Listed below is the step by step procedure of spine surgery:
- What is Spine Surgery ?
- Why is Spine Surgery Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of Spine Surgery
- Post Procedure
- Risks and Complications
What is Spine Surgery?
Spine surgery can be called as any type of surgery to correct problems affecting the vertebral column which cannot be resolved with the help of conservative treatment.
The 33 bones (vertebrae) of the spine define us as vertebrates. One of the strongest group of bones in the body, the spine is responsible for our erect posture and houses the peripheral nervous system. It starts with the atlas and ends at the coccyx. The spine curves according to corresponding regions of the body and can be divided into five parts -
- The cervical spine
- The thoracic spine
- The coccyx
- The sacrum
- The lumbar spine
Deformity or abnormalities in any section/part of the spine which cannot be treated successfully with conventional or non-invasive methods, necessitates the need for surgery. Spine surgeries consist of different techniques and approaches that aim to restore the physiological (natural) form and function of the backbone.
Why is Spine Surgery Required?
- To remove herniated disc (slipped disc): A disc is a kind of spongy bone which is found in the intervertebral space. If it gets damaged due to some reason, it will bulge out of its space or break open.
- Loss of control: When bladder and bowel movements get altered accompanied with progressive sensory and motor weakness.
- Radicular pain: Pain in the lower limbs along the course of a spinal nerve due to inflammation, compression or trauma to the nerve which cannot be resolved with conservative management.
- Spinal stenosis: It is the narrowing of open spaces in the spine which in turn compresses the nerves.
- Degenerative disc disease: Age related natural breakdown of the intervertebral disc.
- Slippage of discs in the spine: Isthmic spondylolisthesis (forward slipping of one vertebral disc over other due to trauma) and degenerative spondylolisthesis (forward slipping of one vertebral disc over the other due to increase in age)
- Scoliosis: S' or 'C' shaped deformity of spine.
- Trauma: The spine may get fractured.
- Tumors of spine: Vertebral column tumors, intradural-extramedullary tumors and intramedullary tumors of the spinal region can be treated with a mixed approach of surgery, chemotherapy and radiotherapy.
- Kyphosis: This is a spinal deformity where in, the spineal column loses its normal curves and person develops a hunched back. It gives a bulge to the patient's back in the shoulder area.
- Joint calcification: Vertebrae located adjacent to each other form a joint together. In some instances, there may be excess of calcium deposition in the joint area which in turn compresses the spinal nerves.
- Cartilage erosion: A layer of cartilage is present between two vertebrae which has a cushioning impact. Due to prolonged stress, this layer of cartilage may erode and reduce the gap between vertebrae, causing compression of nerves that come out of this gap.
To prepare for the battle against your spine issue, it is important that you take care of a few things
- If you are a smoker, try stopping at least a month prior to surgery. You may experience a few withdrawal symptoms once you start doing so. Your doctor can help you with this by suggesting some chewable gums or nicotine patch.
- Control your intake of alcohol.
- If you have a history of any heart, liver, kidney, respiratory or bleeding disorder or you suffer from any metabolic disorder like diabetes, let your doctor know. You should obtain clearance for surgery from your general physician in order to proceed.
- Give details of any medications you are currently taking, especially blood thinners (warfarin, clopidogrel, ticlopidine), oral-hypoglycemic drugs, ACE inhibitors (for high BP), insulin (diabetes) and pain-killers.
- The key to a better recovery is being proactive. You should clarify all your doubts regarding the procedure with your surgeon and anesthesiologist.
- You should stop taking pain-killers like ibuprofen, aspirin, diclofenac (NSAIDs) etc., 7-10 days before surgery. If you take certain herbal supplements, you can avoid them for the same time period.
- Anticoagulants should be stopped as per your surgeon's recommendations.
Routine Tests To Be Carried Out Before Surgery
Before you proceed to any type of surgery, your doctor will advise to undergo some tests. These tests and reports should be prepared in 30 days before the procedure.
- Blood Tests: Complete blood count (CBC), hemoglobin (Hb), blood pressure (BP), erythrocyte sedimentation rate (ESR), blood grouping, bleeding time (BT), clotting time (CT), prothrombin time (PT), partial thromboplastin time (PTT) tests are needed to rule out any abnormalities in blood circulation.
