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Frequently Asked Questions (FAQ’s)

Why Should You Choose a Spinal Neurosurgeon?

An extra year of fellowship training is virtually mandatory for orthopedic spine surgeons. In contrast, neurosurgeons begin operating on the spine from day one of their residency training. The neurosurgeon has 7 years of surgical experience with the spine surgery after completing the neurosurgical residency, the longest residency training program of any surgical specialty. All neurosurgeons are trained in every aspect of surgery for the spine and peripheral nerves.

When is spine surgery necessary?

Spine surgery is necessary and often emergent when the patient has an acute focal neurological deficit such as weakness in the extremities, bladder and bowel incontinence, foot drop, or paralysis. This is the highest tier of surgical necessity. Usually, surgery is also necessary in patients with persistent uncontrollable back or neck pain caused by nerve root or spinal cord compression or spinal instability. If the nerves or spinal cord is compressed, the surgery lowers the pain level by providing decompression of the compressed nerves or spinal cord. Likewise, surgical fusion is necessary in cases of spinal instability created by weakened bones, spinal joints, or ligaments.

When is spinal surgery not indicated or unnecessary?

Lumbar back pain (LBP) is very common and ubiquitous. According to the National Institute of Neurological Disorders and Stroke, around 80% of adults will have lower back pain at some point in their lives. LBP usually develops due to overuse or a minor injury. Most LBP resolves in less than 1-2 months with a regimen of stretching exercises, rest, anti-inflammatory medications, physical therapy, and muscle relaxants. In most cases of temporary acute LBP, surgery is not necessary. When LBP persists or is recurrent, or is associated with radicular pain numbness or weakness, these symptoms indicate that need for further investigation and possibly surgery.

What are the Pros and Cons of spinal surgery with fusion?

When I talk with patients, many patients relate stories of a friend who has had an instrumented spinal fusion and after the surgery, the patient never regained their previous quality of life. They hear cautionary tales from their friends warning them “not to have a surgery with screws and rods.” Many patients express anxiety about an instrumented fusion surgery. They often ask for my opinion on this issue. I usually try to provide them with more information that will help ease their anxiety and provide some understanding in this area.

Instrumented lumbar fusions (surgery with screws and rods) permanently changes the spinal biomechanics, which is the balance and mobility of the spine. The benefit of the instrumentation usually pedicle screw and rods are that it stabilizes an unstable spine segment that can occur with degenerative spine disorders, fractures, and tumors. In these circumstances of spinal instability, the instrumentation is essential to restore the spinal stability.

What is a spinal fusion? In simple terms, spinal fusion is a process which permanently joins spinal bones and eliminates the motion at the intervening discs between the vertebral bones. As in the above-mentioned cases of instability, spinal fusions are often highly successful, resulting in less pain and greater function for the spinal fusion patient.

Spinal fusions can also have some disadvantages. Spinal fusion causes more stress at adjacent spinal segments and can accelerate the degeneration of adjacent facet joints and discs above and below the fusion. Thus, there is a trend for repeat surgery after the initial fusion surgery. Thus, spinal fusions should only be done when absolutely necessary. Multi-level lumbar fusions can often result in more chronic back pain than the original condition.

Neurosurgeons are more likely to operate on the spine without spinal fusion. Most neurosurgeons have very limited indications for spinal fusion. Neurosurgeon’s favor preserving the normal range of motion of the spine and restoring normal spinal biomechanics. In contrast, orthopedic surgeons are more likely to perform spinal fusions especially since most of their residency and fellowship training is focused on performing fusion procedures.

Is there an association between spinal stenosis and fusions?

Lumbar spinal stenosis or narrowing of the spinal canal is the most common indication for performing spinal surgery. For most cases of spinal stenosis, fusion surgery is not indicated unless there is a sign or co-existing instability such as spondylolisthesis. Most research studies demonstrate no benefit to performing fusion surgery (rods and screws) for the treatment of uncomplicated spinal stenosis. Furthermore, many studies demonstrate higher surgical complication rates for laminectomy and fusion vs. laminectomy alone.

Are there any research studies that compare surgery vs. non-surgical management of spine disorders?

Yes, several research studies have investigated whether surgery is superior or inferior to non-surgical treatments. One famous study is the Spine Patient Outcomes Research Trial (SPORT) which was published in many medical journals including The New England Journal of Medicine. This was a multi-center randomized trial of hundreds of patients in 11 different states in which half the patients were referred to surgery and half the patients were treated with non-surgical treatments like physical therapy, NSAID’s, steroid injections, muscle relaxants, etc. The study demonstrated that surgery was far superior to non-surgical management for the treatment of lumbar spinal stenosis and lumbar spondylolisthesis. In regard to lumbar disc herniation, surgery showed an initial superiority over non-surgical treatment, but by six months both the surgical and non-surgical patients were performing equally as well.