• ALIF (Anterior Lumbar Interbody Fusion) —

This technique involves an anterior approach (incision in the abdominal area, in front) to the spine in order to completely remove an intervertebral disc. Once the disc is removed the space is filled with bone (sometimes also using a cage or other device) in order to obtain a spinal fusion.

• Anterior Cervical Discectomy —

This involves making an incision on the side of the neck (usually 2-3 inches long) in order to gain access to the front of the cervical spine. Once the spine is carefully exposed, the selected disc(s) are removed. In most cases, placing a block of bone into the space from where the disc was removed then follows this. Sometimes a metal plate is then placed against the front of the spine, and attached with small screws. This helps stabilize the spine while the bone heals into the position to form a spinal fusion.

• Bone Grafting —

This procedure involves placing bone into an area of the spine in order to get solid bone healing (spinal fusion). There are different types of bone which can be used to obtain a spinal fusion: autologous bone (the patient's own bone), allograft bone (taken from a donor, cadaver), synthetic bone (artificial structure). When bone is taken from another part of a patient's body, the procedure is called 'harvesting', or 'obtaining' bone graft. Common areas from which bone is taken include: the iliac crest (a portion of the pelvis, front or back), the fibula (the narrow long bone on the side of the calf), and sometimes bone near the area of surgery (for instance a spinous process in the surgical area of the spine).

• Bone Harvesting —

There are different types of bone which can be used to obtain a spinal fusion: autologous bone (the patient's own bone), allograft bone (taken from a donor, cadaver), synthetic bone (artificial structure). When bone is taken from another part of a patient's body, the procedure is called 'harvesting', or 'obtaining' bone graft. Common areas from which bone is taken include: the iliac crest (a portion of the pelvis, front or back), the fibula (the narrow long bone on the side of the calf), and sometimes bone near the area of surgery (for instance a spinous process in the surgical area of the spine).

• Dens —

This bone structure is part of the second spinal vertebra (C2), the axis. The dens is like a small bone peg that protrudes upward from C2 into the ring-like structure of C1. Due to the dens there is good stability and yet motion possible between the upper two cervical vertebrae. The dens is vulnerable to injury with trauma and is frequently involved in advanced rheumatoid arthritis.

• Discectomy —

In simple terms, a discectomy is a surgical procedure that involves removing part or all of an intervertebral disc from the spine. Most commonly this is done when a disc is herniated (slipped disc) and is causing symptoms of pain and nerve irritation or injury. Sometimes, a discectomy is done to stop the motion across a portion of the spine and create a solid structure (spinal fusion). A discectomy can be performed in the cervical (neck area), thoracic (upper back) or lumbar (lower back) area. Depending upon the level of the spine (and the reason for removal), the incision to remove a disc will be made in the front or back of the spine. In the cervical spine, the incision is mostly made in the front/side of the neck, the wounds heal very quickly in that area and the recovery is rapid (usually a 3-5 day hospital stay). In the thoracic area, discectomies are usually done through an incision in the side of the ribcage. Following surgery a drainage tube is left in place around the lung (commonly removed after 1-2 days). The recovery from such surgery is a few days in the hospital but the chest area may be quite sore/painful for a while after. New techniques such as endoscopic surgery may lead to a faster recovery. In the lumbar area, a discectomy is most commonly performed through an incision in the back. Using microscopic techniques, the incision for a simple discectomy may be very small (1-2 inches) and recovery rapid (1 day in the hospital).

• Endoscopic Surgery —

Spinal surgery has undergone a significant technological evolution over the past decade. In addition to new spinal fusion devices and spinal instrumentation, the surgical techniques of spinal surgery have been transformed. In recent years developments in video and minimally invasive surgical instruments have spurred a variety of endoscopic surgical procedures. These procedures have identical goals to traditional surgery but make use of an endoscope (like a telescope which permits peering into the body through a small incision) thereby minimizing the size of skin and muscle incisions. Although endoscopic surgery has been applied in general surgical procedures for several years, this technique has only recently been applied to the treatment of spinal disorders. A number of leading teams have pursued research into endoscopic spinal surgery in order to bring this technique into the clinical use. Procedures in which endoscopic surgery can sometimes be applied to the spine include: scoliosis surgery, kyphosis surgery, anterior thoracic discectomies, biopsies, anterior lumbar and thoracic fusions.

