Baylor Scott & White Spine & Scoliosis Center

A disc herniation is the same in the cervical region as it is in the remainder of the spine, but surgical treatment is very different. Initially, treatment starts with medications—usually anti-inflammatories and muscle relaxants—and physical therapy. The next tier of treatment is advanced imaging—usually a MRI—and pain management injections. Finally, the last level of treatment is surgery, which is usually an anterior cervical discectomy and fusion (ACDF). This differs from a lumbar disc herniation in two major ways. One, in the lumbar spine, the incision is made in the back, but in the cervical region, it is made in the front. Secondly, there are no implants with a lumbar disc herniation surgery, but in the cervical region there is. The implants for the cervical disc herniation occur because the herniation is removed from the front requiring the disc to be completely removed. The implants are used to fill this space created by removing the entire disc. The entire disc must be removed to reach the herniation in the back and it is extremely risky to remove the herniation from the back because to do so you would push the spinal out of the way and that can cause a spinal cord injury and paralysis. The ACDF technique has been performed for decades, and research shows it is one of the most successful surgeries.

Stenosis, or pinching or compression of the spinal nerves and spinal cord in the neck region of the spine, is referred to as cervical stenosis. It is the same stenosis we see in the lumbar and thoracic spine, but the neck or cervical region of the spine is shaped quite differently than the other regions. Due to the different shape and location of other organs, the techniques for addressing stenosis in the cervical spine are usually different. For example, someone with lumbar stenosis would likely undergo a surgery from the back to decompress the nerves; however, in the cervical region that surgery would be done from the front of the neck.

The disc is a combination of soft tissue and cartilage that acts as a shock absorber between the vertebral bones of the spine. The outer annulus holds in the inner nucleus like a bag; the inner nucleus acts as the shock-absorbing substance. When a disc herniates, the inner nucleus squirts out from the annulus that contains it; the part that has squirted out can pinch on nerves and cause stenosis and symptoms.

Most disc herniations will not require surgery, but in some severe cases, surgery is necessary. Treatment with surgery involves removing the part of the disc that has been damaged and is pressing on nerves. The technical name for this is discectomy or microlumbar discectomy in the low back region. Prior to surgery medications, physical therapy and injections can be very helpful.

Flat back deformity typically refers to patients who had prior surgery and have lost the normal contour or shape of the spine that prevents them from standing up straight. The inability to stand up straight is referred to as sagittal imbalance and is one of the most disabling spine conditions. Sagittal imbalance can occur with kyphosis and scoliosis in people who have not had surgery before. Surgery can be done to correct the flat back and allow the patient to stand upright.

Loose or broken spinal implants are a sign that the spine did not fusion after a fusion surgery. This is called a spinal nonunion. The metal screws and rods and plates used in spine fusion surgery are placed to hold the spine in the correct position and prevent movement. Stopping spinal motion after fusion is necessary to allow that body to grow new and turn the individual bones into one large bone. The body is unable to grow bone if the individual bones are moving; this is why casts are placed on broken bones. The spinal implants and casts also hold the bones in the correct alignment. Spinal implants take the place of casts. Once the body has grown the fusion bone and all the bones are together as one, the patient’s living bone is what hold the spine in alignment and the metal does not undergo any stress. However, if the spine does not fuse, the metal spinal implants will continue to experience stress and fatigue and will eventually break or loosen. Once that occurs, the spine will have abnormal motion and perhaps instability that is painful. The treatment of choice is to restore alignment and stability to the spine; almost always this can only be done surgically.

Myelopathy is the technical term for symptomatic compression of the spinal cord in either the cervical or thoracic region. The symptoms are generally more and different than compression of the spinal nerves. Pain, numbness, tingling and weakness can come from compression of the spinal nerves and spinal cord, but compression of the spinal cord can also balance difficulty and loss of fine motor control from a lack of proprioception. Proprioception is the ability to sense the position and location of your arms and legs without having to look at them. This helps you do things like walk in a straight line, touch your finger to your nose with your eyes closed and many of the activities we do not even think about. Myelopathy also could represent permanent damage to the spinal cord. The longer there is compression of the spinal cord, more permanent damage could accumulate and the symptoms and loss of function are permanent and no reversible. To prevent possible worsening of spinal cord damage, treatment for myelopathy is surgical to remove the pressure. The timing of surgery is also done expeditiously to decrease them time when more spinal cord damage can occur.

