Surgical Treatment Options
Decompression surgery involves removing a small portion of the bone over the nerve root and/or disc material from under the nerve root to relieve pinching of the nerve and provide more room for the nerve to heal (a microdiscectomy or laminectomy).
Lumbar Spinal Fusion
Lumbar spinal fusion involves using a bone graft to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. Spine surgery instrumentation (medical devices), bone graft procedures, and the bone stimulator are sometimes used along with spinal fusion surgery.
It should be known that while spinal fusion has been a classical treatment for ongoing pain from the lumbar spine, alternatives to fusion do exist for posterior conditions (problems in the back of the lumbar spine) such as spinal stenosis. Inserting an interspinous process spacer like the X-STOP device can actually preserve motion as opposed to stopping it via fusion.
The role of spine fusion instrumentation is to provide additional spinal stability while helping the fusion set up.
Various forms of instrumentation (medical devices) have been developed with the goal of improving the rates of successful spinal fusion. Because bone tends to fuse more effectively in an environment where there is little motion, instrumentation helps the fusion set up by limiting the motion at the fused segment.
Spine Fusion Instrumentation Types
There are three primary types of spine surgery instrumentation: pedicle screws and anterior interbody cages, and posterior lumbar cages.
Pedicle screws provide a means of gripping onto a vertebral segment and limiting its motion.
Anterior interbody cages are devices that are made to be inserted into the lumbar disc space through an anterior (from the front) approach. They can be made of allograft bone, titanium, or carbon/PEEK (radiolucent cages).
Posterior lumbar cages are also made to be inserted into the lumbar disc space, but are modified to be inserted through a posterior (from the back) approach. They can be made out of the same materials as an anterior cage.
In a spinal fusion, a solid bridge is formed between two vertebral segments in the spine to stop the movement in that section of the spine. Bone graft and/or bone graft substitute is needed to create the environment for the solid bridge to form.
The bone graft does not form a fusion at the time of the surgery. Instead, the bone graft provides the foundation and environment to allow the body to grow new bone and fuse a section of the spine together (into one long bone).
At the time of the fusion surgery, instrumentation (e.g. screws and rods) is typically used to provide stability for that section of the spine for the first few months after surgery; over the long term, a solid fusion of bone that has healed together provides stability.
This article reviews the main options available for bone graft. These include using the patient's own bone (autograft), using cadaver bone (allograft), using a bone graft substitute or bone morphogenetic protein (BMP). Some may be used in combination with each other during the spine surgery.
Bone Graft Considerations
There are a number of considerations to evaluate when deciding which type of bone graft options to use. The main factors to be taken into account include:
Type of spinal fusion (e.g. ALIF, PLIF, posterolateral gutter)
The number of levels of the spine involved
Location of fusion - (neck fusion or lumbar fusion)
Patient risk factors for non-fusion(e.g. if patient is obese, a smoker, poor bone quality)
Surgeon experience and preference
To date, using the patient's own bone is considered the gold standard. However, this is not the best option for all patients.
In an effort to reduce the surgical risks and possible complications with using the patient's own bone, and to enhance rates of fusion, the spine medicine community is focusing resources on developing better options.
Surgical Treatments for a Cervical Herniated Disc
In general, if about six weeks of conservative treatment fails to relieve the arm pain or if the patient and the spine specialist determine that surgical removal of the disc is the best course of treatment, patients may consider anterior cervical decompression (discectomy). During this surgical procedure, the disc material is removed through the front of the neck and then the disc space is usually fused to keep the disc space open. Another surgical option to treat a herniated disc is a posterior cervical laminectomy, where the disc material is removed through the back of the neck.
For a more detailed explanation, please see Anterior cervical decompression (discectomy). Cervical decompression can also be performed through the back of the neck as a posterior cervical decompression (discectomy). For more information, please read Posterior cervical decompression (discectomy).