Surgery

Surgery is an absolute last resort for the treatment of back pain (unless it is required for a surgical emergency).Your physician may suggest that you consider surgery if you continue to experience considerable pain despite nonsurgical treatment and if the cause of your back pain is due to something that can be surgically corrected.

• Surgery is an option in the case of a proven herniated disc
  that is causing the pain. Treating a herniated disc involves
  decompressing the nerve in the back that is causing the
  pain.
  
• Traumatic conditions such as fractures of the spine and
  dislocations may require surgery.
  
• Painful spondylolisthesis where one vertebra slips forward
  on the one beneath it, may also be a reason for surgery.
  
• Neurologic deficits caused by nerve compression or
  instability may require surgery.
  

Surgery For Disc Problems

To determine who would benefit from back surgery to decompress a nerve due to pressure from a herniated disc, the following criteria are usually accepted by most physicians.

The individual must:

• Have a disc pressing on a nerve root, as shown by an MRI
  or CT scan
  
• Have consistent pain despite conservative treatments,
  including a prescribed exercise program
  
• Have severe pain radiating into the buttock or leg,(sciatica )
  that does not decrease with conservative treatment such
  as physical therapy and medication, after 4 to 6 weeks of
  conservative treatment
  
• Have neurological warning signs, like loss of an ankle reflex
  or the loss of urinary control (which is a surgical emergency)

There are several options for relieving pressure on a compressed nerve root:

• Discectomy. Discectomy is one of the most common back
  operations. It involves removing the protruding disc, either
  a portion of it or all of it, that is placing pressure on the
  nerve root. This operation has a very high rate of success.
  In the classic discectomy, the surgeon makes a small
  incision over the disc to be operated upon, and removes
  only the disc material that is pressing on a nerve.
  
• Microdiscectomy. Microdiscectomy is similar to discectomy
  except that it is done with the use of magnification such as
  an operating microscope and requires a smaller incision.
  The surgeon removes the disc, freeing the compressed
  nerve. Microdiscectomy often requires shorter hospital
  stays.
  
• Percutaneous disc removal. This procedure involves
  removing the problem disc fragment through an endoscope
  - a small tube inserted through a tiny opening in the skin of
  the back. A miniature video camera is attached to the tube.
  Using specially designed surgical instruments on the end of
  the tube, a surgeon can cut away parts of the disc and
  remove them by suction through the tube. This leaves
  structures important to stability practically unaffected.
  
• This procedure is performed on an outpatient basis
  (without an overnight hospital stay), and recovery is
  generally faster and less painful. It is less expensive and
  does not require general anesthesia.

However, the procedure does have drawbacks. Because the nerve root and the area outside the disc space cannot be fully visualized by the surgeon, loose disc fragments may be missed. The surgeon cannot be certain that the fragments that are removed were actually what was causing the problem.

• Laser disc decompression. Laser disc decompression
  involves an approach similar to percutaneous disc removal.
  However, laser energy is used to remove the disc tissue.
  The laser energy is introduced through a needle to destroy
  a small amount of nucleus pulpous, thereby reducing the
  pressure on the nerve.
  
• Laser disc decompression is a relatively noninvasive
  procedure that takes place in an outpatient setting, and it
  is performed under local anesthesia with a short treatment
  time of approximately 30 minutes. However, results using
  this technique at this stage have not been impressive.
  
• Chemonucleolysis. Chemonucleolysis is an alternative to
  surgical removal of the disc. Chymopapain, which is
  prepared from the papaya plant, is injected into the disc
  space to reduce the size of herniated discs. The resulting
  decrease in the size of the disc releases pressure on the
  nerve root. The injected disc tends to redevelop itself with
  normal tissue. Because of serious side effects, this
  procedure is not as common as it was once was in the U.S.,
  but some physicians still do perform it.
  

Surgery To Stabilize The Spine

Spinal fusion is a process in which two vertebrae are goined together. Bone grafts are placed between or alongside the vertebrae, to join the bones together. Metal plates and screws are often used to attach the bones to be joined as an internal brace.Fusion occurs when the adjacent bones growing together to form a single bone. A single level may be fused, (for example, the vertebrae across one disc space) or multiple levels, depending on the condition. This approach can return normal alignment and strength between the vertebrae in individuals whose intervertebral structures are unstable because of a fracture or other condition such as spondylolisthesis. A new fusion technique employs a small hollow metal cage that is packed with bone graft and placed in the disc space.

Surgery To Create More Space In The Spine

Laminectomy is a surgical procedure that involves removing the laminae parts of the vertebrae. These are the areas of bone in the back of the vertebrae. When the lamina is removed, more space is created in the spinal canal. This decompresses (that is, takes the pressure off) the nerves or spinal cord. This procedure is especially helpful for people with spinal stenosis, in which the narrowed spinal canal lacks adequate space for the spinal cord or nerves, causing pain in the back and buttocks and weakness in the legs.
Laminotomy refers simply to the creation of a small window in the lamina, rather than removing the lamina, in order for the surgeon to reach the disc or spinal canal. This is commonly done when performing a discectomy (removing a disc).