Exploring Back Surgery - Part II

Like some of my clients, I sustained a work related back injury resulting in the need for surgery. In Part II of Exploring Back Surgery, I will discuss the procedure I underwent to repair a large free fragment disc herniation in my back.

A discectomy is a surgery done to remove a herniated disc from the spinal canal. When a disc herniation occurs, a fragment of the normal spinal disc is dislodged. This fragment may press against the spinal cord or the nerves that surround the spinal cord. This pressure causes the symptoms that are characteristic of herniated discs.

The surgical treatment of a herniated disc is to remove the fragment of spinal disc that is causing the pressure on the nerve. This procedure is called a discectomy. The traditional surgery is called an open discectomy. An open discectomy is a procedure where the surgeon uses a small incision and looks at the actual herniated disc in order to remove the disc and relieve the pressure on the nerve.

How is a discectomy performed?
A discectomy is performed under general anesthesia. The procedure takes about an hour, depending on the extent of the disc herniation, the size of the patient, and other factors. A discectomy is done with the patient lying face down, and the back pointing upwards.

In order to remove the fragment of herniated disc, your surgeon will make an incision over the center of your back. The incision is usually about 3 centimeters in length. Your surgeon then carefully dissects the muscles away from the bone of your spine. Using special instruments, your surgeon removes a small amount of bone and ligament from the back of the spine. This part of the procedure is called a laminotomy.

Once this bone and ligament is removed, your surgeon can see, and protect, the spinal nerves. Once the disc herniation is found, the herniated disc fragment is removed. Depending on the appearance and the condition of the remaining disc, more disc fragments may be removed in hopes of avoiding another fragment of disc from herniating in the future. Once the disc has been cleaned out from the area around the nerves, the incision is closed and a bandage is applied.

What is the recovery from a discectomy?
Patients often awaken from surgery with complete resolution of their leg pain; however, it is not unusual for these symptoms to take several weeks to slowly dissipate. Pain around the incision is common, but usually well controlled with oral pain medications. Patients often spend one night in the hospital, but are usually then discharged the following day. A lumbar corset brace may help with some symptoms of pain, but is not necessary in all cases.

What is endoscopic microdiscectomy?
This is a newer technique utilized by my surgeon. This technique may allow your surgeon to perform a procedure called an endoscopic discectomy. In an endoscopic discectomy your surgeon uses special instruments and a camera to remove the herniated disc through very small incisions.

The endoscopic microdiscectomy is a procedure that accomplishes the same goal as a traditional open discectomy, removing the herniated disc, but uses a smaller incision. Instead of actually looking at the herniated disc fragment and removing it, your surgeon uses a small camera to find the fragment and special instruments to remove it. The procedure may not require general anesthesia, and is done through a smaller incision with less tissue dissection. Your surgeon uses x-ray and the camera to "see" where the disc herniation is, and special instruments to remove the fragment.

Exploring Back Surgery - Part I

As many of your are aware, I am the founder of Minnesota Disability and Atkinson Law Offices where I offer nearly two decades of experience handling workers compensation matters. What you may not know is that like some of you, I have suffered from a workers compensation injury that resulted in back surgery.

Though my surgery has had many positive results, I unfortunately have ongoing complications. In this series of articles I want to explore the types of back surgeries that may be recommended to those of you with chronic back pain in an attempt to answer some of your questions. Surgery is a very serious procedure that can have profound benefits for certain individuals. However, surgery is something that has the potential for downsides and careful consideration must be taken before undertaking the same.

In Minnesota there are currently 6 forms of back surgery that are being performed in most major hospitals. They range from the most common procedure, diskectomy, to the newest and least well know, the artificial disk.

Diskectomy. This involves removal of the herniated portion of a disk to relieve pressure on a nerve. It's done as an open surgery, and typically involves full or partial removal of the back portion of a vertebra (lamina) to access the ruptured disk.

Laminectomy. This procedure involves the removal of the lamina that overlays the spinal canal. It enlarges the spinal canal and is performed to relieve nerve pressure caused by spinal stenosis.

Fusion. Spinal fusion permanently connects two or more bones in your spine. It can relieve pain by adding stability to a spinal fracture or when there's excessive motion between vertebrae. It may also be used to eliminate painful motion between vertebrae that can result from a degenerated or injured disk.

Intradiscal electrothermal therapy (IDET). In this treatment, doctors insert a needle through a catheter into the disk. The needle is heated to a high temperature for up to 20 minutes. The heat thickens and seals the disk wall, reducing disk bulge and the related spinal nerve irritation.

