Lumbar micro-decompression surgery

The lamina is a piece of bone that forms the roof over the spinal canal. In patients with spinal stenosis, the spinal canal narrows, with resultant pressure on the nerves. Miro-decompression for lumbar spinal stenosis, also called a laminectomy, is a lumbar procedure that can effectively decompress the nerves and resolve the neurologic symptoms.

This procedure is designed to remove a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the nerve root more space and a better healing environment. The spine decompression surgery involves an incision in the midline of the lower back, depending on the extent of decompression necessary. Most patients note an immediate improvement in the preoperative leg pain.

A small laminectomy can be performed as an outpatient procedure, though usually a one or two night hospital stay is necessary, depending on the extent of decompression required.


Microdiscectomy

A lumbar microdiscectomy, another type of back decompression surgery, is designed to remove herniated disc material that is compressing a nerve root, causing pain and/or weakness in the leg.

In a lumbar microdiscectomy, a small incision is made in the midline of the lower back. Precision tools are used to remove a small portion of the lamina, or the bony roof of the spinal canal. The herniated portion of the disc is removed while carefully protecting the nerve roots, under the magnification of a microscope.

Most patients note an immediate improvement in the preoperative leg pain. Lumbar microdiscectomies can be performed as an outpatient procedure, with most patients going home a few hours after the surgery.


Anterior lumbar interbody fusion (ALIF)

In the ALIF approach, an incision is made in the front of the abdomen and the abdominal muscles are retracted to the side to access the front of the spine.

Since the anterior abdominal muscle in the midline (rectus abdominis) runs vertically, it does not need to be cut and easily retracts to the side. The abdominal contents lay inside a large sack (peritoneum) that can also be retracted, thus allowing access to the front of the spine without actually entering the abdomen.

A vascular surgeon usually performs the approach to the front of the spine, since blood vessels in the vicinity need to be protected in this approach.

The disc is removed in its entirety, and a cage with bone graft material is placed in the disc space, decompressing the nerves, and providing stability to the spine. The vertebrae fuse together over the ensuing few months.

An ALIF surgery is advantageous in that, unlike the posterior approaches, both the back muscles and nerves remain undisturbed. Another advantage is that placing the bone graft in the front of the spine places it in compression, and bone in compression tends to fuse better.

Lastly, a much larger implant can be inserted through an anterior approach, and this provides for better initial stability of the fusion construct.


Lumbar Artificial Disc Replacement (ADR) 

Lumbar artificial disc replacement surgery may be recommended to treat chronic, severe low back pain caused by lumbar degenerative disc disease.

Disc replacement is only advised if a minimum of 6 months of nonsurgical treatments are ineffective and if the pain is limiting ability to function in everyday life.

The procedure consists of replacing the painful spinal disc with a device designed to mimic the disc’s natural movement.

For a lumbar disc replacement, similar to an anterior lumbar fusion, an incision is made in the front of the abdomen and the abdominal muscles are retracted to the side to access the front of the spine.

Since the anterior abdominal muscle in the midline (rectus abdominis) runs vertically, it does not need to be cut and easily retracts to the side. The abdominal contents lay inside a large sack (peritoneum) that can also be retracted, thus allowing access to the front of the spine without actually entering the abdomen.

A vascular surgeon usually performs the approach to the front of the spine, since large blood vessels, the aorta and vena cava, need to be protected in this approach.

The disc is removed in its entirety, and an artificial disc device is placed in the disc space, decompressing the nerves while maintaining the normal motion of the spinal segment.

Lumbar artificial disc replacement is a relatively newer procedure compared to lumbar fusion, but has been available in the U.S. since 2000, when FDA studies began. Three lumbar disc devices have been FDA-approved for use in the US, and two are still available.

Data from FDA studies have shown that an artificial disc maintaining motion in the spine decreases the chances of adjacent segment disease. Additionally, study data have shown that artificial disc replacement requires a relatively short recovery time and allows patients to return to activity soon after surgery.

Not all patients with lower back pain are good candidates for a lumbar disc replacement. This procedure is usually reserved for younger patients with a degenerative disc at one or two levels of the spine, no evidence of instability (ie, spondylolisthesis), and in whom the facet joints are not arthritic.


Extreme lateral interbody fusion (XLIF)

XLIF is a minimally-invasive technique to achieve a spinal fusion.

In this approach, a small incision is made on the side of the abdomen, and a specialized retractor and nerve monitoring equipment is used to safely access the spinal disc. The disc is removed, and a cage and bone graft material is placed in the disc space, decompressing the nerves and stabilizing the spine.

Usually, pedicle screws are then inserted through small minimally-invasive incisions from the back of the spine for added stability. The vertebrae fuse together over the ensuing few months as the healing process progresses.

Minimally invasive surgery is advantageous because it may allow for less tissue trauma, less scarring, shorter hospital stays and less postoperative discomfort, thereby affording a decreased need for post-operative pain medication.

This technique, while very useful, is not applicable in every case where a spinal fusion is required, due to anatomic considerations. When an XLIF approach is not possible or safe, other minimally-invasive approaches could be utilized to achieve the desired outcome.


Posterior lumbar fusion

A posterior lumbar fusion is a procedure that stabilizes the lumbar vertebrae by placing pedicle screws and connecting them with rods. In our practice, a posterior lumbar fusion is usually combined with a fusion procedure from the anterior (ALIF) or lateral (XLIF) approach.

This combination allows for restoration of normal spinal alignment and usually achieves a very high fusion success rate (98-100%). In our practice, the screws are routinely inserted with neuronavigation guidance which enhances the safety of the procedure.

Whenever appropriate, the screws are placed in a minimally-invasive fashion using an advanced surgical robot which minimizes the soft-tissue dissection and shortens the recovery time. Once screws are placed, a bone graft is also placed to induce the vertebrae to fuse together.

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