II. Background

  1. More than 1.2 Million back surgeries are performed in the U.S. per year
  2. Elective low back surgery for refractory symptoms (non-urgent or emergent) is not a universal panacea (see efficacy below)
    1. A majority of Chronic Low Back Pain patients are either not better or are worse after surgery
    2. Most patients do not have significantly decreased pain or improved functional ability
    3. Not associated with significantly higher rates of return to work or patient satisfaction
    4. Other non-surgical measures are preferred in elective cases
      1. See Low Back Pain Management
    5. References
      1. Chou (2009) Spine 34(10):1066-77 +PMID: 19363457 [PubMed]

III. Types: Surgical Procedures

  1. Spinal Fusion
    1. Intervertebral discs resected and two or more Vertebrae are fused via bone grafts or metal bars
    2. Intended for spinal stabilization (e.g. Spondylolisthesis) and prevent painful movement
    3. However, associated with loss of spinal flexibility and associated with prolonged recovery
    4. Disk degeneration is also more common at levels adjacent to the fusion
  2. Intervertebral Disc Replacement
    1. Removal of affected intervertebral disc and replacement with a synthetic disc
    2. Restores height and maintains intervertebral movement (contrast with Spinal Fusion)
  3. Diskectomy or Microdiscectomy
    1. Removal of Herniated disc through a back incision (smaller incision in microdiskectomy)
    2. Typically performed in combination with Laminectomy to decompress a nerve root
  4. Spinal Laminectomy (Spinal decompression)
    1. Performed to relieve pain, numbness or weakness due to nerve compression from a disc or bone spur
    2. Removal of the lamina (Vertebral bony walls) and bone spurs
    3. Often performed in combination with Diskectomy
  5. Foraminotomy
    1. Enlarge foraminal opening exiting the spinal cord where nerve compression is occurring
    2. Space may be narrowed by bony encroachment or bulging disk
  6. Nucleoplasty (Plasma Disc Decompression or PDD)
    1. Radiofrequency energy via plasma laser surgery (40 to 70 Celcius) to mildly Herniated discs
    2. Laser, under X-ray guidance, vaporizes disk tissue
  7. Vertebroplasty and Kyphoplasty
    1. See Vertebroplasty, Kyphoplasty
    2. Indicated in Vertebral Compression Fracture
  8. Interspinous Spacer
    1. Small devices placed with the spinal column
    2. Maintains an opening that decompresses the cord in central spinal stenosis
  9. Radiofrequency Denervation
    1. XRay guided electrical needle insertion to target nerve region
    2. Nerve is ablated, deadening the painful nerve signals and offering temporary relief

IV. Types: Implanted Nerve Stimulators

  1. Background
    1. Low voltage electrical signals are transmitted from implanted generator via wire to target nerves
    2. Applied voltage interferes with afferent or sensory signals to brain, including painful stimuli
  2. Spinal Cord Stimulation
    1. Wire threaded into spinal column and runs along the spinal cord
  3. Dorsal Root Ganglion Stimulation
    1. Dorsal root Ganglion (DRG) targeted at one or more spinal levels
    2. DRG receives sensory signals from Peripheral Nerves at a given spinal level or Dermatome
  4. Peripheral Nerve Stimulation
    1. Specific nerve or nerves targeted at a Peripheral Nerve level, localized and distal to either the DRG or cord

V. Indications: Surgery

  1. Urgent and Emergent
    1. Cauda Equina Syndrome (emergent surgery)
    2. Progressive Motor Weakness (urgent surgical evaluation)
    3. Spinal Infection (e.g. Diskitis, Spinal Osteomyelitis, Spinal Epidural Abscess)
    4. Unstable Lumbar Vertebral Fracture
    5. Spinal Malignancy
  2. Other (poor surgical efficacy)
    1. Disabling Low Back Pain impacting quality of life for >1 year and refractory to conservative measures

VI. Efficacy: Elective Spine Procedures (non-urgent and emergent cause)

  1. Overall only 33% of patients are satisfied with improvement after surgery (33% feel worse)
    1. Chou (2009) Spine 34(10):1066-77 +PMID: 19363457 [PubMed]
  2. No significant benefit for Spinal Fusion after 13 years
    1. Hedlund (2016) Spine J 16(5): 579-87 [PubMed]

VII. Complications

  1. Failed Back Surgery Syndrome (Postsurgical Spine Syndrome)
    1. Persistent Low Back Pain, radicular pain or weakness following surgical intervention
    2. Among the most common causes of Chronic Pain
    3. Associated with functional Disability, as well as psychosocial and unemployment impacts

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