Vertebroplasty. During this procedure, your surgeon injects bone cement into compressed vertebrae. For fractured and compressed vertebrae, this procedure can help stabilize fractures and relieve pain. With a similar procedure — called kyphoplasty — a balloon-like device is inserted to expand compressed vertebrae before bone cement is injected.

Artificial disks. Implanted artificial disks are a treatment alternative to spinal fusion for painful movement between two vertebrae due to a degenerated or injured disk. These relatively new devices are still being studied, however, so it's not yet clear what role they might play as a back surgery option.

GET PROMPT MEDICAL TREATMENT WITH PROVIDER OF YOUR CHOICE

An employee is entitled to payment of medical, psychological, chiropractic, and other treatment for a work-related condition. Minn. Stat. §176.135. This includes any treatment which is reasonable and necessary to cure and relieve the effects of a work injury.

Almost without exception, the injured worker has the absolute right to choose his or her treating doctor for a work injury. The employee can change doctors within 60 days after medical treatment has commenced, without getting the permission of the employer, insurer, or other interested parties. Minn. Rule Part 5221.0430, Subpart 2. After 60 days, the employee can change primary doctors, but only with the permission of the employer and insurer, or by seeking approval of the court. The rule provides that the employee may not change primary doctors if:

(a) A significant reason for the request is to block reasonable treatment or to avoid returning to work;

(b) The change is to develop litigation strategy rather than to pursue appropriate diagnosis and treatment;

(c) The provider lacks the expertise to treat the employee for the injury;

(d) The travel distance to obtain treatment is an unnecessary expense and the same care is available at a more reasonable location;

(e) At the time of the employee's request, no further treatment is needed; or

(f) For another reason, the request is not in the best interest of the employee and the employer.

In other words, even if the employee's initial treatment is at an emergency room or at an occupational medicine clinic favored by the employer, the employee can change doctors within 60 days. Choosing a qualified physician is important. A general orthopedic surgeon may not be you physician of choice if you have a complex hand injury. There are specialties within specialties and attorney Thomas Atkinson with Minnesota Disability can help you sort through this complex system.

Back & Neck Pain - Part II

Facet Joints

Lumbar facet joint are small pairs of joints on the back side of the spine where the vertebrae meet. These joints provide stability to the spine by interlocking two adjacent vertebrae. Facet joints also allow the spine to bend forward (flexion), bend backward (extension), and twist.

Inflammation of facet joints can occur from injuries or from arthritis. Many times, particularly in the case of injuries, one may not see abnormalities on an x-ray or MRI.

Spinal Stenosis
The term lumbar stenosis refers to any narrowing of the spinal canal. There are many causes of spinal stenosis; the most common is degeneration of the spine, which occurs almost inevitably as a part of the aging process.

Several factors contribute to the narrowing of the spinal canal with degenerative changes. First, wear and tear causes the facet joint to enlarge into the spinal canal. Second, the major ligament of the spinal canal, the ligamentum flavum, undergoes hypertrophy (enlargement) and buckling. Third, the intervertebral discs may bulge backwards or herniate into the canal. Fourth, the vertebrae may slip forward in a condition called spondylolisthesis. Finally, these changes may be superimposed on a congenitally narrow canal.

The hallmark of lumbar stenosis is pain in the back and legs which is aggravated by standing and walking and relieved by sitting or forward bending. The syndrome of pain induced by walking is known as neurogenic claudication (from the Latin claudico, to limp). Neurogenic claudication must be distinguished from is vascular claudication, or leg pain on walking caused by insufficient blood flow to the legs. The features which help to distinguish neurogenic from vascular claudication are the following:

1. Pain occurs after varying amounts of exercise, with standing, or with coughing. Vascular claudication is reliably produced with a fixed amount of exercise, such as walking a certain number of blocks, and is rare at rest.
2. Pain relief with rest is variable and slow, usually requiring sitting or stooping. Resting in a standing position is usually not enough to relieve the pain and may even aggravate the pain. In contrast, the pain of vascular insufficiency is usually quickly relieved by resting in a standing position. This is the main distinguishing feature.
3. Pain from spinal stenosis is usually in a distribution of a spinal nerve rather than the muscles exercised.
4. Sensory loss is also in a nerve root distribution, while with vascular insufficiency it is in a stocking-glove distribution.
5. Signs of vascular insufficiency should be absent: diminished pulses, foot pallor on elevation, and decreased temperature of the feet.

Spondylolysis and Spondylolisthesis
The most common cause of low back pain in adolescent athletes is a stress fracture in one of the vertebrae that make up the spinal column. Technically, this condition is called spondylolysis (spon-dee-low-lye-sis). It usually affects either the fourth or the fifth lumbar vertebra in the lower back. The fracture site is called a pars defect.

