SPINE

A variety of acute (e.g. disc herniation) and chronic (e.g. facet joint arthritis) pathologies may result in compression of one or more nerve roots throughout the spine.  This may result in pain in a particular distribution, depending where in the spine the compression occurs.  Compression in the lumbar spine may result in pain in the lower limb, or lumbar radiculopathy, often referred to as sciatica. Compression in the cervical spine may result in radicular pain in the upper limb, often referred to as brachial neuralgia. 

Although the pain may self – limit, a nerve root injection can be performed to ease debilitating symptoms and help you engage with physiotherapy and rehabilitation.  The injection allows delivery of anti – inflammatory medicine around the spinal nerve root.  This may also have a beneficial diagnostic effect in cases where the source of the pain is unclear, allowing identification of which nerve root is causing the symptoms. 

Nerve root injections may be performed under Xray or CT guidance, using local anaesthetic or in some cases sedation.  Imaging is used to carefully guide placement of a needle in proximity to the relevant nerve root after it has exited from the spinal canal.  Radiographic dye may be used to outline the nerve root to confirm accurate needle placement before a small volume of corticosteroid and local anaesthetic is injected. 

Following injection there may be some transient symptoms of numbness / weakness in the limb which usually wears off after a few hours.  The steroid may take a few days or longer to take effect and so pain relief is not always immediate, and additional regular pain medication should continue during this period.  You will usually be discharged a few hours after your injection with subsequent follow up with your surgeon.

Facet joints are joints at the back of the spine that connect each spinal vertebra.  These joints are lined with cartilage and during motion they slide relative to one another.  As part of the normal wear-and-tear process these joints can degenerate and become painful (arthritis).  This effect is augmented by degeneration of the intervertebral discs and core muscle weakness, as this places greater stress on the facet joints.  The paraspinal muscles can spasm in an attempt to protect the inflamed, painful joints, causing severe back pain and stiffness.

Although the pain may self-limit, an injection of anti-inflammatory medicine to the nerves that supply the facet joints (medial branches) can provide pain relief.  This may help you to engage with physiotherapy and rehabilitation.  This may also have a beneficial diagnostic effect in cases where the source of the pain is unclear.

Medial branch blocks may be performed under Xray or CT guidance, using local anaesthetic or in some cases sedation.  Imaging is used to carefully guide placement of a needle in proximity to the medial branch.  A small volume of corticosteroid and local anaesthetic is injected.

Following injection there may be some transient symptoms of numbness.  The steroid may take a few days or longer to take effect and so pain relief is not always immediate, and additional regular pain medication should continue during this period.  You will usually be discharged a few hours after your injection with subsequent follow up with your surgeon.

Coccydynia is pain in the coccyx which is located at the base of the spine.  Common causes of coccydynia include trauma, repetitive coccygeal ligament strain (causing tendinopathy – similar to that of tennis elbow), childbirth, and pelvic floor dysfunction.  In some cases, no clear cause can be identified. 

Treatment is usually non-operative, but in cases which are fail to improve despite non-operative measures, an injection of anti-inflammatory medicine (steroid) and local anaesthetic into the area can be beneficial in providing symptom relief. 

The procedure is usually carried out under sedation.  Xrays are used to accurately guide placement of a needle into the sacro-coccygeal junction (where the sacrum joints the coccyx).  A small volume of steroid and local anaesthetic is then injected.  At this stage your surgeon may insert a gloved finger into the rectum to allow manipulation of the coccyx. 

Following injection there may be some transient symptoms of numbness.  The steroid may take a few days or longer to take effect and so pain relief is not always immediate, and additional regular pain medication should continue during this period.  You will usually be discharged a few hours after your injection with subsequent follow up with your surgeon.

The sacroiliac joints connect the sacrum and iliac bones of the pelvis, and transfer load from the upper body and spine through the pelvis.  As with any joint, the sacro iliac joints can degenerate and develop arthritis which is painful.  Excessive movement or injury may also cause sacro-iliac joint pain.   The pain may radiate into the pelvis and down the back of the legs. 

An injection of anti-inflammatory medicine (steroid) and local anaesthetic into the sacro-iliac joint may be used in order to reduce inflammation and improve the pain symptoms.  This symptoms relief can then facilitate your engagement with physiotherapy and rehabilitation.  This may also have a beneficial diagnostic effect in cases where the source of the pain is unclear. 

The procedure is usually carried out under sedation and using local anaesthetic.  Xrays are used to direct a needle into the sacro-iliac joint.  A small volume of steroid and local anaesthetic is then injected. 

The steroid may take a few days or longer to take effect and so pain relief is not always immediate, and additional regular pain medication should continue during this period.  You will usually be discharged a few hours after your injection with subsequent follow up with your surgeon.

Microdiscectomy is a surgical procedure that is performed through a small incision in the midline of the lumbar spine.  A microscope or surgical loupe magnification is used for optimal visualisation of anatomical structures.  The overlying paraspinal muscles are held apart to gain access to the bony arch of the spine (lamina).  A small portion of the lamina is removed along with some of the underlying ligament (ligamentum flavum) in order to gain access to the nerve root.  The nerve root is carefully retracted and protected and the herniated disc material is removed.  Only the herniated portion of the disc is removed. 

