Mr Neil Orpen

MBChB FRCS (Ed) TR & Orth

Consultant Spinal Surgeon

Lumbar Microdiscectomy

This commonly performed procedure is indicated in the treatment of a lumbar disc prolapse or slipped disc. Micro- refers to the use of an operating microscope which has now become a routine way of performing this procedure as it is considered safer and allows the surgeon to minimise the size of the surgical wound. Microscopes are considered routine in spinal surgery and you should discuss with your surgeon whether an operating microscope is going to be used.

 

Indications

Disc prolapses occur commonly but in the vast majority of cases will resolve spontaneously within 8 weeks. When this does not occur or when the disc prolapse is associated with bladder or bowel symptoms, then Mr Orpen will offer a microdiscectomy. An MRI will always be performed prior to surgery (please see website article on disc prolapse)

 

Aims of Surgery

The main aim of surgery is alleviate pain in the leg (sciatica) and this occurs in excess of 90% of patients. Most experience immediate relief, although because the nerve is swollen, complete relief may take longer to occur and in approximately 5% of cases it may take up to 6 months to get the full benefit of surgery. If weakness or numbness is present, then this may take some time to recover and in many cases does not recover at all. Pins and needles/paraesthesia typically does respond to surgery but may take some time to resolve.

 

Procedure

Prior to surgery, you will be seen in the pre-operative clinic and consent will be obtained and routine investigations including screening for MRSA. This will usually precede admission by a few days. You will be admitted to the ward on the day of surgery and will have an opportunity to discuss any concerns before you go to theatre with Mr Orpen.

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Spinal Microdecompression

Decompression of the lumbar spine for spinal stenosis is the most commonly performed spinal surgery procedure in people over 60 years old. The aims of surgery are to relieve pressure from the spinal nerves whilst retaining the supportive function of spinal column.

Some surgeons have reported poor outcomes and low incidences of long term success using traditional approaches.  One plausible explanation for the late deterioration is that traditional approaches involve some destruction of the the stabilising structures around the spinal canal.

This can lead to an unstable spine or recurrent symptoms, including pain. Lumbar spine “micro-decompression” aims to address this problem by approaching and entering the canal from one side only. After decompressing the first side/open side, the surgeon crosses to the opposite side beneath the overhanging bony structures, allowing a decompression to be done on the opposite side from within the canal.

All the bony and soft tissue structures outside the canal on the opposite side are preserved with no increase in surgery required to the side of canal entry.  Safety is further aided by the use of an operating microscope and specialised surgical instruments.

The results associated with this technique have been reanalysed and Mr Orpen has reported the outcomes in treating spinal stenosis with micro-decompression surgery in a group of 100 patients over a 6-year period (JBJS (Br) 2010).  Mr Orpen and his colleagues aimed to assess the safety and feasibility of this modified technique of bilateral decompression through a one-sided approach and compared it to existing evidence of traditional approaches.

Mr Orpen and his colleagues were also interested in the effects on stability of the lower (lumbar) spine in the longer term and assessed which patients developed symptomatic instability, requiring further stabilisation surgery.  This technique of lumbar micro-decompression has proved to be safe with few complications and good results after an average of 3 years 6 months and for up to 6 years and this looks encouraging for the longer term.

This technique has advantages over wide decompression in that it preserves the supportive anatomy without compromising safety and Mr Orpen continues to evaluate this technique over the long-term. Patients report less pain and are discharged home sooner and the rate of post-operative instability leading to fusion surgery is low and is certainly lower than the published series of traditional approaches.

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Spinal Disc Replacement

Disc prolapses occur in the cervical spine in a similar way to the lumbar spine and cause neck and arm pain ( brachialgia). Successful decompression of the disc prolapse is an effective way of managing pain and this is performed through an incision in the front of the neck.

Once the disc is removed the surgeon has a choice as to what is put in its place and typically this would be either bone (fusion) or an artificial disc replacement. There are specific indications for when each is used and your surgeon should be able to inform you which is best suited for your specific condition.

