MIS Treatment of Low Back Pain
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About Low Back Pain
Low back pain is one of the most common medical complaints. Demographically, the incidence of low back pain crosses age, gender, economic and ethnic borders.
The pain and symptoms from a simple low back sprain or strain may feel serious, but rarely requires spine surgery. Causes of low back pain that may require surgery include:
Degenerative Disc Disease: DDD can cause discs to lose height and become stiff. When disc height is lost, nerve impingement, bone and joint inflammation, and resultant pain can occur. Disc degeneration causes loss of the joint space, similar to arthritis pain and inflammation. (Figure 1)
Herniated Disc: A herniated disc occurs when the disc's outer band cracks or breaks open. The gel-like interior leaks out causing a herniated disc. The disc material may place pressure (compress) on nearby nerve roots or the spinal cord. Additionally, nuclear material releases chemical irritants causing nerve inflammation and pain. (Figure 1)
Spinal Stenosis: Lumbar stenosis develops when either the spinal canal and / or nerve passageways (foramen) become narrow. Lumbar central stenosis occurs when the spinal canal is narrowed. Lumbar foraminal stenosis occurs when the foramen is narrowed. Patients may have both types of spinal cord / spinal nerve stenosis (compression). Although some patients are born with stenosis (congenital), most cases of lumbar stenosis develop in patients over age 50 and results from aging and wear and tear on the spine. Other common causes include osteoarthritis, degenerative disc disease, or bone spurs (osteophytes).
Spondylolisthesis: This spinal disorder occurs when one vertebra slips forward over the vertebra below. The three types of spondylolisthesis are: congenital (present at birth), degenerative (age-related), and isthmic (pars interarticularis defect or fracture). The pars interarticularis is a bone connecting the upper and lower facet joints. (Figures 2 and 3)
Degenerative Scoliosis: The structural effects from degenerative disc disease can cause the spine to curve abnormally to the left or right.
Degenerative Disc Disorders
Important to a proper diagnosis is the patient's medical history, physical and neurological examination, and imaging studies.
- Medical history includes symptoms, their severity, and treatments already tried.
- Physical and neurological examination includes evaluating movement limitations, balance problems, pain, extremity reflexes, muscle weakness, and sensation. The exam may include a series of movements such as bending sideways, forward and backward at the waist, and walking.
- Imaging studies may include standing x-rays (front/back, side). In addition, if necessary, a CT scan, or MRI is performed.
When MIS is Recommended
The indication for minimally invasive spine surgery varies by condition and patient. MIS may be recommended if:
- Pain and other symptoms worsen and are unresponsive to nonoperative treatment
- Pain and symptoms significantly affect quality of life
- Neurologic problems develop, such as weakness, numbness, or bowel or bladder dysfunction
- Imaging tests, such as x-ray or MRI demonstrate spinal instability or slip progression
Surgical goals include:
- Decompress the spinal canal and/or spinal nerves (relieve pressure)
- Stabilize the spine
- Prevent and / or correct spinal deformity
Decompression procedures relieve pressure on the spinal canal and spinal nerves. Discectomy (disc removal), laminotomy, laminectomy, and foraminotomy are common procedures. Laminotomy (partial removal) and laminectomy (complete removal) involve removing the vertebral body?s lamina to increase the size of the spinal canal. The lamina is a section of bone near each facet joint covering access to the spinal canal. Foraminotomy expands the foramen or spinal nerve passageways.
Spinal fusion uses bone graft to fuse or join two or more vertebrae. Fusion is often combined with instrumentation, such as an interbody device (i.e. cage), pedicle screws and rods to immediately stabilize the spine and stop slip progression until the construct fuses. As an example, pedicle screws and rods improve deformity correct and increase the likelihood of successful fusion.
Deformity correction involves restoring the spine to a more normal alignment and fixing the spine in position using fusion and instrumentation.
Minimally spine surgery procedures approach the spine from the front (anterior), back (posterior), side (lateral), or back and side (posterolateral). Procedures such as those listed below share the same surgical goals:
- Anterior Lumbar Interbody Fusion (ALIF)
- Direct Lateral Interbody Fusion (DLIF / XLIF)
- Transforaminal Lumbar Interbody Fusion (TLIF)
- Trans-sacral Fusion at L5-S1
- Transfacet Fusion
The interbody device, such as a Titanium cage or PolyEthylEther Ketone (PEEK) spacer, is implanted into the disc space. Bone graft is packed into and around the device to stimulate spinal fusion.
- ALIF provides access to the spine and disc through the abdomen. This procedure is often combined with posterior fusion and instrumentation for better spinal fixation.
- DLIF provides access to the spine through the side of the body. This procedure involves a transpsoas approach, which means the surgeon accesses the spine through the psoas muscle; a long muscle on both sides of the lumbar spine.
- TLIF provides access to both sides of the disc through the intervertebral foramina, small passageways through which nerves exit the spinal canal. An interbody device, such as a cage or spacer is implanted into the disc space from one side of the spine. Pedicle screws and rods, with additional bone graft, secure the back (posterior) section of the spine. TLIF fuses the front and back sections of the spine all from a single procedure performed from the back of the spine.
- Trans-sacral Fusion is a novel technique that uses a long screw inserted from the back. The L5-S1 level is reached through an incision near the tailbone. Behind the pelvis at the rectum dissection is performed; the L5-S1 disc is removed and bone graft inserted through the trans-sacral device. Usually, additional screws and rods are placed to ensure maintenance of spinal alignment.
- Transfacet Fusion uses small screws to hold the facet joints together during fusion. Screws are inserted through small posterior (rear) stab / incisions.
Risks and Complications
No patients are identical and risks and complications vary. Your surgeon will explain possible risks and complications related to your specific MIS procedure.