- Urinalysis: This helps in checking specific gravity and color of urine. Examining any presence of blood, sugar, pus cells or protein is done using special chemicals.
- Renal function test: Blood urea nitrogen (BUN) and creatinine levels are calculated to check efficiency of the excretory system (kidneys).
- Liver function tests: Aspartate transaminase (AST) and alanine transaminase (ALT) levels fluctuate in presence of liver abnormalities.
- Electrocardiogram (ECG): It is done to plot the current electrical activity of heart.
- Treadmill Test / Stress test: Performed in patients who are suspected of suffering from any heart disease.
- Chest X-ray: An imaging test used to detect any abnormalities of the thoracic (chest) cavity.
- Repeat clinical examination: To confirm final diagnosis
- Airway evaluation: To check suitability for intubation.
Here is a list of a few tests that are specifically used to identify spine issues:
- Physical Exam:
Your doctor will check the signs and symptoms in correlation with your complaint. The kind of pain you are experiencing, muscle weakness, reflexes, spine and neck motion and sensory changes will be evaluated.
There may be some special signs that may or may not be related to your present condition such as abnormal pulse, any abnormality in the chest cavity etc. that cannot be ignored.
This is a standard test used to view anomalies of the spine. Radioactive waves are projected on the affected site and the image formed is studied on a film. Spurs (sharp bony projections), decreased intervertebral space, fractures, facet enlargements are seen easily. Since X-rays can only show hard tissue and not soft tissue, other imaging modalities are needed to study soft tissues.
- Computed Tomography (CT Scan):
Radiations are used to generate 3-D images of the spine in thin slice-like cross sections, thus providing more details of both hard and soft tissues.
- Magnetic Resonance Imaging (MRI):
This technique uses magnetic and radio waves that form an image on the computer screen. It is an ideal imaging test to view soft tissues such as nerves, ligaments and muscles. Facet enlargements, stenosis (narrowing of spinal canal), loss of water from the disc and herniated discs are best seen using MRI.
A radiocontrast dye is inserted in the spinal cord by your doctor using a needle. The dye now mixes with the spinal fluid and an X-ray is taken. This helps in studying both soft tissue as well as hard tissues in the spinal region. A myelogram is often used in combination with X-ray results.
- Electromyogram (EMG) / Somatosensory Evoked Potential (SSEP):
It examines the electrical signals that leave the spinal cord. The function of nerve roots present in the spinal region is tested. Electrodes are placed on the muscles of the lower extremities and a current is passed through them. If the contraction of muscles is alright, then that nerve is functioning fine. But if the results seen on the muscles are abnormal, then there are chances that the nerve has been irritated somehow.
- Bone Scan:
Bone scans find their usefulness in instances where the actual cause of spinal pathology cannot be ascertained. Radioactive markers known as 'tracers' are inserted in the blood stream via intravenous route.
These tracers then attach themselves to areas of bone that are undergoing rapid changes. Because the tracers are radioactive, they will emit radiations which can be captured with the help of a camera.
- Spinal Tap:
Spinal tap or lumbar puncture is done to study cerebrospinal fluid (CSF) found in the meninges (coverings of brain and spinal cord). Normally, CSF is a clear fluid and contains some amount of sugar, proteins, enzymes etc. But in pathologic conditions, CSF samples may contain white blood cells, pus cells or blood.
- Facet Joint Block:
Facet joints if irritated can cause a lot of pain. The clinician will numb the area with the help of a local anesthetic such as lidocaine. If the joint area numbs completely, it can be safely assumed that there is a problem bothering that region.
This diagnostic process takes about 40 minutes. A dye is injected in the intervertebral discs and image is seen via fluoroscopy. It offers a better view of the intervertebral discs than X-rays or myelogram. They determine the extent of damage to discs.0
Day Before Spine Surgery
- Make sure to pack all your things, such as loose comfortable clothing, a pair of slippers, books, anything that will help you keep distracted from thinking about the surgery. You can bring along comfortable sneakers or shoes to wear after surgery.
- You will be required to fast the entire night before surgery. No food or drink for at least 12 hours before the procedure day is allowed.
- Keep all your valuables at home.
