We have outlined below a number of the more common procedures performed by our spinal surgeons. The risks explained are not exhaustive and your own particular risk profile will be given in greater detail by your specialist however this will give you some understanding of what is involved and help inform the questions you may wish to ask.
A lumbar nerve root block is an epidural injection placed near to the nerve as it leaves the spine and is our most common spinal day-case procedure. X-ray is used to guide the spinal needle into position and a contrast agent is injected to confirm the relationship of the needle tip to the nerve before medication is injected. A combination of local anaesthetic and steroid is typically used. The procedure requires you to lie on an operating table and staff will ensure you are comfortable with pillows for support. In some cases light sedation will be provided by an anaesthetist, typically where more than one injection is required or if this is your preference. Injections are generally well tolerated and you can mobilise with the therapists shortly afterwards. The risks are uncommon but range from rare drug reaction, the least common but most serious being anaphylaxis where the anaesthetist will intervene quickly, through to nerve injury, dural puncture causing headache and infection. The success of therapeutic injections varies significantly and depends greatly on pathology however it is certainly our experience that the majority are beneficial and can settle inflammatory change round the nerve and reduce intense neural pain.
A cervical nerve root injection is generally performed for arm pain, or pain around the shoulder or shoulder blade, where a nerve in the neck is thought to be responsible. The injection is undertaken with the patient awake and lying on their back facing the ceiling and guided by x-ray machine. The specialist will ask for you to stay still and gently introduce a very thin needle near to the spine while screening with X-Ray. Contrast agents are used to confirm position and once satisfied with safe placement medication injected. With all injections anywhere in the body there is a small risk of allergy, bleeding and infection. With spine injections to the neck (nerve root, facet joints, or medial branch blocks) there is a very small risk of nerve damage, spinal cord injury, paralysis, stroke, seizure, heart attack, breathing difficulties or death. Therefore if the specialist is not satisfied with placement he will on occasion abandon the procedure in order to keep you safe.
These injections are performed to settle pain originating from joints in the back of the lumbar, thoracic or cervical spine. Again they are performed under X-Ray guidance and frequently a combination of anaesthetic and steroid will be used, with sedation where required to ensure you are comfortable. Medial branch blocks are also injections given when it is thought that back pain is being caused from the joints at the back of the spine. The injection is performed in a similar way to the facet joint injections, but instead of injecting the joint, the nerve that sends pain signals to the brain (the medial branch) is injected instead. A medial branch lock is a diagnostic injection, if successful it can indicated that a further procedure called a radiofrequency ablation may be appropriate. That procedure burns or denatures the medial branch nerve and can give longer lasting pain relief.
The aim of surgery is to remove pressure on a nerve root that is being compresed by a disc herniation. “Micro” refers to the use of an operating microscope providing the surgeon with greater magnification and illumination during surgery to improve visibility, help protect important neural structures and define the surgical target. Surgical time will vary depending on a number of factors with the operative time typically being 30 to 90 minutes. Patients are mobilised by therapists shortly after surgery.
Incision: This is a small longitudinal (top down) cut in the middle of the lower back.
Approach: Muscles are gently lifted off the bony spine and held with retractors.
Procedure: The level of surgery is confirmed at several stages with X-Ray. A bony window is made in the back of the spine adjacent to the site of compression, the yellow ligament (ligamentum flavum) removed and the nerve structures gently moved away from the area of compression. Frequently disc material is seen near the nerve and removed at this point. Often we will make a small incision of 3-5mm in the disc itself entering it to retrieve any protruding tissue underneath. At completion the nerve is left passing freely without compression and the muscles are sutured while the skin is closed with either metal clips or a dissolving stitch before dressings applied.
Risks: The potential complications of lumbar microdiscectomy surgery can be divided into general and specific. The general risks include that of undergoing any operation and include the risk of anaesthetic which your anaesthetist will discuss with you.
