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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Related Studies

Ontology: Laminectomy (C0022983)

Definition (NCI) The excision of the vertebral posterior arch.
Definition (CSP) excision of the posterior arch of a vertebra.
Definition (MSH) A surgical procedure that entails removing all (laminectomy) or part (laminotomy) of selected vertebral lamina to relieve pressure on the SPINAL CORD and/or SPINAL NERVE ROOTS. Vertebral lamina is the thin flattened posterior wall of vertebral arch that forms the vertebral foramen through which pass the spinal cord and nerve roots.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D007796
SnomedCT 50891000, 148704003, 265261000, 148705002, 387731002, 18448001
English Laminectomies, Laminectomy, neurological surgery laminectomy (treatment), neurological surgery laminectomy, laminectomy, Laminectomy spinal, laminectomy procedure, spinal laminectomy, Surgical removal of a part of the vertebra, Spinal laminectomy, Laminectomy (procedure), Laminectomy, NOS, Spinal laminectomy, NOS
Italian Laminectomia vertebrale, Laminectomia spinale, Laminectomia
Dutch laminectomie spinaal, spinale laminectomie, Laminectomie
French Laminectomie rachidienne, Laminectomie
German Laminektomie spinal, spinale Laminektomie, Laminektomie, Wirbelbogenresektion
Japanese 脊椎椎弓切除, セキツイツイキュウセツジョ, 椎弓切除術, 椎弓切除
Swedish Laminektomi
Czech laminektomie, Laminektomie
Finnish Laminektomia
Russian LAMINEKTOMIIA, ЛАМИНЭКТОМИЯ
Croatian LAMINEKTOMIJA
Polish Chirurgiczne otwarcie kanału kręgowego, Laminektomia
Hungarian Laminectomia spinalis
Norwegian Laminektomi
Spanish laminectomía espinal, laminectomía (procedimiento), laminectomía, Laminectomía vertebral, Laminectomía
Portuguese Laminectomia vertebral, Laminectomia

Ontology: Spinal fusion (procedure) (C0037935)

Definition (MSH) Operative immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies with a short bone graft or often with diskectomy or laminectomy. (From Blauvelt & Nelson, A Manual of Orthopaedic Terminology, 5th ed, p236; Dorland, 28th ed)
Definition (CSP) operative immobilization or ankylosis of two or more vertebrae, often with diskectomy or laminectomy.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D013123
ICD9 81.00, 81.0
ICD10 1389
SnomedCT 150134007, 55705006
English Fusions, Spinal, Spinal Fusion, Spinal Fusions, Fusion, Spinal, spinal arthrodesis (treatment), spinal arthrodesis, Spinal fusion (procedure), spondylosyndesis, vertebra fusion, spinal fusions, surgically combining multiple spinal bones into one, Fixation of spine with fusion, Spinal fusion, Spinal arthrodesis (procedure), Spinal arthrodesis, Spinal arthrodesis, NOS, Fusion of spinal joint, NOS, Spinal fusion, NOS, Fusion of vertebra, Spinal fusion NOS, Spinal fusion, not otherwise specified, spinal fusion
Dutch spinale fusie, spinale fusie NAO, fusie van wervels, Spondylodese
French Fusion de vertèbre, Fusion des vertèbres SAI, Arthrodèse spinale, Arthrodèse vertébrale
German Wirbelkoerperfusion, Wirbelkoerperfusion NNB, Spinalfusion, Wirbelfusion
Italian Fusione vertebrale NAS, Artrodesi vertebrale, Fusione di vertebra, Fusione spinale
Portuguese Fusão vertebral, Fusão vertebral NE, Fusão de vértebras, Fusão Vertebral, Artrodese Vertebral, Fusão Espinhal, Fusão Espinal, Artrodese de Coluna
Spanish Fusión espinal, Fusión espinal NEOM, Fusión vertebral, artrodesia vertebral (procedimiento), artrodesia vertebral, artrodesis vertebral, fijación y fusión de la columna vertebral, fusión de la articulación vertebral, fusión vertebral, Fusión Vertebral
Japanese 脊椎固定NOS, 椎骨固定, 脊椎固定, セキツイコテイNOS, ツイコツコテイ, セキツイコテイ
Swedish Spinalfusion
Finnish Spondylodeesi
Russian POZVONKOV ARTRODEZ, SPONDILOSINDES, POZVONKOV SRASHCHENIE, ПОЗВОНКОВ АРТРОДЕЗ, ПОЗВОНКОВ СРАЩЕНИЕ, СПОНДИЛОСИНДЕС
Czech Stabilizace obratle, Stabilizace páteře NOS, Páteřní stabilizace, fúze páteře, páteř - fúze, spinální fúze
Polish Spondylodeza, Usztywnienie kręgosłupa
Hungarian Gerinc fusio k.m.n., Csigolya fusio, Spondylodesis
Norwegian Spinal fusjon