Disc replacements have been used throughout the spine but the most successful outcomes are reported when used in the cervical spine. A number of implants are available but Mr Orpen uses the Prestige Disc Replacement (Medtronic) as this implant currently has the best outcomes with the best long-term data.

The principle behind this implant is that by imitating the normal motion of the spine, the loads and stresses that would otherwise be transferred to adjacent levels are spread in a more natural pattern. This leads to less stress on the other discs and prevents them degenerating earlier than they otherwise would.

So by preserving the natural motion of the spine, degeneration in other segments is prevented and thus the need for further surgery in the future is reduced. A disc replacement is not beneficial in all instances and Mr Orpen will be able to advise you on whether you would be suitable and would benefit from this specialised form of surgery.

Prestige Cervical Disc Replacement

The procedure: This procedure should only be performed by a surgeon specifically trained and experienced in the indications and technique of the surgery. An operating microscope is routinely used to enhance the safety of surgery around the spinal cord.

A right sided approach is most commonly used, using an already present skin crease at the front of the neck if possible. The incision will be 3-4cm long and due to the position of the scar, with time it becomes quite well hidden in the natural creases of the neck and so is not very obvious to see.

The tissues to the front of the spine are moved out the way and as very little is actually cut during this approach, post operative pain is seldom a big problem and post operative recovery is fairly quick. The level of surgery is checked with an xray and the whole disc is removed together with spinal ligament to reveal the front of the spinal cord. The appropriate nerve is then decompressed to relieve the pain.

At this point Mr Orpen can either use a small cage to fuse the spine or a disc replacement is used. This decision is made prior to performing the surgery. Checks are made to make sure there is no bleeding and the skin is closed. A small wound drain is often used and if so will be removed the morning after surgery. No collars are used after a disc replacement operation and most patients will go home the morning after surgery as long as they feel safe to do so.

Complications

Complications are rare from this surgery, but when they do occur, some can be very serious and so are responded to very quickly. From the approach it can be seen that many important structures are retracted and so there is a theoretical chance of damage to any of these during surgery. This includes the oesophagus, trachea, carotid artery, the spinal nerves and spinal cord.

These are rare and although most patients will have the feeling of a lump in the throat for a week or two following surgery, few will experience this in the long term. For any operation there is a risk of bleeding, infection, wound problems, anaesthetic complications and neck surgery is no different.

Bleeding may present as an emergency with difficulty breathing which is why a drain is often used. Nurses are trained to pick this up and know how to respond rapidly. Infection risk is very low and wounds are commonly barely visible after a few months in most patients.

Nearly all patients have some discomfort swallowing due to the swelling but this usually settles in 2-3 weeks. Some also have a hoarse voice due to swelling of the nerves supplying the voice box but this usually will not persist. If the latter is permanent then referral to an ENT surgeon may be necessary to check the vocal cords.

Implant related problems are fortunately rare but if displacement occurs then further surgery may be needed.

Post-Operative Care

This is different for all patients but as a guideline:

Wound - normally no sutures, just paper strips or tissue glue

Physiotherapy - the ward therapist will instruct on how to mobilise the neck but few restrictions are placed and most movements that are controlled and comfortable are allowed.

Driving - when safe and able to do an emergency stop, look in mirrors, reverse. Typically at 2-4 weeks

Work - depends on your job but commonly people return to a desk based job in two weeks and a more physical job in four weeks. No heavy tasks 2-3 months.

Mr Orpen will also be able to discuss his experience with other disc replacement designs and discuss the biomechanics of the spine.

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Spinal Fusion/Spondylosis

Spondylosis is a term that refers to the natural degenerative process that occurs in the spine with ageing. The term itself refers to the radiological appearance of the presence of osteophytes secondary to degenerative discs and does not imply the a particular person will be symptomatic in any way.

