Bulging Disc Treatment

This is generally regarded as the most "tried and tested" method for surgically fusing together two adjacent spinal segments (vertebrae). It involves a three to six inch incision through the midline of the back. A bone graft is harvested from the patient's hip bone (iliac crest) and attached between the "transverse processes" on each side of the vertebrae (such as L4 and L5). Muscles that have been partially dissected during the procedure are then reattached over the graft in order to create tension. Screws, rods and other surgical instrumentation may also be used to encourage a solid fusion by holding the vertebrae in place as the graft heals over time. Whilst the procedure has a long and trusted history, the technique on its own does not offer a way of restoring intervertebral height resulting from a severely thinned disc (spondylosis) and may therefore be reserved for conditions such as sponlylolisthesis, where one vertebrae has slipped forward over another but where the intervertebral disc itself is relatively healthy and does not need to be removed (partially or wholly). The surface area for the graft is smaller and is not exerted to the same amount of body weight compression compared to the "interbody" methods of fusion. This avoids the small risk of graft retropulsion associated with interbody fusion and means the graft does not benefit from compressing forces encouraging bone growth, as opposed to Wolff's law which argues that bones heal better when under compression. This may explain why the chances of achieving solid fusion are reported as being less likely than with the more recently developed interbody methods of fusion.

PLIF is a surgical procedure for fusing together the vertebral bodies of two lower back spinal segments (vertebrae). Most of the damaged disc that lies between the vertebral bodies is removed and replaced with bone graft. This lifts pressure from pinched nerve roots and enables a solid bone mass or "fusion" to form, thus stabilising the spine. With "posterior" interbody fusion, the surgical approach is made posteriorly in the midline of the back. Muscles either side of the spine are stripped away and the laminae and interspinous process from one vertebra are removed so that access can be gained to the intervertebral disc space. The surgeon may also supplement the PLIF procedure with a "Posterolateral Spinal Fusion" whereby a series of screws and rods, as well as bone grafts, are inserted in the back and sides of the vertebrae to provide increased stabilisation.

ALIF is a surgical technique for fusing together the vertebral bodies of two lower back spinal segments (vertebrae). Most of the damaged disc that lies between the vertebral bodies is removed and replaced with bone graft. This lifts pressure from pinched nerve roots and enables a solid bone mass or "fusion" to form, thus stabilising the spine. Surgical access to the disc space is gained from an "anterior" incision through the abdomen. This has the advantage of leaving the bone, muscles and nerves at the back of the spine undisturbed (unlike with other forms of fusion). An anterior approach also allows for a much larger implant, providing better initial stabilisation. However making an incision through the stomach does pose some risk to the important structures in that area, such as major blood vessels, which can require particular expertise from the spinal surgeon and may require an additional (vascular) surgeon to be present during the procedure. For men undergoing an L5/S1 fusion there is also a slight risk (about 1%) of damage to nerve endings controlling valves during ejaculation, meaning that ejaculate can be expelled into the bladder ("retrograde ejaculation"). Erectile function, sensation of ejaculation and orgasm are unchanged, but it can make conception very difficult. For some people a second surgical procedure is planned to take place a week or so after their ALIF surgery to insert screws and/or rods into the back of the spine to provide posterior fixation and additional stabilisation.

This is a minimally invasive surgical procedure for fusing together the vertebral bodies of two lower back spinal segments (vertebrae). Access to the intervertebral disc space is gained through a small incision in the patient's side. This allows major muscles of the back to be avoided. Most of the damaged disc that lies between the vertebral bodies is removed and replaced with bone graft. This lifts pressure from pinched nerve roots and enables a solid bone mass or "fusion" to form, thus stabilising the spine. The procedure may be performed on an outpatient basis, however it is not suitable for all conditions where spinal fusion is an option. For example, it cannot be used on the lowest disc space (L5/S1). A particular risk from the lateral approach is the possibility of damage to the lumbar plexus of nerves serving the thigh (quadriceps) muscles. This risk is minimised by use of an electromyograph (EMG) monitor to warn the surgeon if they are near a vulnerable nerve.

