Spinal surgery -when is it necessary and how is it performed?

Many people suffer from spinal diseases and disorders as a result of old age or wear, an accident or some form of tumour. There is no standard treatment for most spinal diseases, but rather a variety of therapeutic approaches that are tailored to the individual and which may or may not involve surgery. In this article I will explain which factors influence the choice of treatment and what actually happens during spinal surgery.

The most common spinal disorders are slipped discs (herniated discs) and spinal canal stenosis (also known as a constricted spinal canal or constricted vertebral canal) (link only available in German and French). Both disorders are caused by pressure on the nerves, which can lead to pain, disturbances of sensitivity, or signs of paralysis. The treatment of these conditions aims to alleviate the pain and/or resolve the cause of the problem by removing the pressure and ‘freeing’ the nerves again. There are various treatment options available.

Treating spinal disorders with and without surgery

If possible, doctors initially try and treat spinal disorders conservatively and in most cases a combination of pain relief medication and physiotherapy is enough to successfully resolve the problem. Alternative medicine such as acupuncture can also have a positive effect. It is always important to keep moving, in order to strengthen the back muscles. Bed rest and completely resting the back are generally not very beneficial. If normal pain relievers are not enough, pain therapy can be administered using ‘infiltrations’, whereby the medication and pain relievers (e.g. cortisone) are injected directly into the affected area with the help of radiological imaging (e.g. x-ray imaging).

When it comes to surgery, there are also different levels of intervention. The main aim of neurosurgical back operations is always to ‘free’ the nerves and the spinal cord, while also retaining the stability and functioning of the spine. The simplest option is pure ‘decompression’, whereby surgery is performed to free the nerves and no other measures are necessary. In the next level of intervention, the same effect is achieved with mini-implants , which are used for ‘interspinal stabilisation’ or to perform a partial replacement of the intervertebral disc. The implants are positioned in such a way that the spinous process supports the spine and the nerve there is no longer constricted. Furthermore, a mini-implant might be used to seal a hole in the disc. This kind of additional step makes the operation only slightly longer and can be carried out through a tiny incision without much damage to the tissue.

Then there is spinal fusion surgery, which is a more extensive operation. Fusion surgery is performed if the spine requires additional stabilisation. One or more vertebrae are fused together using screws and rods. The longer the fusion, the more complex the procedure. A fusion might be necessary if the spine is already unstable or if it needs to be made unstable in order to free the nerves and the spinal cord. This procedure is also required for the treatment of some tumours, infections or breaks.

Individual factors influence treatment decisions

It is not possible to make blanket statements about when spinal disorders should be conservatively treated or when a certain form of surgery is required. Treatment is always based on the patient’s individual case.

Of course the major indicator is the diagnosis reached using imaging technologies (either x-ray imaging or MRI) (links only available in German and French). But sometimes even these images do not clearly indicate which course of action should be taken. In many cases, the doctor is able to present the patient with various treatment options. The patient can then decide, based on how they feel, whether to continue living with the condition or to undergo surgery. It also entirely depends on the patient’s personal circumstances and expectations.

Take spinal canal stenosis for example, which can occur in different grades of severity: mild, moderate, severe and complete stenosis. In the case of severe or complete stenosis, there is basically no room left for the nerves and the patient can only walk for a few minutes at a time. Under such circumstances, it is relatively clear that surgery would be advisable.

In less severe cases, the decision for or against an operation is not simply based on the images. Some patients’ x-ray images reveal a pronounced stenosis, yet they have relatively few symptoms. Conversely there are patients with a mildly constricted spinal canal who suffer from lots of symptoms. The art lies in weighing everything up based on your experience and the surgical methods available, and present the patient with all the possible options. The patient’s personal circumstances and expectations play a key role in the decision. For example: How physically demanding is their work, what sports would they like to continue playing and how often? It is important that doctor and patient work together to define some kind of goal. A specific goal could be something like being as pain-free as possible in everyday life and being able to play tennis once a week (with the help of a pain killer, if necessary).

If a person can cope with having an infiltration twice a year and it enables them to play their chosen sport, then there is no immediate need for surgery. However, if they require infiltration every four weeks, have constant pain and can no longer do the things they used to do, then an operation is worth considering.

Other factors to take into consideration include secondary diagnoses and the operative risk. For instance, if a patient has diabetes it is not a good idea to administer multiple cortisone infiltrations and surgery would probably make more sense than pain therapy. Yet if a patient faces a high operative risk (due to heart or lung disease or excess body weight, for example), the doctor will tend to be more reluctant to recommend surgery and instead continue trying conservative therapies.

In summary it can therefore be said that treatment is always very individual and is based on the following factors: Diagnoses drawn from medical imaging, the patient’s own perception of pain, their personal circumstances and expectations, secondary diagnoses and the operative risk. The doctor takes all of this into consideration and discusses the relevant options with the patient, so that the patient can make an informed decision. The two major factors that will influence the success of the treatment are the patient’s expectations regarding the operation and the level of trust they have in the surgeon.

Technological advances provide increased safety during spinal surgery

Many patients have a lot of respect for spinal surgery. Of course every procedure entails a certain degree of risk that must be carefully taken into consideration. That said, today’s operations involve far fewer risks than in the past: anaesthesia techniques are safer, operations are shorter and modern implants are easier to use. The incisions are smaller, as many operations are minimally invasive, i.e. they can be performed with much less damage to the surrounding tissue.

Operating theatre equipment has also substantially improved. For a start, we work with the latest microscopes (magnification) and/or endoscopes (cameras for looking inside the body). During complex procedures where it is not possible to precisely see the nerve, for example, neuromonitoring also comes into play. The nerves are stimulated with an electric current, so that they respond and we can localise their position. This technique helps surgeons to avoid cutting the wrong area or placing the implants too close to the nerves.

3D navigation with intraoperative imaging is also very important. For years this technology has been routinely and successfully used for brain operations. In relation to spinal surgery, it is primarily used for spinal fusions. The navigation technology enables us to perform fusions using minimally invasive techniques, without always having to use x-ray imaging. The 3D navigation is similar to a GPS system for a car: first it creates a 3D image. Then reference points are placed on the patient and all the instruments. The camera acts like a satellite within the operating theatre and can reference the position of the points on the 3D image of the body. That means when I use an instrument on the bone, for instance, the computer knows exactly where I am, which I can then see in real time on the image shown on the monitor. So I can use a minimally invasive technique to attach screws and do not have to remove all the muscles in order to see what I’m doing. The 3D navigation can also determine (simulate) a virtual path for the next 1-200 mm, which prevents the surgeon from drilling into the wrong structures. At the end of the procedure, another intraoperative 3D image with CT scan quality is generated in order to see how the implants are sitting. This avoids the need for a second operation later to correct the position of the implants.

There is no straightforward answer when it comes to deciding whether a spinal disorder requires surgery, or what kind of procedure might be necessary. Every treatment should be individually selected and planned, and today’s technologies should ensure that the chosen approach will be as safe as possible.

Article from PD Dr. med. Ali-Reza Fathi, specialist in neurosurgery, areas of expertise: brain, spinal cord and spinal column operations.