Following microdiscectomy discharge may be on the same day or the following day.  It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential.

Lumbar decompression is a surgical procedure that is performed through an incision in the midline of the lumbar spine.  A microscope or surgical loupe magnification is used for optimal visualisation of anatomical structures.  The overlying paraspinal muscles are held apart to gain access to the bony arch of the spine (lamina).  A portion of the lamina is removed along with some of the underlying ligament (ligamentum flavum) in order to decompress the underlying nerves.  The joints in the spine (facet joints) are undercut in order to relieve pressure on the nerves as they exit the spinal canal and hence provide relief of symptoms. 

Following lumbar decompression discharge may be on the same day or the following day.  It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential.

Interbody fusion is performed for a variety of reasons.  These include increasing the height of the disc space, thereby creating space for the nerves, improving spinal alignment, and facilitating spinal fusion. The intervertebral disc is removed and an intervertebral fusion cage is inserted and is often filled with bone graft.

Transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) is performed through an incision in the midline of the lumbar spine.  The overlying paraspinal muscles are held apart to gain access to the bony arch of the spine (lamina).  Screws are placed into the vertebrae above and below the level of the disc that is to be removed. A portion of the lamina is removed along with some of the underlying ligament (ligamentum flavum) in order to gain access to the spinal nerves.  In a TLIF procedure the joint of the spine (facet joint) is removed to allow access to the disc space. In a PLIF procedure only part of the joint is removed. The nerves are carefully retracted and protected and the intervertebral disc is removed.  The intervertebral fusion cage is inserted, along with bone graft.  Rods are now inserted to connect the screws together.  This construct prevents movement at this segment and allows the bone to fuse.

Following TLIF or PLIF It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential. Following initial rehabilitation and upright Xray you may be discharged.

Interbody fusion is performed for a variety of reasons.  These include increasing the height of the disc space, thereby creating space for the nerves, improving spinal alignment, and facilitating spinal fusion. The intervertebral disc is removed and an intervertebral fusion cage is inserted and is often filled with bone graft. 

Anterior lumbar interbody fusion (ALIF) is performed with the assistance of a vascular surgeon to safely facilitate the surgical approach and access to the intervertebral disc.  An incision is made in the abdomen.  The abdominal contents are contained within a ‘sack’ (peritoneum) which is carefully retracted, facilitating access to the front of the spine.  The blood vessels that lay across the front of the spine are carefully mobilised, retracted and protected. The disc is then carefully removed and an interbody fusion cage containing bone graft  is inserted.  The cage may be held in place with screws.  It may be necessary to augment the stability of the construct by inserting additional screws into the bone from the back of the spine, either during the same surgical procedure, or as a second operation. 

Following ALIF It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential. Following initial rehabilitation and upright Xray you may be discharged.

Interbody fusion is performed for a variety of reasons.  These include increasing the height of the disc space, thereby creating space for the nerves, improving spinal alignment, and facilitating spinal fusion. The intervertebral disc is removed and an intervertebral fusion cage is inserted and is often filled with bone graft. 

Extreme lateral lumbar interbody fusion (XLIF)  incision is performed through an incision on the side of the body.  The abdominal contents are contained within a ‘sack’ (peritoneum) which is carefully retracted, facilitating access to the spine.  Blunt dilators are used to carefully split fibres of the psoas muscle that overlies the spine and identify the disc space.   Neuromonitoring is used to ensure that the nerves which pass through the psoas muscle are not damaged during the procedure. The disc is then carefully removed and an interbody fusion cage containing bone graft is inserted.  It may be necessary to augment the stability of the construct by inserting additional screws into the bone from the back of the spine, either during the same surgical procedure, or as a second operation.  

Following XLIF It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential. Following initial rehabilitation and upright Xray you may be discharged.

Interbody fusion is performed for a variety of reasons.  These include increasing the height of the disc space, thereby creating space for the nerves, improving spinal alignment, and facilitating spinal fusion. The intervertebral disc is removed and an intervertebral fusion cage is inserted and is often filled with bone graft. 

Oblique lumbar interbody fusion (OLIF) may be performed with the assistance of a vascular surgeon to safely facilitate the surgical approach and access to the intervertebral disc.  An incision is made slightly to one side of the abdomen.  The abdominal contents are contained within a ‘sack’ (peritoneum) which is carefully retracted, facilitating access to the spine.  The blood vessels that lay across the front of the spine are carefully mobilised, retracted and protected. The disc is then carefully removed and an interbody fusion cage containing bone graft is inserted.  It may be necessary to augment the stability of the construct by inserting additional screws into the bone from the back of the spine, either during the same surgical procedure, or as a second operation.  

Following OLIF It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential. Following initial rehabilitation and upright Xray you may be discharged.

Sometimes vertebra (bones of the spine) may fracture as a result of injury or weakness of the bony structure, for example due to osteoporosis.  The fractured vertebral bone may compress and can be particularly painful, especially when weightbearing.  If the compression becomes severe this can cause problems with the structure of the spine, and possibly also compression of the nerves in the spine due to narrowing of the spinal canal.  Injection of cement into the vertebra may help to prevent further collapse, and improve pain symptoms. 