In fact the presence of these changes should be considered normal in that they are present in most people as they get older. The condition is different to those inflammatory conditions which result in osteophytes which collectively are referred to as arthritis.

Degenerative spondylosis may result in symptoms though and in the mildest forms this may be in the form of back or neck pain, but also may lead to more serious conditions such as myelopathy. Myelopathy is a condition which occurs when progressive pressure on the spinal cord results in damage which may not resolve.

This damage may be picked up both clinically and on special diagnostic imaging which typically includes and MRI scan of the spine and usually requires surgical management. It must be stressed that the presence of myelopathy is not common in relation to how often spondylosis may be seen but as it is an important diagnosis to make, an MRI scan will often be requested as part of the diagnostic evaluation of the spine.

In the spine there are 3 main groups of symptoms people experience in the presence of spondylosis. Pain- this may be either acute (of short duration, often severe) or of chronic duration ( long standing, often moderate or background pain).

This pain is commonly felt radiating to either the scalp, top of the shoulders or between the shoulder blades and can be very positional. The reason for this distribution of pain is that the structures of the neck and back often share a sensory neurological supply and therefore result in referred pain to regions other that the spine.

Radiculopathy - this refers to the presence of pain of nerve root origin and can be associated with other neurological symptoms such as altered sensation, pins and needles ( paraesthesia), decrease in motor power. In the lumbar spine the term sciatica is often used to describe pain in the distribution of the sciatic nerve which typically involves the lower leg down the back or outer side of the calf.

Femoralgia describes similar pain in the distribution of the femoral nerve which runs down the front of the thigh an inner aspect of the lower leg.

Brachialgia describes similar symptoms in the arms. Specific patterns of pain are associated with specific nerves which can provide a useful clue as to where pain may be arising and these dermatomal patterns can be helpful in directing treatment.

Myelopathy - this is a more serious clinical presentation resulting from compression of the spinal cord. This results in a damage to the nerves that traverse the spinal cord and this damage may be permanent and irreversible. Due to this, removal of this pressure( decompression) is commonly performed to stop deterioration in the spinal cord function although in some patients the clinical damage may improve.

This is not always the case and therefore in the presence of myelopathy, there is some urgency in relieving pressure as soon as possible and being cautious about preventing deterioration while awaiting surgery.

Imaging In Spondylosis

X-Rays: these may be a very good way of making the diagnosis but in isolation are only a part of the diagnostic workup. One major benefit of x-rays is that they may be performed in a variety of positions such as standing upright, flexion, extension and often in the position that brings on symptoms. They also give an impression of how one part of the spine moves in relation to another so form a major part of the diagnosis of deformity and instability.

MRI scanning is essential to assess the neurological structures of the spine as well as those structures not made up of bone such as nerves, spinal discs, muscles etc. They are also an excellent way of diagnosing tumours and infection.

CT SPECT scanning; This new modality is a combination of a CT scan and a specific bone scintogram which are combined together with the use of a computer. This can be a very useful modality in the assessment of back pain in that it can offer some useful information on being more specific about where the pain comes from.

This type of scan does use higher doses of radiation that standard x-rays and therefore are not used in all patients but can be a helpful way of planning surgery for spinal pain. Treatment Spinal spondylosis itself does not require treatment but in the presence of symptomatic spondylosis, treatment is tailored around the specific treatment and the appearance of the spine on special radiological investigations.

Although a number of anaesthetic and steroid injections will be of value in a number of situations, Mr Orpen will also be able to discuss the surgical options in those that have persistent pain or in the presence of Myelopathy.

His emphasis will be on conservative/ non-operative treatment if possible but in specific conditions such as Myelopathy, surgery may be the first choice. These options will be made clear in consultation.

Also see documents on

• Nerve root blocks

• Facet joint injections

• Facet joint rhizolysis

• Spinal decompression

• Spinal fusion

• Disc replacement

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Minimally Invasive Spinal Surgery (Keyhole Surgery)

The concept of minimally invasive surgery is not new and over the years newer techniques have been developed that make surgery more efficient and safer. Part of this development has allowed surgery to be performed through smaller incisions without compromising safety.