• Foraminotomy, Foraminectomy —

Both words may be used to describe one type of surgical procedure. The foramen is the natural passage or tunnel between the vertebrae of the spine through which a nerve root exits from the spinal canal on its path to a specific tissue or organ. When this foramen becomes narrowed, the nerve can become irritated or dysfunctional. This is commonly seen in conditions such as spinal stenosis, lateral disc herniations, facet arthritis.

Removing bone and soft tissues to enlarge the passage for the nerve is called a foraminotomy. A foraminotomy is commonly performed as part of a decompression of the spinal canal itself, such as after a laminectomy. In some specific cases a foraminotomy may be performed from outside the canal and not involve any direct decompression of the central canal. In order to perform this operation, specific fine instruments (kerrison rongeurs) are used to remove portions of bone from the laminae, facets and facet capsules. Sometimes the portion of a facet which constricts the foramen can be removed with an osteotomy (cutting the bone with a sharp metal instrument resembling a fine chisel).

When surgery involves removing a large amount of bone and other tissue, it may be called a foraminectomy instead of a foramenotomy. An example would be opening the foramen widely in order to free the passage for the nerve, remove constriction and gain access to a herniated disc which is to the side (outside) of the spinal canal. Another common reason for performing a foramenectomy may be as part of a PLIF or TLIF procedure.

• Intradiscal Electrothermal Therapy (IDET) —

IDET therapy is a new and minimally invasive treatment that is intended to treat pain due to disc degeneration. The effectiveness of this procedure has not been fully proven in long-term follow up or large controlled studies. Therefore, the procedure is considered experimental by many specialists and with very limited indications for now. The technique essentially involves delivering controlled levels of thermal energy (heat) to a section of a degenerated disc through a fine wire. This heat may cause contraction and thickening of the disc wall possibly resulting in contraction or closure of disc fissures (small tears). Like for any new procedure, the effectiveness, long term risks and complications as well as ideal patient indications are not well established yet and further work is important.

• Kyphoplasty® —

This is a new surgical technique that involves reinforcing a vertebra of the spinal column with bone cement. It can be applied in the setting of bone collapse (fracture) due to osteoporosis or other bone destructive process (tumor, necrosis). The surgical technique involves placing the patient under anesthesia and positioned prone (on the belly, face down). Then, the back area is carefully cleaned and a fluoroscope (an X-ray type machine) is used to view the spine. Using the assistance of the fluoroscope a special needle is then placed (through a small incision in the back), directly into the collapsed vertebra, carefully avoiding the nerves. Once the needle is properly placed, other instruments, including a special balloon are passed into the vertebra. The special balloon is then inflated, by filling it with liquid solution, in order to open up a small cavity in the collapsed bone. Once this has been achieved, the balloon is deflated and withdrawn. Bone cement is then slowly and carefully introduced into the prepared area of the vertebra. In this manner, as the bone cement hardens, a solid support of the vertebra is created. The procedure lasts about 1 hour and can lead to a significant reduction in pain caused by vertebral fracture/collapse. Most patients will spend 1 day in the hospital prior to returning home or to a rehabilitation facility following a kyphoplastyÒ procedure.

• Laminectomy —

When the spinal canal becomes narrowed or the nerves compressed, such as in spinal stenosis or a disc herniation, surgery may become necessary. One type of surgical procedure is called a laminectomy, which refers to freeing up the space of the spinal canal by removing a portion of the lamina. The lamina, which is partially (or completely) removed unroofs the canal and can lead to a marked enlargement of the space available for nerves and the spinal cord. This procedure is most commonly performed in the lumbar spine (lower back).