Vertebroplasty / kyphoplasty is performed through a very small incision in the back.  A hollow needle is passed under Xray guidance through a bony channel (pedicle) and into the vertebral body.  In vertebroplasty, medical cement is injected through the needle into the vertebra, which then hardens.  In kyphoplasty, a balloon is first inserted into the fractured vertebra and inflated, creating a cavity.  The balloon is then removed and medical cement is injected into the cavity under Xray guidance.

Following vertebroplasty / kyphoplasty discharge may be on the same day or the following day.  It is important to engage with physiotherapy to achieve maximum rehabilitation potential.

Surgical coccygectomy is usually considered only as a last resort when non operative treatments have failed to improve symptoms.  Success rates for relieving pain may only be approximately 50%. 

Coccygectomy is performed through an incision at the top of the buttock.  The soft tissues are retracted and the coccyx is exposed. The tendinous attachments are carefully detached and the coccyx is removed.  Meticulous wound closure is extremely important to avoid infection. 

Following coccygectomy It is important to engage with physiotherapy  to achieve maximum rehabilitation potential. Following initial rehabilitation you may be discharged.

Cervical corpectomy (removal of a vertebra) is performed through an incision in the front of the neck.  The structures in the neck are carefully retracted and the spine is exposed.  A microscope or loupe magnification is used to provide optimal visualisation of critical structures.  The discs above and below the vertebral body are removed, and then the vertebral body itself is carefully removed in order to relieve pressure on critical structures such as the spinal cord and cervical nerve roots.  Additionally, bony outgrowths, or ‘osteophytes’ that occur as part of the degenerative process that may also be causing neural compression may be removed.  The vertebra is then replaced with a ‘cage’ containing bone graft.  A cage may also contain integrated screws to allow fixation into adjacent vertebrae.  A plate-and-screw construct may also be used to supplement fixation.   Multiple vertebrae may be removed during one operation. 

Following corpectomy surgery you will be carefully monitored on the ward and following assessment by physiotherapy and an upright may be discharged.  It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential.

Anterior cervical discectomy and fusion is performed through an incision in the front of the neck. The structures in the neck are carefully retracted and the spine is exposed.  The disc is removed under a microscope or loupe magnification to provide optimal visualisation of critical structures. Disc material that compresses the nerve roots or spinal cord is carefully removed in order to relieve the pressure on them.  Additionally, bony outgrowths, or ‘osteophytes’ that occur as part of the degenerative process that may also be causing neural compression may be removed. The disc space is then filled with a ‘cage’ containing bone graft.  Depending on the specific indication for surgery, cages may be stand-alone, or have integrated screws to allow fixation into adjacent vertebrae.  A plate-and-screw construct may also be used.  ACDFs at multiple levels may be performed during one operation. 

Following ACDF surgery you will be carefully monitored overnight and discharge is usually the following day after physiotherapy review and an upright XRay. It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential.

Posterior cervical foraminotomy is performed through an incision in the back of the neck. A microscope or loupe magnification is used to provide optimal visualisation of critical structures.  The muscles are retracted and the spine is exposed.  A portion of the lamina (bony arch) that covers and protects the spinal cord is carefully removed, thereby decompressing the relevant nerve root and relieving symptoms. 

Following foraminotomy surgery you will be carefully monitored on the ward and following assessment by physiotherapy may be discharged.  It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential. 

Cervical laminectomy is performed through an incision in the back of the neck.  A microscope or loupe magnification is used to provide optimal visualisation of critical structures.  The muscles are retracted and the spine is exposed.  The lamina (bony arch) that covers and protects the spinal cord is cut on each side and removed, along with the underlying ligament.  This decompresses the spinal cord thus preventing progression of symptoms.  

Removal of several laminae may mean that it is necessary to augment the stability of the cervical spine. This is performed by placing small screws into bone on each side of the spinal canal called the lateral masses.  These screws are then connected by rods, providing firm fixation and stability.  Bone graft may be added to help the bone to fuse in this area. 

Following laminectomy surgery you will be carefully monitored on the ward and following assessment by physiotherapy and an upright Xray you may be discharged.  It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential.

Cervical laminoplasty is performed through an incision in the back of the neck.  A microscope or loupe magnification is used to provide optimal visualisation of critical structures.  The muscles are retracted and the spine is exposed.  The lamina (bony arch) that covers and protects the spinal cord is cut fully on one side and partially on the other.  This creates a ‘hinge’ that allows the lamina to rotate on the side that is partially cut, thus ‘opening’ the spinal canal.  A spacer is then attached to the bone on the ‘open’ side, preventing the canal from closing.  This technique creates space for the spinal cord and relieves the pressure on it, thus preventing progression of symptoms.  An advantages of laminoplasty is that because the lamina is not removed, there is no need to stabilise the spine with screws and rods. 

Following laminoplasty surgery you will be carefully monitored on the ward and following assessment by physiotherapy and an upright Xray you may be discharged.  It is important to engage with physiotherapy after surgery to achieve maximum rehabilitation potential.