The specific risks are tailored to the operation and you as an individual and taken into account when the decision to operate is made. The surgical risks include the rare risk of injury to a nerve which although uncommon can occur. During surgery nerves are gently moved to access the target disc and this can result in them becoming numb, weak or painful afterwards although in most cases this is short lived. There is a rare risk of persistent weakness, numbness and pain after surgery. The risk of injuring the lining of the nerves (a dural tear) is 2-10% dependent on the complexity of compression. In most cases there are repaired with a suture, patch or glue however occasionally a patient will need to return to theatre for further surgery at a later date due to headaches or wound leak. Rarely, and this is the uncommon worst case scenario, a large tear can cause the nerves inside to be damaged leading to incontinence and a long-term catheter. This is a rare complication of microdiscectomy. Infection is infrequent and antibiotics are given at the start of the procedure and antiseptics used to prepare the skin. If a disc infection does occur a prolonged treatment with antibiotics may be needed and sometimes further surgery. Specific risks tailored to you can be relevant to your past medical history and medications and will be discussed with you by your surgeon and anaesthetist. Other risks can be amplified in certain situations. For example, if you are a professional athlete the rare risk of foot weakness following spinal surgery would be particularly important to you and we will consider these factors with you when taking consent. It is important that you tell your surgeon about any specific concerns you have or activities you do.
This type of surgery is relatively common and intended to relieve pressure on a nerve where the source is bony compression, typically from the overlying facet joint or thickened ligament. Surgery undercuts the overgrown joint to decompress the nerve and removes the ligament.
Incision: A midline (top down) cut is made in the skin of the back of varying length depending on the number of spinal levels involved.
Approach: Muscles are gently elevated and held with retractors.
Procedure: The level is confirmed by X-Ray at several points in the surgery. The bony spine is decompressed by removing part of the bony arch (lamina) on one or both sides then undercutting the overgrown facet joint and removing the flat yellow ligament (flavum) which is frequently also thickened. The nerve is protected and thoroughly decompressed before stitching the muscles closing the skin with metallic clips. Dressings are then applied.
Complications: These range from general complications including those of a general anaesthetic to specific risks concerning either yourself or the surgery concerned. Risks vary considerably from one person or one operation to the next and we will do our best to give you the best possible understanding of the risks and what they could mean for you should they occur.
Injury to a nerve is fortunately rare however if it does occur this can cause long-term weakness, numbness or sometimes pain. A dural tear (injury to the lining of the nerve) occurs in approximately 7% of cases with some exceptions where the nerves are particularly compressed or perhaps inflamed ranging up to 20%. Risks will increase if multiple levels of surgery are considered. In most cases a dural tear is small and this is protected while surgery is completed before repair takes place at the end. Loss of spinal fluid will occur and can result in headaches therefore we typically nurse you flat for one to two days after surgery while more CSF is made by your body. A large tear can cause the small nerves inside, which supply your bladder and bowel continence, to be compromised and rarely a loss of continence requiring a catheter after surgery. Such dural tears are fortunately very uncommon however their risk is increased in more complex patterns of severe stenosis and your surgeon will explain this risk to you at consent where appropriate.
The reason to fuse a segment in the lower back is if instability is present or the nerves are being compressed between the bones where they exit the side of the spine (through the foramen). It is performed as part of the treatment for nerve related pain symptoms and is not a cure for back pain although some patients will receive an improvement in severe back pain. There are a number of ways to approach and fuse part of the spine and your surgeon will discuss these with you when planning the operation. Implants will be placed and typically include large screws (approximately 7mm wide and 40-50mm long) into bony corridors within the vertebra connected by strong titanium rods at closure. In some situations implants called cages will be placed within the disc space itself to encourage fusion and support the spine. A number of factors are considered before proposing fusion.
Incision: Midline (top-down) incision length dependent on the number of levels
Approach: The muscles are gently elevated and held
Procedure: X-Ray is used to help confirm placement of screws for which the surgeon relies on intricate knowledge of bony anatomy. At OneSpine the majority of lumbar fusions are performed by two Consultants in a pair to ensure cross-checking, patient safety and to reduce your surgical time meaning a shorter anaesthetic. Decompression as described in the Lumbar Decompression section is typically undertaken as part of this surgery.
Complications: The addition of placing implants into the spine does invite other risks and while uncommon they can occur. We use surgical knowledge, experience and X-Ray to place screws however in soft bone or complex cases such as those with deformity (change of normal alignment or rotation of the spine) implants can be malpositioned during or move after the operation. While not common this can result in a screw affecting another structure outside the bone such as a nerve which can be painful, a number of nerves which can rarely compromise continence, or rarely a blood vessel which can bleed. In these situations placement is corrected either at the time or surgery or at a later date. We take numerous precautions to make you are as safe as possible and will pre-habilitate you going into the surgery to ensure risk factors such as smoking or excessive weight are optimised so you achieve the best possible outcome and experience the safest possible surgery.