The operative procedure involves placing the patient under anesthesia and positioned prone (on the belly, face down). Then, the back area is carefully cleaned and an incision is made in the midline of the back. After incising (cutting into) into the middling of the layer of muscle and ligament that sits on either side of the spine, the attachments to the spinous process and lamina of the spine are freed. In this manner the laminae are carefully exposed to full view at the selected levels. Using a special instrument that takes little bites off bone (kerrison rongeur) the lamina of the selected level is gradually trimmed until sufficient bone is removed to free the nerves and open the canal as desired. When this has been achieved the muscles are closed against each other by placing sutures (special threads which are knotted together). The skin is then closed and a dressing is placed.

• Laminoplasty —

When the spinal canal becomes narrowed and the spinal cord and nerves are compressed in the cervical spine, such as in spinal stenosis, surgery may become necessary. One type of surgical procedure is called a laminoplasty which refers to opening up the space of the spinal canal by splitting open the laminae. The laminae, which, in simple terms are like a set of double doors over the spinal canal, are swung open. At first the spinous process is removed, then the central portion of the laminae is split and each lamina (right and left) is hinged open. Once opened, the hinged laminae are kept open through bone struts, sutures or other techniques.

A Laminoplasty can lead to marked enlargement of the space available for nerves and the spinal cord. This procedure is mostly performed in the cervical spine (neck), and performed across several levels of the spine. In carefully selected patients this procedure is a good alternative to an anterior cervical spinal fusion and decompression.

• Laminotomy —

When the spinal canal becomes narrowed or the nerves compressed, such as in spinal stenosis or a disc herniation, surgery may become necessary. One type of surgical procedure is called a laminotomy, which refers to freeing up the space of the spinal canal by removing a portion of the lamina. The lamina, which is partially removed unroofs a portion of the spinal canal and can lead to a enlargement of the space available for nerves. This procedure is most commonly performed in the lumbar spine (lower back) although it can also be useful in the cervical spine (neck) in order to free a compressed nerve.

The operative procedure involves placing the patient under anesthesia and positioned prone (on the belly, face down). Then, the back area is carefully cleaned and an incision is made in the midline of the back. After incising (cutting into) into the middling of the layer of muscle and ligament that sits on either side of the spine, the attachments to the spinous process and lamina of the spine are freed. In this manner the laminae are carefully exposed to full view at the selected levels. Using a special instrument that takes little bites off bone (kerrison rongeur) the lamina of the selected level is gradually trimmed until sufficient bone is removed to free the compressed nerve and open the canal as desired. When this has been achieved the muscles are closed against each other by placing sutures (special threads which are knotted together). The skin is then closed and a dressing is placed.

• LASER Surgery —

For several years a number of LASER devices and techniques have been developed to treat spinal conditions. The results in most cases have not shown a fulfillment of initial expectations. Although using a LASER to deliver high levels of energy to a local tissue can vaporize these tissues, the clinical results of using these techniques for disc problems and other spinal ailments are not as good as more traditional treatments. The costs involved, the risks and complications all add to the impression that LASER surgery in its current form is probably not indicated in the vast majority of spinal problems and perhaps not at all.

• Microdiscectomy (minimally invasive technique) —

A microdiscectomy is a surgical technique that involves use of magnification to carefully dissect tissues and remove a disc fragment from the spinal canal. While discectomy is a technique that has been performed for many years, the use of very small incisions (minimally invasive) and specialized instruments is rather recent. Over the past years, a number of systems have developed tubes and special retractors that permit making incisions as small as 1 inch to perform a discectomy and decompression of nerve roots.




With the use of tubes, a small tunnel is first created through the muscles in the back down to where the herniated disc is located. With special lighting equipment and magnification, the surgeon can then free the nerves and remove herniated disc material without disturbing much of the normal structures. In comparison, an open discectomy involves a larger incision and requires moving muscles away from the spinal column for clear visualization of the spine. The actual removal of fragments from the herniated disc is quite similar with both surgical techniques. The principal difference is thus the size of skin incision and the splitting or moving of muscles, which is diminished with the newer minimally invasive techniques using tubes.