This is a surgical procedure for fusing together the vertebral bodies of two lower back spinal segments (vertebrae). Most of the damaged disc that lies between the vertebral bodies is removed and replaced with bone graft. This lifts pressure from pinched nerve roots and enables a solid bone mass or "fusion" to form, thus stabilising the spine. With the trans-foraminal approach, the incision is made posteriorly to one side of the midline, with the procedure involving removal of one of the facet joints that connects the two vertebrae together. The main theoretical advantages in comparison to PLIF are that this allows for greater visualisation into the disc space, increased disc removal, a larger implant/bone graft and greater distraction of the disc space. However this must be weighed against the fact that an entire facet joint from one side of the spine is removed (rather than a portion of each facet from either side of the spine as with PLIF).

The instrumentation used during this type of spinal surgery has evolved from the pedicle screws and rods traditionally used during posterior spinal fusion. However rather than using rigid screws and metal rods, flexible screws and rods with moving parts are now used instead. The goal of such surgery is to offer stabilisation of an intervertebral segment without fusion, i.e. allowing controlled motion between the two vertebrae. By preserving near normal movement at the operated level, the hope is to avoid the increased strain on adjacent levels of the spine that can develop several years after traditional fusion operations.

The lamina is the name of part of a vertebral segment that forms a bony ring or "canal" around the spinal cord and spinal nerves. This canal becomes narrowed in conditions such as spinal stenosis, causing encroachment on the spinal cord and nerves. Spinal stenosis most commonly affects older age groups who suffer generalised wear and tear in the spine. Lumbar spinal stenosis affects the lower back and usually manifests as leg pain whilst walking. "Laminectomy" surgery was developed in the early 1900s and involves a three to five inch incision being made in the lower back. The paraspinal muscles are dissected off the lamina on both sides of the spine, the lamina and spinous process are then completely removed, effectively making the spinal canal at that segment into a semicircle rather than a ring of bone, which frees up or "decompresses" the nerves. Success rates for relieving leg symptoms from spinal stenosis is around 70-80%, although a laminectomy is less reliable for relieving back pain. There is around 1–3% chance of complications occurring, such as nerve damage, incontinence and infections. Also there is a risk for some patients that by removing many of the stabilising muscles and ligaments of the vertebra, segments of the spine may become destabilised, leading to chronic back pain and weakness. Stenosis symptoms can also reoccur several years after the surgery, when the degenerative processes that originally caused the stenosis continue. In some cases where stenosis is combined with an unstable segment, stenosis may be prevented from reoccurring by performing a fusion at the same time as the laminectomy. For some people, an alternative to laminectomy is laminoplasty, which involves a smaller incision, removing the lamina from only one side of the vertebra, thus preserving more of the supporting structures of the spine.

A posterior surgical technique developed in the 1980s as a less invasive alternative to lumbar laminectomy, which involves cutting through the lamina on just one side of a vertebra (rather than both sides as in a laminectomy). This creates a hinge in the lamina which is used to widen the spinal canal in order to decompress the nerves. The newly widened canal is then sealed with a bone graft. One of the main advantages of laminoplasty is that, in contrast to a laminectomy, much of the supporting structures of the vertebra, such as the muscles, ligaments and spinous process, are preserved. Despite the fact that laminoplasty is a less invasive alternative to laminectomy, some surgeons do not offer it because it is a more time-consuming operation and requires specialised training and equipment, such as an operating microscope.

