The Orthopaedic Centre



    The nerves in the spine in the neck region (cervical spine) may be compressed by various disease conditions. This may result in pain, numbness and weakness of the arms and legs. For compression at one or two spinal levels (rarely three or more), Anterior Cervical Discectomy and Fusion is a surgery that may be performed.

    The spine is approached from the front of the neck, utilising a safe “window” between the vital structures of the neck. This approach has been safely used for more than 60 years. At the spine, the discs and structures compressing the nerves are removed under the operating microscope. After decompression of the nerves, the gaps in the discs and bones are reconstructed with bone graft or synthetic spacers. In addition, a titanium plate and screws are inserted in the adjacent bone to stabilise the spine. The locking of the two bones across a disc/joint is called fusion.

    The recovery from Anterior Cervical Discectomy and Fusion is relatively quick. Most patients stay only one or two days in the hospital and no external brace is usually necessary. The success rate of this surgery is usually high (more than 90% of patients experience improvement in their symptoms).

    The spinal cord is an important nerve structure that is normally protected by the bones of the spine. Loss of spinal cord function occurs when it is compressed by various diseases. One common condition is the compression of the spinal cord by degenerative changes of the spine in the neck such as enlarged joints, thickened ligaments, “bone spurs” and disc protrusions. This can result in progressive disability and loss of function (cervical myelopathy), including clumsiness of hands and inability to walk. This usually occurs in older patients.

    Cervical laminoplasty is a type of surgery that is often used to treat this condition. In this surgery, the spine is approached from the back. The back part of the spine (lamina) is “reshaped” with special instruments to create more space for the spinal cord. This relieves the compression on the spinal cord.

    Multiple levels of compression (usually more than 3) can be safely treated at the same time with cervical laminoplasty. The main aim of the surgery is to stop the deterioration of spinal cord dysfunction although a significant number of patients do experience improvement, especially if surgery is performed soon after the onset of symptoms.

    While Anterior Cervical Discectomy and Fusion (ACDF) is an effective and reliable surgery to treat conditions of the cervical spine, there is some concern over the reduced flexibility of the neck joints after surgery. This may result in earlier degeneration of the joints in the spine next to the fused level.

    Cervical Disc Replacement (Arthroplasty) may be suitable for some patients instead. An “artificial disc” is used in the reconstruction of the cervical spine. The “artificial disc” is usually made of metal, ceramic and/or plastic. It acts as a spacer while allowing the joints of the spine to continue to move after surgery.

    Current studies show that the results of the Cervical Disc Replacement with an “artificial disc” are equivalent to those of ACDF. It has not been proven to reduce degeneration of the joints in the spine next to the operated level. The actual longevity of such implants is currently unknown though most of the established models have at least 3 to 10 years of follow-up history.

    A herniated disc, commonly called a slipped disc, is a condition where the jelly-like material in the spine moves out (slips out) of its confined space. This may result in irritation or pinching of nerves in the vicinity of the slipped disc. If the slipped disc occurs in the neck (cervical spine), one can get pain or tingling down the arms and even numbness in the hands. When the disc occurs in the lower back (lumbar spine), similar symptoms can occur down the legs or feet. Terms such as radiculopathy (caused by a pinched nerve) or sciatica (shooting pain down the leg) are used to describe such symptoms. Rarely, a large portion of the disc comes out and can cause severe weakness of the arms, legs or nerves to the bladder or bowel. This condition is serious and an urgent medical consult should be made.   An MRI (magnetic resonance image) of the spine can diagnose a slipped disc. Most patients with a slipped disc improve with non-operative measures such as physiotherapy, traction, brace, medications and/or injections. Surgery (discectomy) is sometimes required which can be done as an open surgery or minimally-invasive spine surgery. In the neck, a cervical disc replacement (where the disc compressing the nerve is removed and replaced with an artificial disc) or a cervical discectomy and fusion (where the disc is removed and the 2 spine segments are fused) can be done. There are some treatments that have been described such as nucleoplasty/annuoloplasty or injections of platelet rich plasma (PRP).

    As a person ages, the joints and discs of the spine degenerate. As part of the degeneration process, the joints and ligaments of the spine can enlarge and thicken. This sometimes leads to compression of the spinal nerves. Surgery may be required to relieve the nerve compression when it causes nerve dysfunction (such as pain, weakness, numbness and difficulty with prolonged standing or walking).

    In Minimally Invasive Laminotomy or Laminectomy, the surgeon uses one or more small incisions and special retractors to visualise the compression area under the operating microscope. He then removes the abnormal structures compressing on the spinal nerves. Patients are usually able to go home within 1-2 days after the surgery.

    Traditional open spine surgery involves cutting and pulling the back muscles out of the way so as to expose the spine before actual surgery is performed. This is necessary in order to see the area of the spine that needs to be operated on. Sometimes more muscle is cut so that the surgeon can see the area better, especially in deeper areas. Injury to the muscles can be significant. While they usually recover, this can take a long time and causes a lot of pain as well as loss of function in the meantime. Additionally when muscle injury is severe the body repairs with scar tissue instead of muscle tissue. The function of that particular muscle may risk being lost permanently.

