Low Back | Lumbar Spine
The low back has 5 lumbar vertebrae, separated by disks. These disks can bulge or herniate into the spinal canal or nerve roots causing referred pain to shoot down the leg. Also, the disks themselves can degenerate or lose their compressive capabilities, which can cause back pain. This can progress to the point where the bones start to run on each other due to complete loss of the disk space. This can lead to a process called spondylolisthesis. Spondylo means spine and listhesis mean shift. This occurs when the superior (higher) vertebrae shifts forward on the one below it. This is an unstable spine, much like a broken forearm that moves around with motion, and can be very painful. This responds quite well to surgical intervention.
Below are examples of disk herniation which is alleviated by performing a microsdicectomy surgery. This is a minimally invasive surgery where the disk that is pinching the nerves is removed by removing a small amount of bone.
Also, is an example of spondylolisthesis which is repaired by fusing the two unstable bones together. My method of choice is going through the anterior (front) and stabilizing it and putting the bones back in their original location, followed by posteriorly (back) stabilizing the two bones with screws and rods. If possible, I place the screws in a percutaneous fashion instead of making a large midline incision which would require significant muscle dissection. This allows my patients to have minimal blood loss, reduce their hospital stays, and return to work and sports earlier.
Patient 1. MRI
Patient 1 is a 60 lady who had the sudden onset of severe right leg pain and difficulty walking. She was told her problem was from her hip for 2 months until it was decided to obtain an MRI of her lumbar spine. As you can see there is a massive disk herniation at the L4/5 level which is pushing on the spinal canal and obliterating it. Using microscopic techniques I was able to remove that huge disc fragment through a 1 inch incision. The patient went home the following morning with complete resolution of leg pain.
Patient 2. X-ray
This is an X-ray of a 50 year old male with over 20 year history of progressive back pain and difficulty walking. On this x-ray on can see that the bone connecting the lowest lumbar vertebra (L5) to the sacrum/pelvis (S1), has fractured. The L5 vertebrae has shifted forward on S1 quite significantly. This is called spondylolisthesis. This pinches the spinal canal and the nerves that innervate the legs.
Patient 2. Post-Op
This X-ray shows the post-operative reduction of L5 back above the S1 with fixation in the front with a PEEK cage with screws within the cage as well as screws and rods in the back holding the bones together.
Patient 2. Post-Op 1 year
This is after 1 year where we can see bone formation in the front around and through the middle of the cage showing fusiong between the two bones. This patient had an excellent result with resolution of his back and leg pain.
Patient 3. MRI
The MRI shows those two lower disks at L4/5 and L5/S1 have significantly degenerated and are now bulging into the spinal canal. Compare them to the healthier disks at L3/4 which are still plump and appear white on MRI because the still maintain their water content.
Patient 3. X-ray
Patient 3 is a 40 year old male with a similar situation is patient 2. He had a spondylolisthesis at the L5/S1 level but also had a retrolisthesis or backward shift at the level above at L4/5. This is often a compensatory response to a spondylolisthesis that is untreated.
Patient 3. Post-Op (Lateral)
This patient had a two level anterior/posterior fusion. This is fusion through the abdomben with complete removal of the disk material and placement of a plastic that gives back the lordosis or curvature of the spine. The screws in the back were placed in a percutaneous fashion.
Patient 4. X-ray (AP)
Patient 4 is a gentleman in his late sixties who has had difficulty with worsening low back pain and difficulty walking for over a decade. At this point he could not stand or walk for greater than 10 minutes. As you can see he spine is collapsing to one side. This occurs as the disks in the lower levels start to degenerate and fail. This puts pressure on the disk above which then fails over time and collapses as well, causing a domino effect to occur. Much like a building with a bad foundation, the entire spine can slowly start to shift to one side. This makes it difficult to stand straight.
Patient 3. Post-Op (AP)
This is the front view.
Patient 4. X-ray (Lateral)
Here is the the side view of the same patient and it is obvious that every disk from the lower thoracic spine down to the sacrum has severely degenerated and collapsed. Due to the collapse of the disk, bone will rub on bone and cause spur formation to occur which is obvious on this x-ray. These spurs can pinch the nerves that goto the legs and cause leg pain in addition to the low back pain.
Patient 4. Post-Op (AP)
This patient had a multi-level fusion to straighten his spine. The L4/5 and L5/S1 levels were approached through an anterior (abdominal) approach with placement of PEEK (plastic) inter body devices. This gives strength to the contract and restores lumbar lordosis (curvature). PEEK cages were also placed through the side at the L1/2, L2/3, and L3/4 Levels. Then a posterior incision allowed placement of screws and rods from the T10-S1 levels to stabilize the spine and correct and residual scoliosis.
Patient 4. Post-Op (Lateral)
This side view x-ray shows the T10-S1 Scoliosis correction and the PEEK cages which help give improved lumbar lordosis which is for sagittal balance, or the ability to stand up straight. This surgery can be completed through the posterior approach alone, but is more difficult to re-create the lumbar lordosis. Also, with the lack of anterior support of the PEEK cages, this puts more stress on the screw-bone interface, which can lead to screw pullout.
This is a patient with degenerative disk disease at the L3/4 level. Given her young age and maintained disk height with minimal facet arthritis, we decided to proceed with an artificial disk replacement. This allows motion at that lumbar segment, whereas a fusion surgery does not. This is done through an anterior (abdominal) approach. The tricky part of this surgery is getting the implant perfectly in the middle of the vertebra, as can be seen here. Even a few millimeters of misplacement can cause a suboptimal result. The other piece of metal visible is a belly button ring.
Patient 5. Post-Op (AP)
Patient 5 (Lateral)
This is the lateral (side) view of the same patient with an artificial disk replacement. One can visualize the titanium on each side of the bone. There is a plastic spacer between them which allows motion at the segment. The issues with artificial disk replacement is that many patients are not candidates for various reasons. Many insurance companies still do not approve this type of surgery. Also if facet arthritis is present, or previous posterior decompression surgery, then this can be a relative contraindication. Also, if a poor or failure occurs, it is not simple to return through an abdominal approach and convert this to a fusion because the main blood vessels from the heart to the legs are in this area and are scarred down from the previous surgery. These issues are less problematic in the cervical spine.
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Patient 3 Post-Op Incision
By placing large PEEK cages through an abdominal approach this allows us to obtain our fusion in the front of the vertebrae where most of the bone is. We can then place the posterior screws via a minimally invasive percutanous fashion. This means we do not open up the muscle to put our screws in, but through these six small incisions, where we can place our screws and rods in without disturbing the muscle. A dime was placed to give a reference to the size of the incisions. For a one level fusion, this would only require four incisions, and for a three level fusion, 8 incisions, etc. By minimizing the muscle dissection this dramatically decreases the pain, rehabilitation, and chance of infection.