How long is the hospital stay after minimally invasive discectomy?




One of the main advantages of performing a lumbar discectomy with the tube-type minimally invasive techniques is less pain after the operation. This leads to a shorter hospital stay and a quicker recovery. In one study it was noted that patients who had a discectomy performed with minimally invasive microsurgery technique stayed in the hospital for almost half the time than for traditional discectomy. In most cases patients who have had a minimally invasive discectomy go home the same day or stay only one night.

• PLIF —

A Posterior Lumbar Interbody Fusion (PLIF) is a surgical technique that involves removing an intervertebral disc and creating a spinal fusion in the lumbar spine all through one incision in the back. This surgical procedure is usually performed for disc problems at one level, such as a recurrent herniated disc, an instability of the spine, a chronic back problem related to disc rupture or disc related pain.

The operative procedure involves placing the patient under anesthesia and positioned prone (on the belly, face down). Then, the back area is carefully cleaned and an incision is made in the midline of the back. After incising (cutting into) into the middling of the layer of muscle and ligament that sits on either side of the spine, the attachments to the spinous process and lamina of the spine are freed. In this manner the laminae are carefully exposed to full view at the selected levels. Using a special instrument that takes small bites off bone (kerrison rongeur) the lamina of the selected level is gradually removed until sufficient bone is removed to see the nerves at the selected spinal level. The nerves are then gently mobilized (moved a small amount) in order to expose the intervertebral disc. Using various instruments, the disc is removed through the right and left sides of the spinal canal and the intervertebral space which has thus been cleared is then packed with bone graft and either a bone block or cage implant. Instrumentation, such as pedicle screws, are then placed in the vertebrae across the level to be fused. Additional bone graft will often be placed across the transverse processes to ensure a solid fusion. Once this has been achieved, and all instrumentation is firmly linked together, the muscles are closed against each other by placing sutures (special threads which are knotted together). The skin is then closed and a dressing is placed. The surgery may take from 3 to 5 hours and recovery usually involves a hospital stay from 4-7 days.

• Scoliosis Correction —

There are many different types of scoliosis and with that different types of procedures to correct these spinal deformities. Additionally, scoliosis surgery spans all ages. Each patient must thus be treated in a very individualized manner and there are no simple guidelines or general techniques that can be applied to all. The ideal operative plan in any given case will thus depend upon a number of aspects including patient factors (age, size, type or curve, levels of curve, stiffness of curve…) and surgeon factors (experience, comfort with certain techniques…).

• Spinal Decompression —

This refers to any surgical technique which aims to free the space for the nerves in the spinal canal or foramena. A number of different surgical methods are commonly used to achieve a decompression, including: laminectomy, laminotomy, laminoplasty, foramenotomy, anterior discectomy… The ideal technique to use will depend largely upon the level of the spine that must be decompressed, the elements which are causing the compression (bone, disc, ligaments or other), the stability of the spine, and the surgeon's experience. A spinal decompression can be performed in the cervical spine (neck) if there is spinal stenosis or a disc herniation, in the thoracic spine for problems such as stenosis and disc problems, and in the lumbar spine for stenosis and disc problems. Less common reasons for performing a decompression include: infection, tumor, fracture. Although in many cases a decompression involves removing tissue which is constricting or compressing nerve structures, in some cases the spine becomes unstable and a spinal fusion is performed at the time of surgery. In rare cases the spine gradually becomes unstable and painful following a decompression due to a loss in stability (and lack of fusion with the original surgery).

• Spinal Fusion —

Fusion is a surgically created solid bone bridge between two or more adjacent, usually freely mobile bones. In a spinal fusion, this is used to create a stability between levels of the spine (vertebrae) that usually have some motion across a disc and the facet joints. In order to achieve a fusion, bone must grow across the desired area in a gradual and solid fashion. A number of techniques can increase the chance of this to occur. The basis principle is to place bone tissue (bone graft) into the area of desired fusion, ensure sufficient immobility across that area (brace, cast, spinal instrumentation…) and then waiting for the spinal fusion to take place (6-9 months or more).