This is one of the most widely available minimally invasive surgical techniques for treating sciatica due to a pinched nerve root from a herniated or bulging disc. The surgeon uses an operating microscope or glasses (Loupes) in order to reduce the size of the incision needed to access the disc. A small 1 to 2 inch incision is made, slightly to the side of the midline in the lower back. Muscle tissue is gently divided and a small amount of ligament and bone is removed from the lamina and/or facet joint in order to create a window through which the surgeon can remove the bulging portion of the disc and free the trapped nerve root. Lumbar microdiscectomy is reportedly 95% successful at reducing sciatic pain in the leg, with the best outcomes experienced by patients who have had sciatica for less than three to six months. Many cases of sciatica caused by an isolated disc bulge will improve on their own or with the help of physical therapy. If such improvement is going to be achieved without surgery, it will generally happen within 6 to 12 weeks. Therefore, except for severe cases or in the presence of "Cauda Equina Syndrome", the usual advice is to wait at least 6 weeks before considering surgery. There is a small risk (5–10% chance) of the disc bulge reoccurring after surgery, which is more likely within the first 3 months, but can occur several years after surgery. For this reason some surgeons excavate some of the inner part of the disc in addition to removing the bulging portion so that there is less disc material capable of herniating again in the future. This must be weighed against the fact that the more of the disc material removed, the less of it there will be to perform its roles of providing shock absorption and height between the vertebrae and exiting nerve roots. Excessive disc excavation could potentially lead to premature load and degeneration on other structures of the spine, such as the facet joints, several years later.

This is a minimally invasive surgery performed through a small diameter tubular device inserted into the back. This technique is most commonly performed to remove the herniated or prolapsed portion of an intervertebral disc that is compressing the adjacent nerve root causing sciatic pain in the leg. Unless using a "transforaminal approach", access to the spinal nerves is gained through the midline, which involves removing small amounts of bone, similar to a microdiscectomy. An endoscopic lumbar discectomy is designed to be even more minimally invasive than using a microscope (microdiscectomy). Popularity for endoscopic lumbar discectomy is lacking amongst some surgeons because of concerns it gives limited visualisation of the disc compared to microdiscectomy. The complication rate is also reported as being higher, with the procedure requiring specialised training and being technically more difficult to perform.

This is keyhole lower back surgery, whereby an endoscope is used to "walk up the nerve" through the neural foramen (the hole through which the nerve root emerges from the bony spinal canal). This "transforaminal" approach is designed to cause the least amount of disruption to the spinal musculature and bony architecture (even less than traditional endoscopic spinal surgery), whilst at the same time allowing for good visualisation. Once in the foramen, the bulging portion of a herniated disc can then be removed in order to reduce nerve root compression.

As above, this is keyhole lower back surgery, whereby an endoscope is used to "walk up the nerve" through the neural foramen (the hole through which the nerve root emerges from the bony spinal canal). This "transforaminal" approach is designed to cause the least amount of disruption to the spinal musculature and bony architecture whilst at the same time allowing for good visualisation of the nerve, disc, facet and associated ligaments. Once in the foramen, as well as removing bulging portions of intervertebral discs, the neural foramen can be cleared of scar tissue, nerve adhesion and bone spikes with the use of a laser. This type of surgery is not widely available and is technically difficult, requiring specialised equipment and training.

This is the most minimally invasive of all the surgical techniques, designed to reduce an intervertebral disc protrusion. The procedure is performed under x-ray guidance using a probe or needle inserted into the affected disc. The intention is that there is the least amount of disruption to the posterior spinal muscles and other soft tissues. In reality, the surgeon cannot visualise or access as much of the disc as with other minimally invasive procedures, such as microdiscectomy, and the success rates are not as good, however it may be appropriate for some selected cases. If the procedure fails the patient may be able to move on to others, such as microdiscectomy or endoscopic surgery.

This procedure is usually performed on an outpatient basis, involving a device introduced via a hollow needle that removes part of the inner nucleus of an intervertebral disc in order to reduce pressure within it, thereby shrinking the disc so that it exerts less pressure on neighbouring structures, such as pinched nerves.

These relatively new surgical implants are designed to replace the facet joints and associated bony projections that form the posterior architecture of a vertebral segment in the spine. They are primarily used for patients with unresolved facet joint pain and/or spinal stenosis caused by severe degeneration of the facet joints. These devices are designed to preserve movement of the spinal segment, unlike spinal fusion, yet allowing more stabilisation and control of movement than a total laminectomy. However these devices are relatively new on the market and do not have the outcome history of more extensively used procedures.