Ontology: Operative procedure on spine (C0185908)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 392236004, 32433005, 83395009
Italian Intervento spinale, Intervento spinale NAS
Dutch ruggenmergoperatie NAO, spinale operatie
French Chirurgie du rachis SAI, Chirurgie du rachis
German Wirbelsaeulenoperation NNB, Wirbelsaeulenoperation
Portuguese Operação à coluna vertebral NE, Operação à coluna vertebral
Spanish Cirugía de la columna vertebral NEOM, procedimiento quirúrgico sobre estructura vertebral, procedimiento quirúrgico sobre estructuras vertebrales, procedimiento quirúrgico sobre la columna vertebral, procedimiento quirúrgico sobre estructuras vertebrales (procedimiento), procedimiento quirúrgico sobre estructura vertebral (procedimiento), cirugía de la columna vertebral, procedimiento quirúrgico en la columna vertebral (concepto no activo), procedimiento quirúrgico en las estructuras espinales (procedimiento), operación de la columna vertebral, procedimiento quirúrgico en las estructuras espinales, procedimiento quirúrgico en la columna vertebral, intervención quirúrgica en la columna vertebral, Cirugía de la columna vertebral
Japanese 脊椎手術, 脊椎手術NOS, セキツイシュジュツNOS, セキツイシュジュツ
English Operative procedure on spinal structures, Operative procedure on spinal structure (procedure), Operative procedure on spinal structure, Spinal operation NOS, operations spinal, spinal operation, Operative procedure on spinal structures (procedure), Spinal operation, Operative procedure on vertebral column, Operative procedure on spinal structures, NOS, Operative procedure on spine, NOS, Operative procedure on vertebral column, NOS, Spinal operation, NOS, Operative procedure on spine
Czech Operace páteře, Operace páteře NOS
Hungarian Gerincvelőműtét k.m.n., Gerincvelőműtét

Ontology: Foraminotomy (C0196248)

Definition (MSH) Surgical enlargement of the intervertebral foramina to relieve NERVE ROOT COMPRESSION.
Definition (MSHNOR) Kirurgisk forstørring av intervertebrale foramina for å minske nerverotskompresjon.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D059526
SnomedCT 62409009
Dutch foraminotomie
Japanese ツイカンコウカクダイジュツ, 椎間孔拡大術
Czech Foraminotomie, foraminotomie
English foraminotomies, foraminotomy, Foraminotomy, Foraminotomies, Foraminotomy (procedure), Foraminotomy, NOS
Hungarian Foraminotomia
French Foraminotomie
Portuguese Foraminotomia
Russian ФОРАМИНОТОМИЯ, МЕЖПОЗВОНКОВОГО ОТВЕРСТИЯ РАСШИРЕНИЕ, MEZHPOZVONKOVOGO OTVERSTIIA RASSHIRENIE, FORAMINOTOMIIA
Spanish Foraminotomía, foraminotomía (procedimiento), foraminotomía
Polish Foraminotomia
Italian Foraminotomia
German Foraminotomie
Norwegian Foraminotomi

Ontology: Implantation of electronic stimulator of spine (C0196431)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 84448004
English Implantation of electronic stimulator of spine, Implantation of electronic stimulator of spine (procedure)
Spanish implante de un estimulador electrónico en la médula (procedimiento), implante de un estimulador electrónico en la médula

Ontology: Diskectomy (C0206078)

