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Lumbar surgery - Best Neurosurgeon and Neurologist in Bangalore | Dr.Venugopal

Lumbar surgery

Lumbar surgery refers to any type of surgery in the lumbar spine, or lower back, between one or more of the L1-S1 levels.

There are two general types of lumbar spine surgery that comprise the most common surgical procedures for the lower back:

The goal of a decompression surgery is usually to relieve pain caused by nerve root pinching. There are two common causes of lumbar nerve root pressure: from a lumbar disc which is herniated or stenosis of lumbar spine.

This type of pain is usually referred to as a radiculopathy, or sciatica.
A 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. The most common types of decompression surgery are microdiscetomy and laminectomy which were a explained earlier

There are also a few alternatives available to the above two standard procedures, such as an X-STOP which is a possible option instead of a laminectomy for lumbar spinal stenosis.

The goal of a lumbar fusion is to stop the pain at a painful motion segment in the lower back. Most commonly, this type of surgery is performed for pain and disability caused by lumbar degenerative disc disease or spondylolisthesis.

A spinal fusion surgery 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 a bone stimulator are sometimes used along with spinal fusion.

There are also many surgical approaches to performing spinal fusion, such as ALIF, PLIF, XLIF, TLIF, posterolateral gutter fusion, anterior/posterior fusion, and certain minimally invasive approaches.

In addition to the above conditions, decompression and/or spinal fusion may be performed to address other types of lumbar spine pathologies, such as infection or tumors.

Kyphoplasty

One or more vertebral compression fractures can potentially cause back pain and an abnormal hunching forward (kyphosis), symptoms can typically be managed without surgery. If nonsurgical treatments fail to relieve the pain, a minimally invasive surgery called kyphoplasty may be considered.

The vertebral body is the strong, thick cylindrical front of the vertebral bone that plays a crucial role in handling large axial loads placed on the spine. When a vertebral body becomes weakened, such as from osteoporosis it is less capable of handling axial loads and more susceptible to vertebral compression fractures. The most common type of vertebral fracture is a wedge fracture, which involves the front part of the vertebral body collapsing at least 15% compared to its normal height.

A kyphoplasty procedure uses x-ray guidance to place a needle through a small incision in the back and into the vertebral compression fracture. After the needle is accurately placed, a balloon is slowly inflated to help restore vertebral height and form a new cavity. Bone cement is then injected into the new cavity and quickly hardens, which alleviates pain by strengthening and solidifying the damaged vertebra.

Most vertebral compression fractures heal on their own as the pain eventually goes away. In cases where a vertebral compression fracture has been verified via x-ray and significant pain persists for more than a couple weeks despite nonsurgical treatments, kyphoplasty may be considered if the following

If back pain worsens when axial loads are applied to the spine, that is an indication that the vertebral compression fracture is indeed the pain source and could be treated with a kyphoplasty or other vertebral augmentation procedure. Clues that axial load worsens pain include increased pain when carrying heavy items, such as groceries or suitcases, or getting into and out of bed.

Pain is not accompanied by tingling, numbness, or weakness.

Kyphoplasty is unlikely to relieve neurological symptoms of tingling, numbness, or weakness that occur when part of the vertebra pushes against the spinal cord or nerve root. If the vertebra has started to cause symptomatic nerve inflammation, fusion surgery may be recommended instead.

Vertebra collapses between 30% and 70%.

Due to its ability to restore some vertebral height, kyphoplasty is typically not recommended unless the front part of the vertebral body has collapsed at least 30% compared to the back of the vertebral body. In cases where the vertebral body has collapsed less than 30%, the simpler vertebroplasty procedure might be recommended because stabilizing the fracture without restoring vertebral height may be sufficient. Furthermore, kyphoplasty is not recommended if the vertebral body has collapsed more than 70%, in which case a more extensive surgery may be needed.

Fracture is less than 3 months old.

Vertebral compression fractures that occurred more than 3 months prior to surgery have already started to heal and are unlikely to experience the vertebral height restoration normally associated with kyphoplasty.

Other factors to consider before deciding on kyphoplasty also exist, such as whether the patient is healthy enough for surgery. For example, if the patient is of advanced age or has the compression fracture as a result of a bone infection, the surgery is unlikely to be well tolerated.

