Spinal Surgery Q&A

Mr Sean Molloy
Spinal surgery for scoliosis in a young person is needed if the magnitude of a curve is so large there is a significant risk this will continue to increase after skeletal maturity

Spinal surgery in an adult is only needed if:
• Conservative measures have been exhausted with no benefit
• The pain and disability is so severe that quality of life is very poor
• The risk of not operating is higher than the risk of operating

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Mr Neil Orpen
Surgery for the spine is used in a number of situations but usually as a way of either taking pressure off spinal nerves or stabilising the spine in situations of deformity (loss of normal spinal shape). Fortunately it is often a choice once all other treatment modalities have been exhausted but still it can be a very effective and permanent solution to spinal related pain.

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Mr Matthias Radatz
Surgical intervention is the most invasive treatment option and needs to be very carefully considered. Depending on the circumstances of presentation with or without an increasing neurplogical deficit surgery might be avoidable. Surgery carries risks and there is never a guarantee of a  favourable outcome. Most important is paying attention to detail and tailoring treatment options to each patients individual underlying problem and there needs and expectations. Less invasive treatment modalities should have been tried and exhausted before entering spinal surgery, which should be seen as the last resort in the absence of clear urgent or emergency indications.

Mr Sean Molloy
Depending on the problem, other treatment forms may be appropriate:
• Physiotherapy
• Osteopathy
• Chiropractic treatment
• Spinal injections such as caudal epidural, facet joint injections and nerve root block

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Mr Neil Orpen
Depending on the condition, a number of alternatives often exist but consideration must always be given to whether these are likely to be a long term solution. Steroid based spinal injections, particularly for nerve pain, can be very effective in bringing a pain episode to a more rapid end. In situations of back and neck pain, more commonly physical and manipulative therapies will be the first choice.

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Mr Matthias Radatz
Yes there are many alternatives, which should be trialled in the first instance.

Medicinal treatment, physio, osteopathy, chiropractice and alternative treatments of TENS, acupuncture, reflexology and physical therapy. The next line of management would be to engage into a pain management program with possible injections to help in particular with pain.

Mr Sean Molloy
It depends very much on the procedure. 

• A simple discectomy involves taking a small piece of disc out from the spine.
• Spinal decompression involves cutting a piece of bone away (de-roofing the spine) to improve the space for nerves
• Spinal fusion involves insertion of metal work. This can include surgery from the front of the spine – usually to put in cages – and from the back to put in screws and rods
• Spinal scoliosis correction of young people can involve surgery from both the front and the back – or only from the front or the back depending on the size of the curve
• Spinal scoliosis correction and reconstruction  in adults is very complex surgery that may or may not include all of the above

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Mr Neil Orpen
Spinal operations are quite varied and are dependent on the aims of the particular operation. Although injections are simple procedures performed under local anaesthetic in an outpatient setting, more typically surgery is performed under general anaesthetic as an inpatient. Many procedures can now be performed utilising minimally invasive surgery (key-hole techniques) and patients should always enquire whether this is an option available. Surgery typically is aimed at taking pressure off nerves or stabilising bones in the spine, in the form of fusion

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Mr Matthias Radatz
The procedure chosen entirely depends on the underlying abnormality which needs to be addressed. Nearly all procedures are carried out with the use of an operating microscope, some with spinal cord monitoring and image intensifier or image guidance. What happens during surgery depends on the procedure, the most common problem is a disc prolapse which will typically removed with specialist instrumentation. Excellent microsurgical technique , meticulous dissection and tissue handling are very important factors deciding surgical outcome.

Mr Sean Molloy
The risks depend on the type of spinal surgery.

• Infection: There is always a risk of infection when having surgery. This can be of the wound, more deeply or of the inserted metal work. 
• Developing  blood clots in the legs or lungs which is why mobilisation as soon as possible after surgery is important
• Damage to nerves. All surgery of the spine has a risk of damaging nerves. This can be minor or major. 