    Minimally invasive spine surgery modifies the approach to the spine by reducing the trauma to the back muscles, while still allowing the surgeon to see and access the area of the spine that requires surgery. This is achieved with special access retractors, x-ray imaging and guidance equipment. Several small incisions are made instead of a large one, sparing all the muscles in between. With special retractors, the same size incisions are made whether the area to be operated on is deep or superficial.

    The advantages of minimally invasive spine surgery are:

    • much faster recovery
    • shorter stay in hospital (half as long as open surgery)
    • less blood loss (1/10 as open surgery)
    • less pain for the patient (10 times less painkillers required in the early period after surgery)
    • lower risk of infection

    The long term effectiveness of the minimally invasive spine surgery is the same as the traditional approach. However the spine surgeon needs to undergo special training in order to perform the surgery well. In addition, the equipment is more expensive compared to traditional surgery and the approach cannot be applied to certain areas of the spine.

    Sometimes the ring (annulus) around a spinal disc ruptures and part of the core (nucleus) protrudes out of the ring. This is a “slipped disc” (prolapsed intervertebral disc or herniated nucleus pulposus). The protruded disc fragments can compress on the spinal nerves causing pain, weakness and numbness. This may be treated with surgery if conservative treatment fails or if symptoms are severe, threatening nerve damage.

    Minimally invasive lumbar microdiscectomy is a more advanced approach of performing surgery to treat this condition. Under X ray guidance a small incision is made over the back. Special retractors are inserted to approach the spine. Under the operating microscope, a small area of bone and ligament at the back of the spine is removed. The spinal nerves are identified and protected. The prolapsed disc fragments are then removed with fine instruments. Patients are usually able to go home within 24 hours after the lumbar microdiscectomy surgery.

    The spine consists of multiple segments of bone (vertebral bodies) in between which are intervertebral discs (behaving like shock absorbers). Behind these structures are the spinal cord or nerves. Behind the nerves are the joints of the spine (termed facet joints). With age, the discs undergo changes in their chemical composition causing it to lose its water content as well as disc height. This can cause additional stress on the facet joints causing arthritic changes of the joints. Back pain can be a symptom of spine degeneration. In some cases, the vertebral bodies can slip (termed degenerative spondylolisthesis). In those cases, nerves in the spine can be compressed causing pain, tingling or numbness in the legs. Terms like radiculopathy or claudication may sometimes be used to describe these symptoms.

    Performed under X-ray guidance, spinal injections can be used for diagnosis of pain source or treatment for pain relief.

    For pain relief, spinal injections can be more effective than an oral medication in delivering medication directly to the source or location of the pain. The duration of back pain relief provided depends on the type of spinal injection. The most common epidural steroid injection is used in temporarily relieving lower back pain especially for people who experience episodic severe back pain.

    For diagnosis of pain, spinal injections (together with physical and other imaging examinations) can help in developing further treatment for the patient.

    Tumours of the spine can be secondary (i.e. spread from elsewhere) or primary (i.e. tumour occurring in the spine or spinal cord/nerves itself). They can sometimes be picked up incidentally or present with a wide variety of symptoms such as persistent neck or back pain, pain shooting down the arms, chest or legs (termed radiculopathy), weakness or numbness of the arms or legs. They can sometimes be associated with loss of appetite and/or unexplained weight loss. It is important to always maintain a high degree of suspicion in patients with a previous history of cancer as the spine is a common site for tumour spread from another site, termed metastases. As there are many considerations, it would be prudent to seek a medical consult for cases of spine tumours.
    Spondylolisthesis refers to the phenomenon where one bone of the spine (vertebral body) has slipped over another vertebral body. This can imply a certain degree of instability of the spine. There are different types of spondylolisthesis. They can be congenital or develop later in life from processes such as degeneration (degenerative spondylolisthesis) or from an injury (spondylolytic spondylolisthesis). Spondylolisthesis can cause back pain and sometimes result in compression or pinching of the nerves. This can result in pain, numbness or tingling in the legs. A medical consult should be made if there are such symptoms.

    In persons with osteoporosis, the bones become weaker and can break or fracture with minor or even no trauma. One common area where fractures occur is the spine and a common fracture that occurs is a compression fracture. In a spine compression fracture, a bone in the spine (vertebra) fractures and becomes flattened.

    Sometimes the fracture does not heal or takes too long to heal causing prolonged pain, disability and deformity. When this happens, the patient, who is usually an elderly person, is unable to get out of bed and be mobile due to pain. This can lead to many complications such pressure sores, lung and urinary tract infections.

    Vertebroplasty or kyphoplasty is the surgery performed to relieve the patient's pain from the spine fracture. In the surgery, bone cement is injected into the fractured vertebra through 2 small puncture wounds. This stabilises the fracture and reduces pain significantly, allowing the patient a quick return to function. The difference between vertebroplasty and kyphoplasty is that in the latter, a balloon is used to “jack” the fractured parts of the vertebra apart before injecting the cement thus restoring, at least partially if not completely, the original shape of the vertebra.

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