It is important to understand that in the process of preparing an area of the spine for fusion a commitment with little room for error has been made. If a fusion fails to heal (often called a pseudarthrosis or non-union) repeat surgery (revision surgery) must often be done with more bone graft and spinal instrumentation until the fusion area heals solidly.

There are numerous spinal problems for which spinal fusion may be planned. In simple terms there are long spinal fusions (across many levels) and short segmental spinal fusions (one or a few levels).


Long spinal fusions are commonly performed for correction of deformity such as idiopathic scoliosis, adult scoliosis or Scheuermann's kyphosis. The goal is to correct a deformity and to maintain the correction with spinal instrumentation until the spinal fusion is completed and the healed bone takes over the task of the hardware to stabilize the correction.

Short spinal fusions are often performed to stabilize some form of instability ranging from the acute instability caused by a fracture or large disc extrusion to the chronic instability caused by disc, ligament and cartilage wear and tear called degeneration. In many cases spinal instrumentation is placed during the spinal fusion surgery to optimize the chances of successful bone healing. For unclear reasons, in many cases short fusions do not have a better chance of solid healing than long fusion. This fact may be due to the difficulty to achieve solid fixation (blocking all motion) between two or three mobile vertebrae in the spine. The difficulty to obtain successful spinal fusion at the lowest level of the spine (L5-S1) is illustrated by the amount of different techniques which have been proposed to achieve fusion at that level (in some textbooks there are outlines of more than 25 techniques). Despite the many different surgical techniques available to achieve short spinal fusions, they are not all alike and each has advantages and disadvantages. Each patient must be treated in an individual fashion and the optimal surgical fusion technique is dependant upon many factors.

In addition to consideration of the surgical technique applied, and the type of spinal instrumentation used (if it is necessary), there are also several options in the choice of bone graft material. It must be remembered that ultimately for a spinal fusion to be successful, bone must grow across the selected spinal levels. There are a number of possible sources for this necessary bone graft. One option is bone harvested from the patient (autologous bone graft) from the spine itself or an area near the lower spine, from the iliac crest (part of the pelvis). Another option is obtaining bone graft material from a bone bank (harvested from cadavers and sterilized), this is called allograft. A further option is using synthetic bone materials made from demineralized bone matrix (DBM) and calcium phosphates or hydroxyapatites (some are derived from sea corral).

• Spinal Instrumentation —

There are numerous reasons for planning surgery that involves correcting the position of the spine or creating stability through a spinal fusion (bone healing across levels of the spine). Common examples are: scoliosis surgery, kyphosis surgery, fracture treatment, spondylolisthesis treatment. In order for these operations to be successful the goal involves achieving solid healing of bone across the spine. The use of metal devices, also called implants or instrumentation (screws, rods, plates, cables, wires…) can help correct a deformed spine and will also increase the probability of obtaining a solid spinal fusion.

Spinal instrumentation can be placed in the front or in the back portion of the spine. The devices are usually made of metal, commonly stainless steel or titanium. In order to place this instrumentation into the spine, the spine is at first exposed by making a skin incision, and then gently clearing the muscles, ligaments and other soft tissues from the levels of the spine to be fused. When it comes time to place the implants/instrumentation, specific tools are used to carefully prepare the bone in such a way to obtain good seating of the implants (screw, rod, wire, cable or other). When these devices are in the proper position then a rod, or rarely a plate, is positioned to link the implants together. This essentially forms a rigid scaffolding to hold the spine in the desired position. If all heals well, then it is expected for the bone graft which has been placed into the area of fusion to gradually solidify over several months. The spinal instrumentation is gradually covered by scar tissue and sometimes bone which the body lays down. Even when the spine has healed solidly the instrumentation is rarely removed, although its role as scaffolding is usually completed.