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Mr Neil Orpen
Safety in spinal surgery is vastly improved compared to 20 years ago but still is to be taken seriously. As surgery is performed on nerves, these are at risk of being injured. Utilising a surgical microscope improves the safety of this and surgeons experience is also a factor. Risks are identifiable and so surgical techniques have been developed to improve the risk profile. Because bones are at risk of not fusing in the presence of nicotine, patients will routinely be asked to stop smoking prior to considering a fusion procedure.

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Mr Matthias Radatz
The risks involved in spinal surgery depend on many factors.

At a rule of thumb:

• the more invasive , the more risky
• the more implants used the more risky

The general advise:

• keep it simple and safe and rely on proven techniques and evidence based procedures

Careful selection and procedure planning can reduce risks significantly.

Risks are Infection, root damage, cord damage, cerebro-spinal fluid leak, increased neurological deficit, incontinence, scarring, chronic pain, recurrent problems, instability and need for further surgery to achieve fusion.

The use of implants adds another level of risk as those can fatique, fracture, migrate, dislodge and can potentially be malplaced.

Mr Sean Molloy
Depending on the procedure there will be a period in hospital. This could be very short, ie a few days - or very long, ie several weeks. This depends on how large the procedure has been. Initially there will be discomfort from the surgery itself. You will be expected to have a period of time off work/school depending on the procedure performed. This is usually a minimum of 3-6 weeks but can be as long as 6 months with larger procedures. You will have physiotherapy in the hospital and given exercises to continue to do. You may not be given specific spinal physiotherapy to start with as the spine will need time to fuse if you have had a fusion. You may or may not need more specific spinal physio at a later stage. You will need to come back to have the wound looked at and possibly stitches taken out by the nurses in the outpatient department. You will come back to clinic six weeks after the surgery initially and the surgeon will arrange further follow up from then on. 

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Mr Neil Orpen
Recovery plans depend entirely on what procedure has been performed and the surgeon in conjunction with physiotherapy will direct a plan. Following a simple discectomy and decompression surgery, patients will often return to work within 3-4 weeks. Following minimally invasive fusions, approximately 6 weeks. Usually following cervical disc replacement surgery return to driving and work is within 2 weeks.

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Mr Matthias Radatz
Recovery from spinal surgery requires time. The time required depends on the extent of the procedure and the underlying pathology and varies greatly. Most important is the guidance and supervision from physiotherapists and occupational therapists. In case of spinal cord injury specialist in patient rehabilitation may be necessary. Recovery from disc surgery typically requires a rehabilitation for 4-6 weeks. Driving will be affected in the first few weeks after intervention. Most important is the gradual increase of activity over the rehabilitation period and patience to allow for a  gradual re-conditioning.

Mr Sean Molloy
That depends on the procedure done and type of sport and will need to be discussed individually with the surgeon at the time

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Mr Neil Orpen
Sport is naturally possible following surgery and the return to full activities will need to be planned.

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Mr Matthias Radatz
Again this needs to be individually evaluated. Spinal surgery is in general carried out to restore the physical abilities and in this context typically allows individuals to re-integrate into there sport of choice. It is important to discuss these issues with your surgeon as certain sports will put individuals at a higher risk of suffering recurrent problems. Your surgeon will typically advise on dos and don’ts and take your physical abilities into account as well as the underlying pathology.

Mr Neil Orpen
My interest in spinal surgery started after a very inspiring exposure as a junior doctor. Although following that the training was long and arduous, my interest in the specialty remained the driving factor. It is one of the most rapidly evolving specialties and I have been part of the process as the exciting subspecialty field of minimally invasive spinal surgery has developed.

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Mr Matthias Radatz
To help patients to improve there quality of life is challenging on one side but very rewarding on the other. The interaction with my patients  is the most satisfactory part of my work as a consultant.

Mr Neil Orpen
I expect I will reflect that being involved in the development of minimally invasive fusion techniques will be the cornerstone of my career. I do envisage that over time these will become the gold standard for spinal surgery and that these will improve many aspects of the patients experience in undergoing a surgical procedure on the spine. We are training more surgeons at becoming confident in performing these operations and progressively this is being established as the norm for spinal surgery in a number of situations.

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Mr Matthias Radatz
There is not one single scenario which I can highlight. The highlight really is the fact that I can make a positive difference to many of my patients. The challenge is to be always up to date and offer the best possible care.