure, it is possible to take a biopsy for histological examination of the material.

Discectomy with fixation with an artificial prosthesis

The operation is performed using the standard method using an anterior approach. An innovation used in surgery is the use of an artificial disc as an implant. Its task is to maintain and restore mobility of the spine in the operated area. Recommended for patients with discopathy without displacement into the spinal cord canal.

For endoscopic spine surgery in Germany, modern, expensive equipment is used. High-quality optics and lighting make it possible to clearly distinguish all nerve and bone elements, which significantly increases the safety of the operation and the effectiveness of the neurosurgeon’s work. The surgical operations performed in Germany are unique on a European scale.

Endoscopic spinal surgery

This is a modern and safer alternative to open access to the operated parts of the spine and spinal cord. All manipulations are performed using special endoscopic equipment. To insert instruments into the patient’s body and guide them to the desired area of ​​the spine, only 3 skin punctures up to one centimeter in size are performed. The surgeon monitors all movements of the instruments through a special monitor in the operating room.

Such operations are most often used for protrusions and herniations of intervertebral discs, as well as other degenerative changes in cartilage tissue. Among the main advantages of endoscopic spinal surgery

• minimal trauma;
• short rehabilitation periods;
• shortened period of hospitalization (up to 3 days);
• minimal anesthesia load, and therefore less likelihood of anesthetic complications;
• less chance of postoperative complications.

Cervical spine surgery: objectives and techniques

If degenerative changes in the cervical spine lead to the development of myelopathy (spinal cord dysfunction), radiculopathy (nerve root dysfunction), neck pain or abnormal mobility, then surgery may be required. The goal of surgery is to relieve pain and restore stability to the spine.

Surgeons use 2 main surgical methods to solve problems in the cervical spine:

• Decompression: removal of tissue that puts pressure on the nerve structure
• Stabilization: restricting movement between vertebrae.

These 2 techniques may be used in combination, or the patient may simply undergo decompression surgery or simply undergo stabilization surgery.

Rehabilitation after spinal surgery

Rehabilitation after spinal surgery is no less important than the operation itself. The course of rehabilitation should be selected individually for each patient, depending on the disease, its degree and complications, as well as the type of operation. Most rehabilitation courses include:

• therapeutic exercises;
• massage;
• mechanical and kinesiotherapy;
• wearing orthopedic devices (bandages or corsets);
• physiotherapy and reflexology.

It is important to remember that all permissible loads and procedures are prescribed by a rehabilitation doctor or physiotherapist. And a properly selected course of rehabilitation is 70% of the success of surgical treatment of spinal diseases, so in no case should you neglect it!

Displacement of the cervical vertebrae: treatment

Displacement of the cervical vertebrae is a serious disease that can lead to irreversible destruction processes leading to disability. This is why you need to start treatment immediately.

The latter is prescribed by a doctor, who constantly monitors all manipulations during recovery. The main method of treatment is surgical. Stabilization of the cervical vertebrae will avoid serious consequences. The operation is performed under general anesthesia. Discharge after 10 days.

Robotic surgery

Robotic surgery refers to the use of a special robot controlled by a remote control. All operations on the spine are performed by robotic technology under the supervision of a surgeon.

These manipulations are relevant when performing both open and closed operations. The main advantages: maximum precision of movements, minimal risk of accidental damage to nearby tissues and organs, short postoperative recovery time.

Percutaneous discectomy

If a patient is diagnosed with a hernia with the formation of intervertebral disc defects without penetration of the nucleus pulposus into the spinal canal, percutaneous discectomy is often prescribed. It is also relevant when unequal endings in the leg are affected, and when there is numbness in the lower extremities.

The operation lasts about 40 minutes. This time is enough to remove a fragment of the disc using a scalpel, laser or vacuum instrument. There is no compression of the fibers around the nerve, and there are no stitches left after the operation. Practice shows that this manipulation is effective in 60% of cases.

Rehabilitation

An operation to remove a lumbar disc herniation will not give a significant result if the patient does not adhere to the recommendations received from specialists. The duration and characteristics of the recovery period directly depend on the type of surgical intervention performed and the general health of the person. In some cases, patients can immediately return to daily duties and do light housework.

After an open discectomy, patients are forced to remain in the hospital for at least a week, and during the first day they must constantly remain in a supine position. Subsequently, they are allowed to carefully stand up and walk, the duration of walking depends on the general well-being of the patient.

More gentle interventions, in particular microdiscectomy, endoscopic and percutaneous operations, do not involve interruption from the normal rhythm of life. After them, patients can walk almost immediately and leave the clinic in a day or less.

When treating your lumbar spine at the SL Clinic, you will not face restrictions on how long you can sit or lift heavy objects. So, after nucleoplasty you can get up, walk, sit without restrictions, and after endoscopic surgery you can become active the next day. Thus, in each case, patients receive recommendations on an individual basis.

Wearing an orthopedic corset is prescribed for prolonged loads after surgery. It is designed to reduce the load on the spine. With the permission of a doctor, you need to start doing exercise therapy. It is better if the first sessions are carried out under the supervision of a specialist who can correctly calculate the load and increase it as the body recovers.

An operation to remove a herniated lumbar disc forces patients to take care of their health, reduce excess weight, avoid lifting heavy objects, and understand one simple truth - your health is in your hands.

To avoid relapse of the disease, it is recommended:

• get rid of excess weight;
• adhere to proper nutrition;
• swim regularly;
• conduct training to strengthen the muscle corset;
• periodically undergo sanatorium-resort treatment.

In most cases, the results of surgery are assessed after 2 weeks. A follow-up examination by a spinal surgeon is planned one month after discharge from the hospital.