If the stress fracture weakens the bone so much that it is unable to maintain its proper position, the top vertebrae can shift forward on top of the bottom vertebrae. This condition is called spondylolisthesis (spon-dee-low-lis-thee-sis).

In adults, a spondylolisthesis is usually caused from degenerative changes in the spine. If too much slippage occurs, the bones may begin to press on nerves and surgery may become necessary to correct the condition.

Causes

• Genetics: There may be an inherited aspect to spondylolysis. An individual may be born with a thin vertebral bone and therefore may be predisposed to this condition. Rapid growth spurts in a teen may also encourage slippage.
• Overuse: Several types of athletics, such as gymnastics, weight lifting and football, put a great deal of stress on the bones in the lower back. They also require that the individual constantly over-stretch (hyperextend) the spine. In either case, the excessive stress can lead to fractures of the vertebrae.
• Spondylolisthesis may also develop because of degenerative changes in the vertebral joints and certain medical conditions such as cerebral palsy.

Sacroiliac Joints
The sacroiliac joint connects the sacrum (the triangular bone at the bottom of the spine) with the pelvis (iliac crest). The joint:

1. Transmits all the forces of the upper body to the pelvis (hips) and legs
2. Acts as a shock-absorbing structure
3. Does not have much motion

The sacroiliac joint can become inflamed from an acute injury or from chronic postural abnormalities such as undue stress on the joint following low back fusion surgery. Pain from sacroiliac joint abnormalities can occur in the low back, buttock/hip, abdomen, groin, or legs.

Ankylosing Spondylitis
Ankylosing spondylitis primarily affects the spine or back. In a person with ankylosing spondylitis, the joints and ligaments that normally permit the spine to move become inflamed and stiff. The bones of the spine may grow together, causing the spine to become rigid and inflexible. Other joints such as the hips, shoulders, knees, or ankles also may become involved.

Other rare causes of back pain include:

• Benign or malignant tumors
• Infections
• Problems of the digestive tract or genitourinary tract
• Vascular problems such as an aneurysm or hardening of the arteries

Back & Neck Pain - Part I

Causes of back pain

Muscles/Ligaments

There are many causes of back pain, the most common of which is a sprain or strain of muscles or ligaments. Muscle spasm can occur after twisting or bending awkwardly, or from a simple sneeze or cough. The majority of muscle spasms tend to get better over time. Severe cases of muscle spasms are treated with medication, physical therapy, or injections.

Discs

Disc Degeneration
Disc problems are common causes of back pain. Discs are usually moist, like a sponge with water in it. After a disc injury, or as we age, discs lose water and deteriorate in a process called disc degeneration.

The earliest form of injury to a disc is in the form of tears or fissures in the annulus fibrosis (outer portion) of the disc. The annulus fibrosis is like a large round ligament that prevents the nucleus pulposus (inner portion) of the disc from pushing outward. Tears in the annulus heal by scar formation resulting in tissue that is not as strong as normal tissue. The repeated cycle of many annular tears healing by scar formation lead to a disc that begins to degenerate.

As a disc degenerates it becomes stiff, narrows, and losses it's ability to act as a shock absorber. Bone from the vertebrae above and below the disc may grow forming bone spurs. If bone spurs get large enough, they may cause pressure on nerves in the spinal canal, causing pain, numbness, and weakness in the arms or legs. The combination of disc degeneration and bone spur formation in the spine is called spondylosis. Any narrowing within the spinal canal, from bone spur formation or from any other cause is called spinal stenosis. Spondylosis or spinal stenosis can occur at any level in the spine-cervical, thoracic, or lumbar.

Bulging Disc, Protruding Disc, Herniated Disc, Extruded disc
Over time, because of injury or degeneration, discs start to change shape. Many terms describe this change in shape including bulging, protruding, herniated, prolapsed, slipped. They generally describe a disc that is displaced beyond the limits of the intervertebral disc space.

The earliest change in shape many times is in the form of a disc bulge-a wide based extension of the disc. Often, disc bulges do not cause pain. As the degenerative process progresses, the central, nucleus pulposus portion of the disc can extend through a tear in the outer annular wall of the disc, resulting in a focal protrusion or herniation of the disc. Disc protrusions can cause symptoms of pain, numbness, or weakness from nerve root pinching. In some individuals however, disc protrusions will not cause any symptoms. A disc extrusion is a severe version of a disc protrusion in which a large portion of the nucleus pulposus is displaced through the wall of the disc. A disc extrusion is almost always symptomatic.