• Spinal Osteotomy —

An osteotomy refers to a controlled breaking or cutting of a bone. This is sometimes done in the setting of spinal surgery when a significant rigid deformity is present (flatback, flatbuttock, congenital scoliosis, revision surgery…). In order to permit a correction of a deformed spine, the bone must on occasion be cut, the spine realigned and then instrumentation placed to maintain the corrected position of the spine. Performing an osteotomy of the spine can be very risky due to the nerves/spinal cord and other vital structures that are near the spinal column. Numerous techniques have been developed to permit a controlled correction of a rigid spinal deformity, techniques such as spinal cord monitoring increase to safety of such procedures.

• Thoracoscopic Release —

This refers to a technique of spinal surgery in the thoracic spine (chest area) involving endoscopic surgery. In recent years developments in video and minimally invasive surgical instruments have spurred a variety of endoscopic surgical procedures. These procedures have identical goals to traditional surgery but make use of an endoscope (like a telescope which permits peering into the body through a small incision) thereby minimizing the size of skin and muscle incisions.

Although endoscopic surgery has been applied in general surgical procedures for several years, this technique has only recently been applied to the treatment of spinal disorders. Endoscopic thoracic release (thoracoscopic release) involves the removal of discs, the separation of ligaments and in some cases the removal of a portion of several ribs in order to permit correction of a deformed spinal column such as in scoliosis and abnormal kyphosis. In the majority of cases after the thoracic anterior surgery, a posterior procedure is performed on the same day in order to finalize the correction of the deformed spine, place instrumentation and create a spinal fusion.

The thoracoscopic release technique involves placing the patient under general anesthesia, and then positioning the patient to be lying on the side. The chest area is cleaned and draped in the usual operative fashion. Small skin incisions are made in the side of the chest (approximately 1 inch long) in order to introduce the endoscope, and other fine specialized instruments into the chest cavity. The lung in the surgical area is deflated by the anesthesia team (through special intubation techniques that permits patient ventilation by one lung only). Due to a camera attachment on the endoscope the chest cavity and spinal column are seen on a TV monitor. Using the other specialized instruments the discs, ligaments and rib segments at the selected levels are then resected to gain motion across the deformed spine. Once this has been achieved successfully, the instruments are withdrawn, the lung is reinflated, the small skin incisions are closed and the procedure is completed.

• TLIF —

A Transforamenal Lumbar Interbody Fusion (TLIF) is a surgical technique that involves removing an intervertebral disc and creating a spinal fusion in the lumbar spine all through one incision in the back. It is very similar to a PLIF but differs in that the disc removal is performed through an approach that is more lateral (to the side) and in some cases only one side of the disc needs to be exposed (right or left) in order to perform the procedure. This surgical procedure is usually performed for disc problems at one level, such as a recurrent herniated disc, an instability of the spine, a chronic back problem related to disc rupture or disc related pain.

The operative procedure involves placing the patient under anesthesia and positioned prone (on the belly, face down). Then, the back area is carefully cleaned and an incision is made in the midline of the back. After incising (cutting into) into the middling of the layer of muscle and ligament that sits on either side of the spine, the attachments to the spinous process and lamina of the spine are freed. In this manner the laminae are carefully exposed to full view at the selected levels. Using a special instrument that takes small bites off bone (kerrison rongeur) the lamina of the selected level is gradually removed until sufficient bone is removed to see the nerves at the selected spinal level (sometimes an osteotomy is performed to resect the lamina). The nerves are then gently mobilized (moved a small amount) in order to expose the intervertebral disc. Using various instruments, the disc is removed through the right and left sides of the spinal canal (although sometimes all this can be done through one side only) and the intervertebral space which has thus been cleared is then packed with bone graft and either a bone block or cage implant. Instrumentation, such as pedicle screws, is then placed in the vertebrae across the level to be fused. Additional bone graft will often be placed across the transverse processes to ensure a solid fusion. Once this has been achieved, and all instrumentation is firmly linked together, the muscles are closed against each other by placing sutures (special threads which are knotted together). The skin is then closed and a dressing is placed. The surgery may take from 3 to 5 hours and recovery usually involves a hospital stay from 4-7 days.

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