Conquer Back and Neck Pain - Walk It Off! (18 page)

What are the risks of disc surgery in your low back? How can you avoid the risks of disc surgery? In obtaining an informed consent for surgery from my patients, I always list these risks: death, paralysis, infection, nerve damage, and spinal-fluid leakage. I go on to explain that the risk of death from anesthesia is less than one in 15,000. It is much lower in people who are in good health. Smokers are at the greatest risk for this complication, which would stem from a stroke or heart attack. You should stop smoking before having surgery and be cleared for surgery by your PCP to avoid this complication.

Many years ago there was a famous movie actor who bled to death while undergoing disc surgery as the result of the surgeon pushing an instrument through the disc into a major blood vessel in front of his spine. This is an extremely rare complication of low-back surgery. The best way to avoid this complication is to pick a well-qualified and experienced spinal surgeon — orthopaedic or neurosurgical specialist — to perform the operation. This is a dreaded complication that well-trained spine surgeons are always on the alert to avoid.

The risk of paralysis from a disc excision in the low back is less than one in 5,000. The risk of paralysis from the surgery itself is rare; it is in the day or two following surgery that bleeding in the wound can press on the nerves and cause weakness leading to paralysis (epidural hematoma). One way to prevent this complication is to stop taking anti-inflammatory medication, aspirin, vitamin E, garlic, herbal medicines, and blood thinners prior to surgery. If you have a tendency to bleed or bruise easily, you should alert your surgeon so that they can test your blood to see if it clots normally. Your doctor must take you off of Coumadin, Plavix, and other blood thinners (anti-coagulants) before having spine surgery of any kind to avoid the complication of excessive bleeding and post-operative epidural hematoma. The risks of stopping blood thinners for a period of four to six weeks around the time of spine surgery should be explained to you by the doctor who prescribed them. That doctor should be the one who coordinates with your spine surgeon about taking you off the blood thinners and putting you back on them at a specified time following the surgery.

The risk of infection from disc surgery is less than one in 100 cases. Optimizing your health prior to surgery — no smoking: smokers are 10 times more apt to have a post-operative infection compared to non-smokers — can decrease the risk of infection considerably. You should alert your surgeon if you are prone to urinary tract infections, even if you do not have symptoms at the time. Also tell your surgeon if you have a toothache, periodontal disease, earache, ulceration, or boil on your skin. If you have a cold, flu, or upper respiratory tract infection you should delay surgery. Active skin acne in the area where the incision will be made must be treated before having surgery on your spine. All of these precautions decrease the possibility of a post-operative infection following disc excision.

Nerve damage can result from surgically manipulating the already compressed nerve. Sometimes a disc fragment is stuck so tightly to the nerve that it is difficult to remove it without further stretching the nerve. When weakness or numbness occurs from this type of surgical manipulation, it will usually clear up within a few weeks of surgery. This is one reason why I think it is safer to have a routine laminectomy through an adequately sized skin incision. The surgeon can see the nerve more easily and can manipulate it more gently through this approach, thus avoiding this complication.

No matter how carefully the surgery is performed, 5 percent of the time a hole is made in the dura, the sac that contains the spinal nerves and spinal fluid. Sometimes holes are already there from a previous epidural steroid injection. Either way, they should be closed with stitches. When a hole occurs in the dura during surgery, instead of getting out of bed the night of surgery you should stay flat in bed for a day or two until the leak is sealed. Except for the dangers of bed rest and the nuisance of a spinal headache, there are usually no bad consequences from a hole in the dura. Despite these risks of disc surgery, it is a relatively safe procedure — safer than having your gall bladder removed.

There are some specific complications associated with removing a disc in the neck. The spinal cord takes up more space and is at more risk for injury in your cervical spine. Thus, spinal-cord injury with paralysis is a potential — though rare — complication of cervical-disc surgery. While surgically exposing the disc in your neck, it is possible that the nerve to your vocal cords can be stretched, causing a hoarse voice. The tube leading from your mouth to your stomach, the esophagus, can be punctured. The major vessels to and from your brain can be damaged, leading to a stroke, blindness, or death. Major things can go wrong! To avoid having one of these complications of disc surgery in your neck, choose a well-trained spinal surgeon who is experienced in neck surgery.

Disc herniations in the thoracic spine are sometimes very difficult to remove because they tend to stick tightly to the spinal cord. Some of these disc herniations are gradually causing paralysis and must be removed in an attempt to prevent this from happening. I have seen patients become paralyzed from attempts to remove these discs even by very experienced and careful surgeons. In light of these rare cases, both the patient and the doctor must have a clear understanding of the dangerous risk of paralysis, and the patient must be the one to make the final decision for surgery.

