Procedures

Cervical disc replacement was approved by the FDA over ten years ago but was not being paid for by insurance companies routinely until the 5-year outcome data from the FDA trials came out. In general, the outcome for these trials looked quite good for cervical disc replacement and insurance companies started routinely approving this procedure. A cervical disc replacement is an alternative to a cervical fusion in many patients. We have found that 70% of the patients that we previously treated with a cervical fusion can now be treated with a cervical disc replacement. We often have patients come in that have been told that a cervical fusion is their only option when, in our opinion, this is not the case, and they are candidates for disc replacement. As of 2020, we have performed over 700 cervical disc replacements. Overall, we are fans of this technology and indeed Dr. Rutz has a cervical disc replacement in his own neck.

Postop Recovery: The cervical disc replacement is performed with an incision on the front of the neck to get to the front of the spine. This is the same approach as is used in a cervical fusion. The difference in the postop recovery is that we generally do not place any restrictions on the patient from the very beginning. Our premise is that the implants are stable from the moment that they are put in; much like a knee replacement is stable from the moment it is performed. Your neck will be sore, however, performing various activities such as lifting, twisting, and bending will not change the ultimate outcome of the procedure. Patients vary in how sore they are after surgery. The average patient will take Ibuprofen 3 times a day until they return to see us for their 2-week follow-up visit. The average patient notes that they needed narcotic pain medication for only a day or two, and then they take only the Ibuprofen. About 20% of patients take no narcotic pain medication after surgery at all. It is normal for patients who have pain down their arm before surgery, to find that it is gone when they wake up. The pain from the surgery itself is referred to the back of the neck and down between the shoulder blades and out over the shoulders. In the average patient, this is 50% better by 2 weeks and 90% better by 6 weeks. It is common for people to have small aches and twinges that are relatively minor but noticeable and these seem to fade away by 6 months. People that do office- type work will often return to work within a week. People that do heavy physical labor might take 6 to 8 weeks because of soreness.

A cervical fusion is a procedure in which the surgeon approaches the cervical spine through the front of the neck. The disc is removed from the level or levels that are pathologic and then appropriate decompression of the spinal cord or nerve roots is performed. This can be done for cervical stenosis and cervical radiculopathy. It has an extremely high success rate for resolving cervical radiculopathy and stopping cervical myelopathy. After the nerves are decompressed, either a bone graft or cage is placed in the disc space and secured with a plate. In our practice, we currently use 3-D printed titanium cages and man-made bone graft and a plate. With this, our fusion rate is over 98% and we do not place our patients in a collar after surgery. We do recommend a 20-pound lifting restriction for approximately 2 months. Once the bones are healed, those levels should no longer be pain generators.

Postop Recovery: An anterior cervical discectomy and fusion procedure in our practice requires an overnight stay. The surgery itself, in our opinion, is an out-patient level procedure except for the rare risk of a postoperative bleed, which occurs in 1 out of 500 patients. Because a postoperative bleed can affect the airway, I have most of my patients spend the night for observation. By the time morning comes, that risk becomes negligible and I feel comfortable discharging them home. After surgery, patients will often complain of a sore throat, feeling like they have a lump in their throat. Some people can be a little hoarse and will notice that they are sore and achy in the back of their neck, down between their shoulder blades, and out over their shoulders. This is the normal referred pattern of discomfort from the procedure, which resolves as they heal. I do not normally place my patients in a neck brace/collar after surgery, as I believe that the implants that we use are adequately stable. It takes 2 to 3 months for the bones in an anterior cervical fusion to heal together and therefore, we recommend a loose 20-pound lifting restriction for a few months after surgery. After the fusion has healed, the patient does not generally have any permanent restrictions.

A posterior cervical fusion is a procedure in which a vertical incision is made in the middle of the back of the neck and the muscles are elevated off the bones of the spine from the back. By placing screws connected by rods into the bones and packing bone graft on the spine, 2 or more bones can be connected to form one bone. In our practice, we reserve posterior cervical fusions for patients who are not candidates for an anterior cervical fusion, as we believe an anterior fusion has an easier recovery and better likelihood of a good long-term outcome. Studies have shown higher rates of persistent neck pain in posterior cervical fusion patients than the average anterior cervical fusion patient. A posterior cervical fusion is an effective way to fix an anterior cervical fusion that did not heal, known as a non-union.

A posterior cervical foraminotomy is a procedure in which a small incision is made in the back of the neck and the muscles in the neck are carefully elevated off the lamina of the spine in the affected area. Care is made to perform as little soft tissue disruption as possible. After the spine is exposed and the levels confirmed, a small window is made in the bone to enlarge the tunnel where the nerve exits the spine. This is done in order to relieve symptoms of nerve compression, such as pain, numbness, or tingling going down the arm. This is an out-patient procedure, and recovery takes 4 to 6 weeks. Bracing is not required. The recovery is simply the time it takes for the muscles to heal and the skin to heal. In our practice, we find that there is a small number of patients where a posterior cervical foraminotomy is the best option. However, it is a less definitive procedure than a cervical disc replacement or fusion.

Lumbar disc replacement is a surgical procedure to remove a damaged disc in the lower spine and replace it with an artificial disc. The lumbar spine is made up of the 5 vertebral bones and intervertebral discs between the rib cage and the pelvis. When one of these discs is damaged or pinches surrounding nerves, removing the diseased disc and replacing it with an artificial disc can relieve pain and restore spinal mobility.