- You can ask a dear one to accompany you to the surgical center and be with you throughout the recover in hospital.
- Take a bath before the procedure day. Your doctor would have provided you with an antiseptic cleanser that you can apply over the affected area before surgery.
- Do arrange for a conveyance to drop and pick you up from the surgical center.
- Take care to reach the surgical center on time.
- Bring all your previous test reports and CT/MRI scans so that your surgeon can review them.
- Hypertensive patients should not take ACE (Angiotensin converting enzyme) inhibitors and ARBs (Angiotensin receptor blockers) on this day.
- Diabetics can avoid taking oral-hypoglycemics or insulin.
- Unless you are suffering from congestive heart failure, it is advisable that you don't take your morning dose of diuretics.
- Your surgeon and anesthesiologist will discuss the procedure with you one last time. If you have any doubts, feel free to clarify.
- The nursing staff will measure your vitals (BP, pulse, temperature) and repeat few lab tests if any.
- Remember to go through the consent form carefully, which outlines the procedure with associated risks and complications. Once satisfied, you can sign the form.
- You will be draped in a clean surgical gown before being taken to the operation theater. An I/V line will be placed in your vein and TED (thromboembolism deterrent) stockings/hose will be placed on your legs. This prevents any clot formation in your legs during and after surgery.
Being a spinal surgery, airway management is of utmost importance to help breathing after administering anesthesia, especially in cases of disorders of cervical and thoracic spine. The respiratory system is usually impaired in people with spine problems. A full neurological and cardiac examination should also be carried out to avoid any further deterioration of the present condition.
Bronchodilators (medicines which widen your air passages) are used sometimes to increase efficiency of the respiratory system. Anti-cholinergic drugs can be used in people who are suffering from high spinal cord lesion.
Oxygenation should always be done prior to giving anesthesia. General anesthesia is the preferred approach and is given either by intravenous or inhalational route. The route selection is dependent on the patient's physical condition and ease of maintaining proper airway.
Isoflurane, halothane or propofol are the choice of anesthetics for spine surgeries. A sedative drug such as remifentanyl is given to put you to sleep. The anesthetic state is maintained with the help of nitrous oxide and oxygen. The choice of muscle relaxants to be given this time should be decided after its effects on the cardiovascular system and electrolyte levels.
Methods/Techniques of Spine Surgery
Various approaches to spine surgery are discussed here:
- Discectomy (to remove herniated/slipped disc)
A discectomy procedure intends to stop motion across a certain section of spine in order to encourage fusion of bone. It can be performed in cervical, thoracic or lumbar spine.
Incisions measuring 2-3 inches are made in the affected region, thus exposing the spine. The overlying fascial and muscular attachments are separated and the bulging disc is removed with the help of special surgical instruments. After this, a piece of bone graft is placed in the gap created. Metal plates are fixed with the help of screws over this graft to secure and stabilize the spine into position. The wound is later on closed in layers.
It is a minimally invasive procedure in comparison to conventional discectomy, which is an open surgery. Instead of complete removal of the herniated disc, only bulging pieces of disc are taken out and wound is closed. It gives better results and has a shorter recovery time, with no major alteration in structure of the spine.
- Foraminotomy, Foraminectomy
These terms can be used interchangeably to describe a procedure which is used to relieve pressure on the spinal nerves. Spinal nerves travel through small tunnels and openings known as foramina (singular - foramen). In conditions such as spinal stenosis, facet arthritis and disc herniations, these foramina narrow down and compress the nerve, which leads to irritation and associated symptoms.
When a large section of bone and tissues need to be removed for decompression, the procedure is termed as foraminectomy.
- Laminectomy, Laminotomy, Laminoplasty
A pair of laminae along with the spinous process, form the posterior (back) wall of the bony spinal canal. Thickening of the bone in lamina region can compress and irritate the nerves. Depending on the amount of lamina that is removed or recontoured, the procedure is termed as laminectomy, laminotomy or laminoplasty.
The area to be operated upon is cleaned with a disinfecting solution and an incision is made. The muscles and other attachments to the lamina and spinous process are separated. Using a surgical instrument called kerrison rongeur, bits of bone are carefully trimmed away to achieve the desirable shape of lamina. Thus, the spinal canal is enlarged and the wound is closed in layers using sutures (stitches).