You should consider all of the benefits and possible risks of any elective surgery (elective surgery is one that can be planned ahead of time) before having it performed. Your surgeon should discuss these issues with you, answer all of your questions, and let you make the final decision. One of the best ways to prevent bad things from happening to you, as I mentioned before, is to pick a qualified surgeon. Ask around to see if others in your community have heard of or used the surgeon and whether they have a good reputation.

Neurosurgeons and orthopaedic surgeons specialize in spine surgery and both are fully qualified to perform a disc surgery at any level of the spine. Both specialties are trained to do most spinal surgery. Tumors involving the spinal cord and nerves are usually handled by neurosurgeons, and instrumented spinal fusions and deformity are attended to by orthopaedic surgeons. In our institution at the University of Miami Miller School of Medicine, orthopaedic and neurosurgical spine specialists work together in difficult cases involving tumors and sophisticated reconstruction of the spine that require instrumented spinal fusions. We train our residents and spine fellows together. Both specialties are fully qualified to perform most spinal surgery. This is the case in most major spine-surgery centers.

Assuming responsibility for your own health is as important as picking the right surgeon. Tell the doctor about all your medical conditions, medications, tendency to bleed, and of any recent infections; stop smoking, stop taking aspirin and other anti-inflammatories, and stop all herbal medications; lose weight if you are overweight. Overweight individuals have a higher risk of developing a post-operative infection, pressure sores, and blood clots in the legs. On the other hand, you should gain weight if you are too thin. Undernourished individuals also have a higher risk of developing a post-operative infection and wound-healing problems. Have your doctor help you stop taking narcotics and muscle relaxants prior to surgery. The last measure helps you tolerate anesthesia better and gives you better relief from post-operative pain medication. Make sure you cooperate with your primary care physician to obtain all the appropriate pre-operative tests and his or her medical clearance for your surgery. Have all of this information ready for the anesthesiologist, who should also clear you for surgery before you come in the hospital. Overall, the success rate for disc surgery is high and the risk rate is low, so you should not be unnecessarily frightened by the prospect of disc surgery if you have taken the precautions listed above.

One of my patients wrote me the following email, and both she and I thought you would benefit from hearing her story. It illustrates the dilemma that patients and doctors have in deciding when and if to operate for a herniated disc. The story is not uncommon and is quoted directly from her e-mail to me:

This story is typical of the natural course of disc herniations. If you can wait out the symptoms, over 80 percent of the time they will resolve spontaneously. The symptoms resolve because the body has defense mechanisms that dissolve that part of the disc that is herniated out of place.

In the next chapter I will discuss spinal stenosis, a condition that most commonly results from advanced disc degeneration. Like disc herniation, spinal stenosis is a common cause of back and extremity pain. Unlike disc herniation, which is more common in middle-aged people, spinal stenosis occurs more often as we get older. It is a very common cause of back and leg pain in people over the age of 60, yet hardly any of those who suffer from spinal stenosis know what it is!

Spinal stenosis literally means constriction or narrowing of the spinal canal. Most commonly it is the result of the disc going flat from aging. To understand how disc degeneration leads to spinal stenosis, we need to look at how the spinal canal is built.

Attached to the back of your vertebrae are bony arches. These bony arches are comprised of the walls (pedicles) and the roof (lamina) of your spinal canal. Attached to the bony arch are the bones that project to the sides, called the transverse processes, and those that project to the back, called spinous process. These processes are for attachment of the muscles of your spine. Finally there are bones on either side that project upward toward you head and down toward your feet at each vertebra, the facet processes. The facet processes from one vertebra form a joint, about the size of the joint in your thumb, with the facet processes of an adjacent vertebra. These joints are called facet joints, and they are located just behind and to the side of the spinal canal at the level of the disc space. If you look at the cross section of a spine through the disc space, you will see that the spinal canal is surrounded by the disc in front and the facet joints to the back and sides. There are also ligaments, which are strong attachments between bones, like the ACL (anterior cruciate ligament) in your knee, that keep the vertebrae together. They are located just in front of the spinal canal and behind it as well.

This illustration of the anatomy of the spine from the side, cross section, and from behind shows the relationship of the disc and facet joints to the spinal canal that contains the nerves.

How do changes in these structures cause spinal stenosis? (See illustrations on pages 71, 73). As a degenerated disc becomes flat, it bulges and causes the bony arches of the vertebrae to come together. This in turn causes the facet joints to be pushed out of alignment and then become arthritic and enlarged. As the disc narrows, the ligaments of the spine become shortened and thick. All of these consequences of the disc degeneration, along with the bulge of the disc itself, result in narrowing of the spinal canal and nerve channels that contain the nerves going to your arms and legs.