A lumbar microdiscectomy is an extremely common procedure. A small incision is made, muscles are elevated off the back of the spine, and a small retractor is placed to create a small tunnel through which the surgeon can work to take care of the problem. A small amount of bone is removed from the spine in order to gain access to the spinal canal. The nerves are identified and carefully moved to the side so that the disc material that has ruptured up against the nerves can be removed. Once the nerve compression is relieved, the wound is closed with absorbable sutures and in our practice, we often use skin glue for the outer layer to seal the wound. During the procedure, local anesthetic is placed in the skin and muscles, so many patients wake up without surgical pain for at least 8 to 24 hours. In most of our patients, we prescribe Ibuprofen or some other anti-inflammatory for postoperative pain. Narcotic pain medication is provided; however, approximately 20% of patients do not require any narcotics after surgery and the average patient might take narcotics for a day or two after surgery and then stop. Overall, this is not an intrinsically painful procedure compared to others. It takes 4 to 6 weeks to heal from a lumbar microdiscectomy. There are some patients in the first week or two after surgery that will have a flare-up of back or leg pain, which can be uncomfortable, but often responds to steroids. This is not a predictor of a poor outcome. If a patient is 6 weeks out from a lumbar microdiscectomy and develops new symptoms or has symptoms that did not resolve with surgery, we believe that we should not blame the symptoms on a flare-up from surgery, but investigate as to whether there is some other source for their persistent symptoms. Although most patients do quite well with a lumbar microdiscectomy, if they have continued symptoms, there is usually a reason for this and often there are other options to treat these symptoms. Approximately 10-15% of patients that have a disc herniation will have another one at the same location whether they have surgery or not. This is because the piece of disc material that ruptured into the spinal canal is only a small percentage of the overall disc and the remainder of the disc still has the ability to rupture additional pieces into the canal. Gratefully, this only occurs in a minority of patients.

Postop Recovery: In our practice, a lumbar decompression or lumbar microdiscectomy is an out-patient procedure. During the surgery, local anesthetic is placed in the skin and in the muscles so that when the patient wakes up, much of their postoperative pain is blocked. This can last between 8 and 24 hours and people are able to ambulate out of the hospital. I tell patients that the skin heals in 1 to 2 weeks unless a patient has a wound healing problem. In this surgery, the muscle is lifted off the spine so that decompression can be performed. It takes 4 to 6 weeks for the muscle to heal back down to the bone. In the first week or two after surgery, because of swelling from surgery, some patients can have a flare-up in the pain in their legs, which we may treat with oral steroids. I expect for patients to be 90% better by 6 weeks postop. People that do office/desk type work will typically return to work between 3 days and 2 weeks after surgery. People that perform physical labor may be off work 6 to 8 weeks.

A lumbar fusion procedure can be performed in many different ways. Some surgeons go through the belly to do this, others go through the back, and some use a combination of both techniques. In our practice, the majority of the time we perform a lumbar fusion through a midline incision in the lower back. We elevate the muscles off the spine just enough to create necessary space to place screws in the bones, which are later connected by rods. We then decompress the nerves, typically going around them to take out the disc. Next, we place a metal box, called a cage, in the disc space. The screws and rods act like a clamp to hold the cage in place. In the cage, and around the cage in the disc space, bone graft material is placed. Over time, the two bones grow together to become one bone as the disc space fuses. There are other techniques used for fusing from the back, including the packing of bone on the back of the spine. We try to employ the least invasive surgical techniques necessary, to decrease blood loss and postoperative pain, while still obtaining a high fusion rate.

Postop Recovery: In our practice, 90% of patients that have a lumbar fusion will either go home the same day or the following day. Patients that are older and live alone and have limited support, are the ones that seem to be in the hospital a few days longer or might require rehab. After surgery, we do not use lumbar braces, as we believe the implants that we place in the spine are strong enough to hold the patients’ bones together without the need for a brace. After surgery, my patients are allowed to walk, do stairs, bend over and twist, although they might be sore doing those things. The volume of activity is less about doing any one thing and more about the volume of it. I encourage gradual physical activity and walking without “overdoing it”. Too much exertion too soon has the potential of working the screws loose before the bones are healed together. In many patients, by 2-1/2 months, the bones are healed together enough that I do not worry about them increasing their activity level. Whether a patient is my best patient or worst patient as far as postoperative recovery is concerned, their activity restrictions are the same, as it simply takes time for bones to heal properly. I do not see a benefit of increasing activity levels until the bones are adequately healed. As with other procedures, the skin heals within a few weeks. The muscles heal in 6 weeks and the bone takes between 2-1/2 to 4 months in the average patient. Even once the fusion is solid, when the patient returns to heavier activities, it is relatively common to be sore for the first month of increased activities, before once again trending in a good direction.

This is a fusion of at least one level in the thoracic spine involving implantation of hardware and the use of bone graft. This procedure is often performed for spinal cord compression or a significant fracture in the thoracic spine.

This is a fusion of at least one level in the thoracic spine involving implantation of hardware and the use of bone graft. This procedure is often performed for spinal cord compression or a significant fracture in the thoracic spine.

This procedure is p performed to treat a compression fracture of a vertebral body in the spine. A balloon is inserted into the bone and then inflated. The void created in the bone is then filled with cement to stabilize the fracture and provide pain relief.

This is the surgical removal of the coccyx, the tiny bone at the bottom of the sacrum. This procedure is performed when a patient suffers from chronic pain created by the joint between the sacrum and the coccyx.