- LASER Surgery
LASER stands for Light amplification by stimulated emission and radiation. An intense beam of energy (light and heat) is used to cut through and vaporize tissues. Laser surgeries give the added benefit of an almost bloodless surgery and no requirement of stitches.
- Spinal Osteotomy
An osteotomy refers to cutting or sectioning of bone in a controlled manner. Spinal osteotomies find their use in treating a prominent deformity such as flatback, flatbuttock, scoliosis, etc.
The required bone is cut into sections after exposing and the remaining portion is stabilised with the help of other biocompatible materials. Being a risky procedure, osteotomy poses risk to damage of delicate soft tissues like nerves and blood vessels.
- Spinal Fusions
Spinal fusions involve types of surgeries meant to create a solid bony bridge between two or more bones. For fusion to be successful, bone should be able to grow in the area it is placed in a gradual and solid fashion.
Bone graft (a piece of living tissue transplanted surgically) is placed in the gap created in spinal area and stabilised with the help of brace, cast or spinal instrumentation. This is followed by a waiting period of about 7-9 months to allow room for bone growth.
The source of bone graft can be:
Autologous grafts and allografts are obtained from the iliac crest (a part of pelvic bone), fibula (bone along the inner side of calf) or the spinous process. Demineralized bone matrix (DBM) and calcium phosphates or hydroxyapatites can be used as synthetic graft materials.
- Autologous: From the patient's own body.
- Allograft: From a cadaver (dead body) or a donor.
- Synthetic: An artificial made graft.
Types of spinal fusion surgeries:
The success of spinal fusion is dependent on the technique used, graft adaptation and proper post operative rehabilitation.
- Long spinal fusion: Used to treat scoliosis and Scheuermann's kyphosis.
- Short spinal fusion: Fractures or long disc herniations may be treated using this method.
Vertebrae of the spinal column are strengthened with the help of a cement-like material called polymethylmethacrylate (PMMA). Incisions are made on the back and a small needle is passed inside the collapsed bone. After gaining proper entry, instruments including a small tube having a balloon is inserted and inflated inside. This creates a space where PMMA will be filled. Slowly this cement hardens, creating a set support for the spine.
Kyphoplasty is especially beneficial in cases of fractures of the spine.
- Thoracoscopic Release
Kyphosis and scoliosis can be treated with this type of approach. It is a special type of surgery of the thoracic spine using an endoscope. The endoscope is fitted with a camera which helps in visualization of the affected area.
The patient is made to lie on the side and the chest is cleaned with a disinfecting solution. Small incisions are made here for entry of the endoscope and other surgical instruments. The lung overlying the affected portion of spine is deflated and respiration is enhanced with help of the other lung and special intubation techniques.
Using visuals from the endoscope, the chest cavity and spinal column are seen and required muscles, ligaments and bones are resected as needed to restore normalcy of the spine. After successfully gaining motion, the surgical instruments are removed, lung is re-inflated and incisions closed.
For most of the spinal procedures except thoracoscopic release, the patient is made to lie in a prone position (lying on the belly).
On an average, all spinal procedures take about 1-3 hours to reach completion.
Immediately after surgery, you will be taken to the recovery room or surgical intensive care unit (SICU). You would have to spend 1 night there, after which you will be shifted to your ward.
- The nursing staff will give you pain-relief medications through an I/V line. Soon the I/V line will be stopped and you will be able to take pain-killers orally.
- You would be given a brace to wear after surgery so that your affected portion of spine remains stabilised after surgery.
- A simple bland diet will be given to you while you are in the hospital. Most of it will consist of fluids. Once you are comfortable with taking fluids, your diet will be modified as per your needs.
- After sometime, a physiotherapist will be in touch with you and ask to perform a few exercises such as simple stretches, leg and ankle rotations.
- You will feel tired for some time after the surgery. So it is important that you take plenty of rest.
- Simple exercises should be started as soon as possible to help your spine regain the necessary strength.
- Always keep your head slightly elevated while sleeping or lying down on your back. You can use a few pillows to prop-up your head, or an adjustable chair is just as good. Put some pillows below the knees so that they remain bent throughout.