Offered by some surgeons as an alternative to lumbar fusion, whereby a damaged intervertebral disc (the cartilaginous cushion that sits between two vertebrae) is replaced with an artificial one. Advantages over spinal fusion are that the surgery is less complex and is quicker to perform, with the main theoretical advantage being that movement between the vertebrae is preserved, thus reducing the negative effects on adjacent levels that can occur with spinal fusion. More recent styles of prosthetic discs also offer shock-absorbing qualities. Lumbar artificial disc surgery has been available in European countries for around 15 years. Currently only around 50% of spinal surgeons offer the procedure, often because they are sceptical about the reality of how much movement the prosthesis allows or are concerned about the possibility of the artificial disc becoming dislodged.

A small prosthetic spacing device is inserted between the spinous process of two adjacent vertebrae to limit the amount of backward bending movement (extension) allowed at that level of the spine, thus preserving the patency of the foramina or tunnels through which the spinal nerves pass. This procedure is designed to alleviate pressure on spinal nerves experienced in conditions such as spinal stenosis. Some reports have also suggested that, in some cases, patients will experience other unintended benefits, such as reduced pressure on painful degenerative discs. The procedure is relatively inexpensive and since the spinous processes lie near the surface of the body, the procedure is relatively uncomplicated and may be performed on an outpatient basis. However it is by no means suitable for everyone: for example, people with weakened bones, such as those with osteoporosis, may be at risk of the device causing a fracture to their spinous processes.

ACDF is one of the standard techniques used to treat degenerative disc disease in the neck (cervical spine). An incision is made through the front of the neck to avoid the delicate nerve endings and spinal cord that would be vulnerable from accessing the spine with a posterior incision. The damaged disc and debris is removed, ready for insertion of a spacer device containing a bone graft. This lifts pressure off of nerve roots and the spinal cord, which may have been caused by the damaged disc. The vertebrae above and below the disc space may be fixed together using a plate and screws. Over time the bone graft knits the two vertebrae together, forming a solid stable bone mass or "fusion". This is a reliable technique with good success rates and outcomes. However there are concerns that, for some individuals in the longer term, fusing two vertebrae together, thereby eliminating movement at that level, may cause premature wear and tear at other nearby levels of the spine.

This surgery is designed to treat severe cervical stenosis or diseased vertebral bodies in more than one level of the neck. This procedure is completed through an incision in the front of the neck. The surgeon removes one or more vertebral bodies as well as discs above and below each segment in order to fully decompress the spinal canal. The defect is then reconstructed with a bone graft to create a multilevel fusion. This is extensive surgery performed on cases involving significant deformity, therefore the risks of complications, such as damage to the spinal cord and nerves, are higher than with other procedures.

This type of surgery is completed through a 3 to 4 inch incision in the back of the neck. During the procedure the lamina, spinous process and overlying muscle on both sides of the neck is removed from one segment of the cervical spine. This effectively turns the ring of bone called the spinal canal, through which the spinal cord passes, into a semicircle. This alleviates pressure on the spinal cord in cases where it was being compressed due to narrowing of the bony spinal canal. The main risk from this operation is that damage could be caused to the spinal cord, nerves and membranes. To lessen this risk, the surgeon will often use specialised electrodes to monitor spinal cord function during the procedure (Somatosensory Evoked Potentials – SSEPs). By cutting away much of the supporting muscle, ligament and bone of the operated segment there is also risk of the spine at that level developing instability and deformity. Therefore cervical laminectomy is sometimes performed in combination with cervical fusion surgery.

This is a surgical technique involving cutting through one side of part of a bony segment in the neck called the lamina. The lamina forms part of a ring of bone at each vertebra, called the spinal canal, through which the spinal cord passes. This canal becomes narrowed in conditions such as spinal stenosis, causing encroachment of the spinal cord and nerves. Once an opening has been created in the lamina, this creates a hinge allowing the spinal canal to be widened, with a bone graft then used to seal the opening. An attractive feature of cervical laminoplasty is that, unlike fusion, it preserves movement of the operated segment, therefore lessening the likelihood of premature degeneration of adjacent segments. Also, compared to laminectomy, much of the muscle, ligament and bone is preserved, thus reducing the likelihood of post-operative instability. However by approaching the cervical spine posteriorly and cutting through the lamina on just one side, it may be more difficult for the surgeon to assess whether or not the canal has been well decompressed. Also, there is a small amount of risk of damage to the spinal cord and nerves exposed in the area during such a posterior approach. This risk is less for other procedures used for spinal stenosis that access the spine from the front of the neck, such as Anterior Cervical Discectomy and Fusion (ACDF).