Current medical literature indicates that kyphoplasty is an effective treatment for restoring vertebral height and eliminating pain from vertebral compression fractures. Compared to a similar procedure called vertebroplasty, which stabilizes the fracture without restoring vertebral height, kyphoplasty appears to offer the same amount of pain relief with similar risks.1,2

Some studies have also found that kyphoplasty (and vertebroplasty) may help older adults who have had a vertebral compression fracture to live longer.3,4 One possible reason may be that, compared to nonsurgical treatments for vertebral compression fractures, kyphoplasty may help the patient achieve better functioning to protect against future falls or other serious complications. However, more research is needed.

Sciatica

Sciatica is a term used to describe nerve pain in the leg that is caused by irritation and/or compression of the Sciatic Nerve. Sciatica originates in the lower back, radiates deep into the buttock, and travels down the leg.

The symptoms of Sciatica are commonly felt along the path of the large sciatic nerve. Sciatica is often characterized by one or more of the following features:

Pain

Sciatica pain is typically felt like a constant burning sensation or a shooting pain starting in the lower back or buttock and radiating down the front or back of the thigh and leg and/or feet.

Numbness

Sciatica pain may be accompanied by numbness in the back of the leg. Sometimes, tingling and/or weakness may also be present.

One-sided symptoms

Sciatica typically affects one leg. The condition often results in a feeling of heaviness in the affected leg.1 Rarely, both legs may be affected together.

Posture induced symptoms

Sciatica symptoms may feel worse while sitting, trying to stand up, bending the spine forward, twisting the spine, lying down, and/or while coughing. The symptoms may be relieved by walking or applying a heat pack over the rear pelvic region.

It is important to note that any type of lower back pain or radiating leg pain is not sciatica. Sciatica is specific to pain that originates from the sciatic nerve.1

Sciatica is a term used to describe a set of symptoms caused by an underlying medical condition; it is not a medical diagnosis

Common medical conditions that may cause sciatica include:

  • Herniated lumbar disc
  • Lumbar spinal stenosis
  • Lumbar degenerative disc disease
  • Sponsylolisthesis
  • Muscle spasm and/ or inflammation of the lumbar and/ or pelvic muscles
  • Sacroiliac joint dysfunction
  • Rarely, tumors, blood clots, or other conditions in the lower spine may cause sciatica

The sciatic nerve is the largest single nerve in the body and is formed by the union of 5 nerve roots in the lumbar and sacral spine. There are 2 sciatic nerves in the body—the right and left nerves, supplying the corresponding lower limb.

A few anatomical characteristics of the sciatic nerve include:

Origin

Starting at the level of the spinal segment L4, the sciatic nerve is formed by the merging of spinal nerves roots from L4 to S3.3 The emerging nerve roots converge into a single sciatic nerve making it large and bulky, typically up to 2cms in diameter.

Path

After its individual contributions end, the sciatic nerve exits the pelvis through the greater sciatic foramen, below the piriformis muscle. The nerve then runs along the back of the thigh, into the leg, and finally ends in the foot.

Branches

The sciatic nerve branches into 2 main divisions behind the knee—the tibial nerve and the common peroneal nerve. The tibial nerve courses down and supplies the back of the leg and the sole of the foot. The common peroneal nerve supplies the front of the leg and foot.Rarely, the sciatic nerve may split into 2 nerves near the sciatic foramen, which merge again into a single nerve.

The specific sciatica symptoms largely depend on the nerve root that is pinched.3 For example, an L5 nerve impingement can cause pain in the back of the thigh and weakness in lifting the big toe and the ankle

Often, a particular event or injury does not cause sciatica—rather it tends to develop over time. Sciatica affects 10% to 40% of the population, typically around the age of 40 years.1 Sciatica is found to be common in certain types of occupation where physically strenuous positions are used, such as machine operators or truck drivers. Specifically, people who often bend their spine forward or sideways or raise their arms frequently above the shoulder level may be at risk of sciatica

The vast majority of people who experience sciatica typically get better within 4 to 6 weeks with nonsurgical sciatica treatments.1 If severe neurological deficits are present, recovery may take longer. An estimated 33% of people, however, may have persistent symptoms up to 1 year..When severe nerve compression is present with progressive symptoms, surgery may be indicated.

Certain symptoms of sciatica may indicate a serious medical condition, such as cauda equina syndrome, infection, or spinal tumors. These symptoms may include, but are not limited to:

  • Progressive neurological symptoms, such as leg weakness
  • Symptoms in both legs
  • Bowel and/or bladder dysfunction
  • Sexual dysfunction

It is advised to seek medical attention immediately if such symptoms develop. Sciatica that occurs after an accident or trauma, or if it develops in tandem with other symptoms like fever or loss of appetite, is also cause for prompt medical evaluation.