Some commonly performed procedures which involve minimally invasive techniques include

• Microdiscectomy

• Microdecompression

• Kyphoplasty

• Vertebroplasty

• Cervical disc replacement surgery

• Tumour and fracture stabilisation

• Lumbar spine fusion

Some of these techniques are truly percutaneous procedures while others are minimally or less invasive. The addition of an operating microscope as a routine tool for use in surgery and effective and accurate fluoroscopy in the operating theatre have made this possible. These are not simple techniques and should only be performed by surgeons with training and experience in their use with the abilities to deal with any complications which may arise.

Now minimally invasive techniques have been extended to be used in fusion surgery and in particular these techniques may be used for posterior spinal fusion and for management of tumours and spinal fractures.

This means previously where fairly large incisions with large muscle dissection was required to expose the spine, similar outcomes may be achieved using minimally invasive techniques. Patients should be encouraged to ask their surgeon if minimally invasive options exist for surgery when a surgical solution to their symptoms is offered by their surgeon.

Fracture Management

Fractures of the spine are common and the most common causes for these are typically high energy trauma (car accidents, falling from a height or horse) or in the older patient in the presence of osteoporosis.

Fortunately, the majority of fractures in both these groups do not require surgery but when surgery is indicated, minimally invasive options can be considered. Traumatic fractures may be effectively managed with the use of percutaneously placed pedicle screws.

This may result in smaller scars, shorter hospital stay and less additional trauma to the already injured soft tissues such as muscle, ligaments and tendons. Commonly, spinal fusion is not required for the management of a fracture and so these techniques may be particularly attractive as an alternative to traditional wide open techniques.

Osteoporotic fractures that remain symptomatic can effectively be managed with cement augmentation and techniques such as kyphoplasty and vertebroplasty. These techniques should be performed by a surgeon with experience and training in performing and dealing with any complications which may arise, albeit rarely.

Tumour Management

Symptomatic spinal metastatic disease is common and previously very little options existed for patients that experienced pain or neurology associated with the expanding tumour or fractures that occurred with weakened bone.All patients with metastatic spinal lesions should be under the care of an oncologist.

The oncologist will have a through knowledge of chemotherapy and radiotherapy options for the treatment of pain and metastasis related spinal cord compression. In the presence of spinal cord compression surgery needs to be considered and often this may be an urgent priority.

Minimally invasive options may be a good option in that surgical trauma is limited without an increase in risk to the patient. Cement augmentation can be used for the management of painful metastasis and has the advantage that it may often be performed under local anaesthetic and as a day case procedure.

Patients should ask their surgeon about their involvement with a multi-disciplinary team for the management of tumours and their experience and training in the use of these techniques.

Disc Replacement Surgery

Disc prolapses occur in the cervical in a similar way to the lumbar spine and cause neck and arm pain ( brachialgia). Successful decompression of the disc prolapse is an effective way of managing pain and this is performed through an incision in the front of the neck. Once the disc is removed the surgeon has a choice as to what is put in its place and typically this would be either bone (fusion) or an artificial disc replacement.

There are specific indications for when each is used and your surgeon should be able to inform you which is best suited for your specific condition.

Microscopes

The use of an operating microscope has meant that not only can surgery be performed carefully around the delicate neurological structures of the spine, but also smaller incisions can be used as the microscope aids the surgical view for the surgeon.

Procedures routinely performed with the aid of the operating microscope are discectomies/microdiscetomies, cervical disc replacements, lumbar microdecompression surgery, minimally invasive fusions. The microscope vastly improves the surgical view making these procedures safer and lowers the risk of complications.