- Stretching regularly with the help of your physiotherapist keeps your spine supple in the long run.
- Start with slow gentle activities like walking daily to increase blood circulation in the treated area. But take care that you avoid any twisting or bending activities. Heavy weight lifting, pushing or pulling activities aren't allowed either.
- Whenever you experience little discomfort or pain, use ice-packs over the affected area. Using hot fomentation (the usage of heat to relieve pain) should be avoided in the initial days because heat can trigger inflammation and result in swelling of the area.
- Always try to maintain a good back posture throughout the day. You can start lifting things as and when your spine starts to regain its strength.
- You can start driving 2 weeks after surgery on the approval of your surgeon. Begin with small trips and gradually move on to longer trips. But take care to take small breaks after 30-45 minutes of driving. It is preferable that you take the passenger seat until you recover completely.
- The incisions would have been closed with either dissolvable sutures or staples. The staples will have to be removed 10-14 days after surgery by the nursing staff.
- A small drain is usually placed with the incision which is removed once the wound becomes dry. The incision can be left open to the air after this.
- Take careIf you happen to experience any of these problems after your surgery, contact your doctor at the earliest not to let the incisions get overtly wet. Avoid applying any lotions or antiseptics in the area.
- Eat a diet rich in calcium, protein, vitamins and minerals.
- Drink plenty of fluids everyday and have a lot of fiber. Stool softeners should be taken so that constipation is relieved because of narcotic medications.
- You will be prescribed pain-medications on the day of discharge. Take them exactly as prescribed by the doctor.
- Ideally you should be able to wean off these medications in 3 months or so. If not, tell your doctor at the earliest.
- Instead of conventional non-steroidal anti-inflammatory drugs (NSAIDs), a multimodal approach is used which combines NSAIDs with opiod analgesics. This helps in delivering effective analgesia with lower side effects.
- In severe cases of pain, the surgeon might consider giving you a spinal or an epidural anesthesia to numb the region.
- When it comes to taking a bath post surgery, opt for sponge-bathing. Showers and tub baths put you at a risk of reinfection.
- Cover your incisions with a plastic wrap whenever you clean yourself.
The initial recovery period after a spine surgery will take about 6-12 weeks during which your first follow up visit will be scheduled.
After a period of 6 weeks you will be recalled by your surgeon to check how well are you doing. X-rays of the spine will be taken and your incisions will be inspected for abnormalities. If you experience any discomfort you can tell the doctor about your experiences. Your physiotherapist will teach you a new set of exercises to strengthen the lower back.
Risks and Complications
Complications associated with spine surgeries can be categorized into:
- Complications associated with use of general anesthesia:
These include nausea, vomiting, dizziness, respiratory distress, coma, death.
- Complications associated with spine surgeries:
- Possible damage to spinal nerves and other soft tissues
- Permanent numbing of the nerves
- Possibility of spine not healing properly and instability persisting
- Back pain not subsiding
- Pain radiating from the lower back to legs, a condition known as sciatica
- Inspite of patient given to wear TED stockings, chances of formation of blood clots in the legs; thus increasing the risk of deep vein thrombosis
- Body rejecting bony graft placed during spinal fusion surgery
- Malunion of the joints takes place if enough immobilization and stabilization is not done. This is known as pseudoarthrosis.
- Uncontrolled bleeding during or after surgery
- Loss of control over bladder and bowel movements
- If you happen to experience any of these problems after your surgery, contact your doctor at the earliest:
- Shortness of breath
- Worsening pain or pain not subsiding
- Different sensations in your arms (if you had neck surgery) or legs (surgery in the back)
- Pain in the calves
- The drainage from incision changeing its color (green)
- Fever (101 degree F) with chills
- Poor control on bladder and bowel movements
The road to recovery from a spine surgery is a long one. A proper post operative rehabilitation along with regular follow up appointments will help you maintain good spine health and give a better quality of life.
More information related to Spine Surgery
- Information on Spinal Fusion Surgery
- Information on Spinal Decompression Surgery
- Information on Laser Spine Surgery
- Information on Cervical Spine Surgery
- Information on Laminectomy
- Information on Lumbar Discectomy
- Information on Lumbar Puncture
- Information on Vertebroplasty