This is the surgical replacement of a damaged or degenerated disc in the neck, initiated by making an incision in the front of the neck. This enables the surgeon to avoid the delicate nerve endings and spinal cord that would be vulnerable from accessing the spine posteriorly. The defective disc is removed, the area cleaned and a new artificial disc is inserted into the disc space. This lifts pressure off of nerve roots and the spinal cord at the same time as maintaining movement at that level of the spine. Artificial disc replacement in the neck is now an established reliable technique, although it is not as "tried and tested" as other more traditional techniques, such as Anterior Cervical Discectomy and Fusion (ACDF). The obvious advantage over ACDF is that it allows movement of the vertebral segment and so reduces the chance of premature adjacent level wear and tear that is associated with fusions.

This keyhole surgery performed on the cervical spine (neck) is most commonly performed to decompress trapped nerves caused by disc herniation. The advent of such technology in the cervical spine has allowed for small incisions and less disruption to muscle and other tissues than with other more invasive techniques, such as disc fusion or disc replacement. Also, whereas removal of the whole disc may once have been a patient's only option, where appropriate, cervical endoscopic spinal surgery potentially means removing just the herniated portion of a cervical disc is possible whilst preserving its remaining healthy portion. Popularity for endoscopic spinal surgery is lacking amongst some surgeons because of concerns it gives limited visualisation, the procedure requires specialised training and is technically more difficult to perform.

Spinal surgery is performed on the middle back (thoracic spine), which is the part of the spine where the rib cage attaches to it. Thoracic spine surgery is far less common than neck or lower back surgery because degenerative changes in the discs and joints are often asymptomatic. It is usually only reserved for rare cases that cause spinal cord compression, progressive neurological deficit and intolerable pain. Thoracic laminectomy is the traditional historical approach to thoracic spine surgery, involving an approach through the midline of the spine, removing the lamina (portion of a vertebral bone) and pushing the spinal cord aside in order to gain access to degenerative discs. This approach has now largely been replaced by more minimally invasive procedures.

Spinal surgery is performed on the middle back (thoracic spine), which is the part of the spine where the rib cage attaches to it. Thoracic spine surgery is far less common than neck or lower back surgery because degenerative changes in the discs and joints are often asymptomatic. It is usually only reserved for rare cases that cause spinal cord compression, progressive neurological deficit and intolerable pain. During the Costo-Transverse Ectomy procedure, a small amount of vertebral bone (transverse process) and rib is removed in order to gain access to the thoracic spine.

Spinal surgery is performed on the middle back (thoracic spine), which is the part of the spine where the rib cage attaches to it. Thoracic spine surgery is far less common than neck or lower back surgery because degenerative changes in the discs and joints are often asymptomatic. It is usually only reserved for rare cases that cause spinal cord compression, progressive neurological deficit and intolerable pain. Trans-thoracic surgery involves approaching the thoracic spine through the front, either via an open procedure through the chest cavity or, in some centres, via a minimally invasive procedure involving a number of small incisions, arthroscopes and a video screen (Video Assisted Thoracic Surgery, VATS).

This minimally invasive surgery for the middle back (thoracic spine) involves an anterior approach through the chest cavity, using a number of small incisions, arthroscopes and a video screen.

Spinal surgery is performed using an endoscope whilst the patient is sedated, but conscious, to enable the patient to provide instant feedback to the surgeon about sensitive pain-provoking structures. This technique is most appropriate in cases where there may be some doubt as to the exact cause of a patient's pain pattern, so that the source of pain can be more accurately identified, rather than relying on what "looks" likely from an MRI scan.