A fusion in the cervical spine (neck) is undertaken for two reasons. Nerve pain due to disc and bony overgrowth putting pressure on the nerve or secondly the spinal cord itself being compressed. For this surgery we are approaching the surgery from the front of the neck and the disc is removed. An operating microscope is used to magnify and illuminate the surgical field and ensure the areas of compression are fully removed. An implant (cage) is placed between the vertebra and sometimes a metal plate is applied onto the front of the vertebra with screws holding it in place.
Incision: A small incision is made in a skin crease at the front of the neck on either right or left sides.
Approach: A fan like muscle called platysma is incised and a window opened between several blood vessels (within the carotid sheath) and the oesophagus (gullet) and trachea (windpipe). Retractors are placed to keep these structures safe and the level check undertaken with X-Ray.
Procedure: The disc is removed and microscope used to visualise the spinal cord and nerve structures which are thoroughly decompressed. The implant is sized, placed and secured. A small drain is left in the wound overnight so any blood is not able to accumulate and the wound closed with sutures and metal clips to the skin.
Complications: While these operations are typically performed to decompress the nerves after they have left the spinal cord rather than the spinal cord itself the rarest but most important risk is spinal cord injury and paralysis. We reduce the risk significantly by using operating microcopes to visualise the neurological structures and this catastrophic outcome is extremely rare. As a consequence of the surgical approach to the spine there is a risk (4-7%) of voice change following surgery due to small nerves with variable path that supply part of the voicebox (larynx) being near to the site of surgery and the retractors. The risk of this does depend on several factors including the level of surgery. In most cases this does improve but there is a risk in some that long term hoarsenes and difficulty coordinating coughing will result. Again this is not common but is of particular importance is you are for example an opera singer. Other risks include the risks of any surgery such as the anaesthetic, bleeding, infection, blood clots on the leg that can travel to the lungs, heart attack, stroke, and in particular to this operation: leakage of spinal fluid, damage to the trachea, the oesophagus, the thoracic duct and the sympathetic chain causing a Horner’s syndrome.
Posterior cervical spine surgery is performed typically for 2 reasons, either to free up the spinal cord when there is pressure on the spinal cord which causes a loss of manual dexterity or balance issues (myelopathy), or when there is pressure on a spinal nerve as it leaves the cervical spine. Posterior cervical spine surgery is typically performed when there are more than 2 levels of involvement of the cervical spine. In certain circumstances a posterior cervical decompression is combined with a posterior instrumented fusion. Typically this is done when there is instability, which can be seen when 1 vertebra moves forward in relation to another vertebrae in the neck. Small screws are inserted into the bone at the side on the back of the neck and the screws are linked by a rod. Some pathologies of the neck are amenable to surgery via either the anterior or the posterior approach. Your surgeon will discuss which procedure is more appropriate for you. The posterior approach avoids risks such as damage to the nerve to the voice box, but typically the posterior approach is more painful and the surgery may take longer to recover from.
Incision: A longitudinal midline incision is made on the back of the neck.
Approach: Muscles are gently elevated and held with retractors.
Procedure: The level is confirmed by X-Ray at several points in the surgery. The bony spine is decompressed by removing the bony arch (lamina) on both sides of the spine and removing the flat yellow ligament (flavum) which is frequently also thickened. The nerves and spinal cord are protected and thoroughly decompressed. If the decompression is to be combined with a fusion, holes are drilled in small bony projections at the side on the back of the neck (lateral masses). These holes are then palpated with a ball-tipped implement to ensure that they are in the correct place and checked with x-ray, then the screws are inserted. The screws are then linked with a rod which is secured with locking nuts. Bone graft is then applied laterally to the metalwork to achieve a fusion. Finally the muscles are stitched, before closing the skin with metallic clips. Dressings are then applied.
Complications: These range from general complications including those of a general anaesthetic to specific risks concerning either yourself or the surgery concerned including bleeding, infection, blood clots on the leg that can travel to the lungs, heart attack, stroke. Risks vary considerably from one person or one operation to the next and we will do our best to give you the best possible understanding of the risks and what they could mean for you should they occur.
Injury to a nerve is fortunately rare however if it does occur this can cause long-term weakness, numbness or sometimes pain. Paralysis is a rare complication of posterior cervical surgery A dural tear (injury to the lining of the nerve) occurs in approximately 7% of cases with some exceptions where the nerves, or the spinal cord are particularly compressed or perhaps inflamed ranging up to 20%. If a dural tear occurs, most often it can be repaired at the time of surgery, but occasionally patients have to return to theatre so that a persistent spinal fluid leak can be addressed.