Treatment, surgery, management.

Surgery for Sciatica

Most patients with sciatica respond well to non-surgical treatments (such as medication), so spine surgery is seldom needed to treat it. However, there are situations when you may want to go ahead with spine surgery:

• You have bowel or bladder dysfunction. This is rare, but it may occur with spinal cord compression.
• You have spinal stenosis, and your doctor feels that surgery is the best way to treat it.
• You are experiencing other neurologic dysfunctions, such as severe leg weakness.
• Your symptoms become severe and/or non-surgical treatment is no longer effective.

There are many types of surgical procedures used in spine surgery, and your spine surgeon will recommend the best procedure to treat your sciatica. And remember, the final decision to have surgery is always up to you.

Two common spinal surgeries for sciatica are:

• Discectomy or Microdiscectomy: In both of these procedures, the surgeon removes all or part of a herniated disc that's pushing on your sciatic nerve and causing your sciatica symptoms. The difference between the procedures is that a microdiscectomy is a minimally invasive surgery. The surgeon uses microscopic magnification to work through a very small incision using very small instruments. Because the surgery is minimally invasive, you should recover more quickly from a microdiscectomy.
• Laminectomy or Laminotomy: These procedures both involve a part of the spine called the lamina—a bony plate that protects the spinal canal and spinal cord. A laminectomy is the removal of the entire lamina; a laminotomy removes only a part of the lamina. These procedures can create more space for the nerves, reducing the likelihood of the nerves being compressed or pinched.

MicroEndoscopic Discectomy (MED)
A patient is brought into the operating room and is put under general anesthesia. Some surgeons have chosen to perform MED under local or spinal anesthesia allowing the patient to stay awake throughout the procedure. The patient is turned onto his abdomen and padded into position. A fluoroscope (floor-o-scope, a machine which projects live x-ray pictures onto a screen) is brought in for use during the remainder of the operation. The patient's back is scrubbed with sterile soap, and a sterile field is cre-ated. Drapes are placed accordingly, and the surgery begins.

The disc space is confirmed using the fluoroscope, and a long acting, local anesthetic is injected through the muscle and around the bone protecting the disc. A half to one-inch incision is made. A thin wire is placed through the incision and lowered until it touches the bone. Progressively larger dilators are brought down on top of one another following the wire. In this manner, the muscle is stretched rather than cut. By the time the 4th or 5th dilator is placed, the muscles are stretched to an opening roughly the size of a nickel. It is through this opening that the procedure is performed. Over the last dilator, a working channel is positioned; this circular retractor holds back the muscles and now the dilators can be removed. The retractor is held in place by a mechanical arm attached to the table.

Finally, the endoscope (en-doe-scope) is attached to the edge of the working channel. The endoscope is a camera about as thick as the ink in a ballpoint pen. It projects an image of the base of the working channel blown up to the size of the TV screen. This allows for microscopic manipulation and removal of the tissues.

When a small amount of muscle is left over the lamina (lamb-in-ah), or exposed bone, this is cleaned off. In order to access the nerve, this roof of bone must be removed; this can be done with a small, high-speed drill or a small bone-biting tool called a Kerrison rongeur. The bone just below the endoscope covers the nerve, as it is about to exit the spine. By removing the bony cover, the nerve can be exposed and then safely moved away. After the bone is removed, the yellow ligament (a rubbery layer of tissue) can be seen which protects the underlying nerves. All the nerves, except the exiting nerve, are grouped together in the thecal sac where they float loosely in spinal fluid.

Care is taken as the yellow ligament is separated and removed, exposing the thecal sac and the exiting nerve root. A very small retractor is placed just on the outside of the root, and the nerve and thecal sac are moved together. Directly below the retractor lies the ruptured disc.

Ruptured disc material has a consistency similar to uncooked shrimp. When a small puncture is made into the tissue covering the disc, the disc will often times begin to ooze out. Various tools are used to remove the ruptured disc and other loose fragments of disc in the surrounding area. No attempt is made to remove the entire disc at that level - that is what is supporting those vertebrae. When completed, the small hole will fill in on its own. The case at this point is essentially finished.

The wound is irrigated with antibiotics. As the scope is withdrawn, your surgeon can see the tissues coming back together. A stitch or two is placed at various levels to hold the tissues together to help healing. Typically, buried stitches are used to close the skin, and none need to be removed at a later date. Commonly, Steri-Strips® (small sterile tape) and a loose bandage are applied to the wound. The patient is then positioned on a stretcher, woken up, and sent to the recovery room. In a few hours, if all goes well, he or she may leave the hospital.

Laminectomy

The goal of a laminectomy is to relieve pressure on the spinal cord or spinal nerve by widening the spinal canal. This is done by removing or trimming the lamina (roof) of the vertebrae to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disc. Various devices (like screws or rods) may be used to enhance the ability to obtain a solid fusion and support unstable areas of the spine.

The patient is usually positioned face down on an operating frame. A small incision (usually about 3-4 inches, though it may be longer depending on how many levels of the spine are affected) is made in the lower back.

The surgeon uses a retractor to spread apart the muscles and fatty tissue of the spine and exposes the lamina. A portion of the lamina is removed to uncover the ligamentum flavum - an elastic ligament that helps connect two vertebrae.

Next an opening is cut in the ligamentum flavum in order to reach the spinal canal. Once the compressed nerve can be seen, the cause of compression can be identified. Most cases of spinal compression are caused by a herniated disc. However, other sources of pressure that can cause compression may include:

1 - A disc fragment (this will often cause more severe symptoms)

2 - An osteophyte or bone spur (a rough protrusion of bone)

3 - Protruding/degenerating discs

4 - Facet arthritis and/or cysts

5 - Tumors

The surgeon retracts the compressed nerve and the source of the compression is removed and pressure on the spinal nerve or nerve components is relieved.

If necessary, the surgeon will perform a spinal fusion with instrumentation to help stabilize the spine. This occurs when a lot of bone needs to be removed and/or when multiple levels are operated on. A spinal fusion involves grafting a small piece of bone (usually taken from the patient's own pelvis) onto the spine and using spinal hardware, such as screws and rods, to support the spine and provide stability.

Then the procedure is finished! The surgeon will close the incision either using absorbable sutures (stitches), which absorb on their own and do not need to be removed, or skin sutures, which will have to be removed by the surgeon after the incision has healed.

Pictures and a simple explanation will be delivered on Friday.

The other aspects of treatment is covered by the rest: Medications and CAM.