Definition (MSH) Excision, in part or whole, of an INTERVERTEBRAL DISC. The most common indication is disk displacement or herniation. In addition to standard surgical removal, it can be performed by percutaneous diskectomy (DISKECTOMY, PERCUTANEOUS) or by laparoscopic diskectomy, the former being the more common.
Definition (NCI) Surgical excision of an intervertebral disc. Often performed for pain relief.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D017586
ICD9 80.51
SnomedCT 150124003, 178671008, 148717000, 265262007, 3418002
English Discectomy, Diskectomy, Discectomies, Diskectomies, Excision intervertebr disc NOS, Excision intervertebral disc, Excision of intervertebral disc NOS, Discectomy NOS, Excision intervert disc, diskectomies, discectomies, excision of intervertebral disc, surgical cutting of the intervertebral disk, Excision of intervertebral disc (procedure), Excision of intervertebral disc NOS (procedure), Chondrectomy of spine, Chondrectomy of intervertebral cartilage, Excision of intervertebral cartilage, Excision of intervertebral disc, Arthrectomy of intervertebral disc, Intervertebral discectomy, Chondrectomy of spine (procedure), Discectomy, NOS, Diskectomy, NOS, discectomy, diskectomy
Dutch discectomie, Discectomie
French Ablation d'un disque intervertébral, Discectomie
Portuguese Discectomia, Discotomia
Swedish Diskektomi
Japanese ツイカンバンセツジョ, 円板除去, 椎間板切除, 椎間板切除術, 円板切除, 円板切除術, 椎間板摘出, 椎間板摘出術, 髄核摘出, 髄核摘出術
Czech meziobratlová ploténka - ektomie, Diskektomie
Finnish Diskektomia
Russian DISKEKTOMIIA, ДИСКЭКТОМИЯ
Croatian DISKOTOMIJA
Polish Wycięcie jądra miażdżystego, Wycięcie krążka międzykręgowego, Dyscektomia, Wycięcie dysku
Hungarian Discectomia
Spanish escisión de disco intervertebral, resección de disco intervertebral (procedimiento), condrectomía de la columna vertebral, condrectomía de la columna vertebral (procedimiento), resección de disco intervertebral, condrectomía de columna vertebral, escisión de cartílago intervertebral, resección de disco intervertebral, SAI (procedimiento), resección de disco intervertebral, SAI, artrectomía de disco intervertebral, condrectomía de cartílago intervertebral, discectomía intervertebral, discectomía, Discectomía, Disquectomía
Norwegian Diskektomi
German Diskektomie, Diskotomie
Italian Discectomia

Ontology: Operation on lumbar spine (C0408578)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 265711005, 178659002, 178599007
English Lumbar spine operations, Lumbar spine operations NOS, Lumbar spine operations (procedure), Operation on lumbar spine (procedure), Operation on lumbar spine, lumbar spine surgeries, lumbar spine surgery, Lumbar spine operations NOS (procedure)
Spanish operación de columna vertebral lumbar, operación de columna vertebral lumbar (procedimiento), operaciones de columna vertebral lumbar (procedimiento), operaciones de columna vertebral lumbar, operaciones sobre columna lumbar, SAI, operaciones sobre columna lumbar, SAI (procedimiento)

Ontology: Failed Back Surgery Syndrome (C1963763)

Definition (MSH) A condition of persistent pain and discomfort in the BACK and the LEG following lumbar surgery, often seen in patients enrolled in pain centers.
Concepts Disease or Syndrome (T047)
MSH D055111
English FBSS, Failed back surgery syndrome, Failed Back Surgery Syndrome, Failed Back Surgery Syndrome [Disease/Finding]
Spanish Síndrome por fallo en cirugía de espalda, Síndrome de la cirugía de espalda fallida, Síndrome de Fracaso de la Cirugía Espinal Lumbar
Italian Sindrome da chirurgia non riuscita della schiena, FBSS, Sindrome da fallimento della terapia chirurgica lombare, Sindrome dell'intervento chirurgico alla schiena fallito, Sindrome da fallimento chirurgico spinale
French Syndrome d'échec de chirurgie vertébrale, Syndrome d'échec de chirurgie vertébrale (FBSS), Lomboradiculalgies chroniques rebelles post-chirurgicales, Lombosciatalgies chroniques rebelles après chirurgie, Douleurs radiculaires basses persistantes postopératoires, Lomboradiculalgies rebelles postopératoires, Lombosciatalgies chroniques rebelles postopératoires, Douleurs chroniques au dos ou aux jambes après chirurgie du rachis, Douleurs radiculaires basses persistantes après chirurgie, Lomboradiculalgies rebelles après chirurgie
Dutch FBSS, Failed Back Surgery Syndrome
German FBBS, Postdiskotomiesyndrom
Portuguese Síndrome de fracasso de cirurgia vertebral dorsal, Síndrome Pós-Laminectomia
Japanese セキツイシュジュツノシッパイショウコウグン, FBSS, 脊椎手術の失敗症候群, FBSS
Czech Syndrom neúspěšné chirurgie zad, failed back surgery syndrom, FBSS, syndrom neúspěšné operace bederní páteře, syndrom selhání operační léčby bederní páteře, syndrom neúspěšné chirurgické léčby bederní páteře, syndrom neúspěšné chirurgické léčby degenerativního onemocnění bederní páteře
Russian SINDROM NEUDACHNYKH OPERATSII NA POZVONOCHNIKE, СИНДРОМ НЕУДАЧНЫХ ОПЕРАЦИЙ НА ПОЗВОНОЧНИКЕ
Swedish Misslyckad ryggkirurgi
Polish Zespół pooperacyjnego bólu pleców
Hungarian Sikertelen hátműtét syndroma, FBSS
Norwegian Mislykket ryggkirurgi-syndrom, Mislykket ryggoperasjon-syndrom