Suggested links for additional information:

• Viper 11

• XLIF

• Longtitude

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Vertebroplasty/Kyphoplasty

Certain conditions may result in painful fractures of the spine and although these commonly result in pain, this is usually self limiting as the fractures heal themselves. The vast majority of osteoporotic fractures of the spine resolve without any form of intervention and in fact most osteoporotic fractures are not diagnosed as they never produce any symptoms.

Occasionally however, the pain persists beyond a reasonable period of conservative treatment with pain killers and anti-inflammatory medication and in these circumstances further intervention may be useful in helping to manage the pain and reduce the risk of future fractures around this level.

Intervention in the form of augmenting the vertebral bodies with a specialised form of bone cement (the same as used in hip or knee replacements) is advocated as a way of reducing pain and disability associated with osteoporotic vertebral fractures and in painful tumours or multiple myeloma of the spine. It is a minimally invasive procedure which should be performed by someone trained in performing these interventions and knowledgeable about the options available.

Typically these are performed by spinal surgeons or specialist interventional radiologist. There are a number of theories as to why cement augmentation may be useful. One of these is that the cement helps to stabilise the small fragments of bone around the fracture which reduces inflammation and allows the body to continue to heal itself.

The procedures themselves are briefly outlined below but the principles behind them are similar. They are to help with pain management and are particularly useful in painful osteoporotic fractures which have not healed or in painful spinal tumour metastasis in conjunction with other treatments usually specifically tailored to individual patients and their underlying condition.

Do all osteoporotic fractures need a vertebroplasty? Most osteoporotic fractures need little or no intervention and they will heal without treatment. To assess whether a fracture is likely to respond to cement augmentation, a set of facet joint injections (a much more straight-forward intervention) is carried out prior to considering vertebroplasty or kyphoplasty. Usually if the facet joint injections help the pain, then more intervention is not required

Vertebroplasty

This procedure is usually performed as a day case although occasionally a patient requires an overnight stay. This is usually performed under general anaesthetic but may be performed under local anaesthetic and sedation if patients can tolerate lying flat on their stomach’s for approximately 30 min.

A needle is passed under careful x-ray guidance from the back into the vertebral body where the fracture or tumour deposit lies. A liquid cement is then injected into the vertebrae while carefully noting where this is being distributed and then over the next 10-15min the cement sets. This can be repeated at up to 3 levels in each sitting.

Patients typically have some discomfort when the local anaesthetic has worn off but typically this is less than before the procedure and they are allowed up to walk around immediately. Further information may be found on the De Puy sponsored web site.

Kyphoplasty

This is essentially a very similar procedure except that a small balloon is placed inside the vertebral body and inflated. This compresses the bone to help healing and provides a small cavity which can accommodate the bone cement.

This has a potential benefit in reducing the amount of cement that may be distributed in places other than where it is intended. Some people also feel it may help to correct the deformity created by the fracture itself and so decrease the incidence to future fractures around the first fracture area.

This concept is debatable though and is likely to be a potential benefit rather than one we see in practice. It is a topic of much research. Your surgeon should be able to advise which procedure is to be considered in individual circumstances. In kyphoplasty a small balloon is used to create a cavity which can be filled with cement.

The balloon is removed and the void created may be filled with soft cement which hardens over 10-15 minutes. further information can be found at the medtronic sponsored company website for Kyphon.

Further info

• National Osteoporosis Society

• Myeloma UK

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Consulting Rooms

The Ridgeway Hospital

Moormead Rd
Wroughton

Swindon
Wiltshire

SN4 9DD

 

NHS Secretary (Ridgeway)

Wendy Spencer

National BMI Spinal

MDT Co-ordinator

Tel: 01793 814848

Email Wendy here

Private Secretary (Ridgeway)

Geraldine Jackson

Tel: 01793 816006

Email Geraldine here

Private Secretary (Berkshire)

Andrew Capel

Tel: 0118 9028147

Email Andrew here

Berkshire Independent Hospital

Swallows Croft
Wensley Road
Reading
RG1 6UZ