The need for revision spine surgery generally has three causes: a previous spine surgery that did not heal correctly, new or worsening problems at a site of previous surgery, and/or problems above or below an old spine surgery. For surgeries that did not heal correctly, there could be a lack of fusion, loose or broken screws and rods, or the spine could be fused in a bad position. Worsening or new problems at a site of previous surgery could be instability or spondylolisthesis that has developed after a decompression type surgery. In the case of pinched nerves, often times decompressing the nerves surgically without fusing can lead to a good result. However, over time further degeneration of the disk and facet joints can lead to recurrent stenosis and instability. Lastly, most problems that require spine surgery in adults have a significant, if not sole, etiology from degeneration. When surgery is done and that level of the spine is addressed, the degenerative processes are still occurring at the other levels of the spine. If those other levels progress to the point of needing surgery, it is quite common that the new surgery levels and the old surgery levels will need to be joined together during surgery.

Treatments in the case of revision spine surgery are varied and have to be tailored to the problem, as well as the individual person. Revision cases are more challenging than operating on a spine that has not undergone surgery; it takes experience and skill. Most importantly, it takes willingness, not just from the surgeon but also the patient. Patients facing revision spine surgery are often looking at a bigger surgery than they had previously, as well, they have experienced the recovery once before and sometimes that may have been a trying experience. Ultimately, it is important for the patient to have courage and realize that revision spine surgery can provide a huge improvement in symptoms and quality of life.

The three main types of adult scoliosis congenital, idiopathic and degenerative. Congenital scoliosis occurs when there is a malformation of the spinal bones causing an abnormal shape or even a partial fusion of the bones that then causes the spine to curve. Idiopathic is one of the most common forms and has an unknown etiology, although there is a genetic, inherited component. Idiopathic curves tend to fall into reproducible groups; there is also significant research that has been done and is currently underway that provide evidence help develop treatment plans for patients. Lastly, degenerative scoliosis is caused when there is substantial degeneration of the spine causing either instability or abnormal alignment. Often times in adults, idiopathic and degenerative scoliosis are present at the same time, meaning degeneration within an idiopathic curve can cause increase in the curve size, pain and stenosis. Kyphosis is the term used to describe an abnormal position of the spine in a font to back direction. Usually the abnormal kyphosis is a bent forward position of the spine, making it difficult or impossible to stand upright.

Treatment of scoliosis, like most spine conditions, is based on the symptoms and the severity of the condition. Initial treatment may solely be monitoring for curve progression if there are no or very mild symptoms. Curve progression can occur with or without pain and if the progression is significant is generally an indication for surgical correction to prevent further curve increase and harmful effects on the internal organs such as the heart and lungs. As symptoms increase anti-inflammatory medications, muscle relaxers and physical therapy for core strengthening can be helpful. Research shows that narcotic medication should be avoided if at all possible. The next tier of treatments involves pain management injections usually epidural steroid injection and facet injections and ablations. Ultimately, surgical correction is the definitive treatment when indications arise. The two major indications are curve progression and symptoms. The symptoms are generally back pain in the area of the spinal deformity and leg symptoms of pain, numbness and weakness. Surgery for scoliosis can be very involved, but the amount of improvement it can make for a person, both for symptom improvement and quality of life, is dramatic.

The technical term for spinal instability caused by degeneration is spondylolisthesis, the different types were discussed in the spondylolisthesis section. There can be spinal instability from trauma that causes injury to the spinal ligaments, discs and soft tissues or fractures of the spinal bones. In general, it takes a significant amount of force to cause trauma that would destabilize the spine, almost all of these patients are first evaluated in the Emergency Department.

A nonunion occurs when a surgery has been done to fuse two bones into one and for whatever reason it does not happen. During a spinal fusion surgery, the two bones to be fused together are roughed up and bone graft is placed in between; to the body this seems like one bone that was broken and the body forms new bone that joins or fuses the two bones together. A nonunion occurs when that new bone does not join the two spine bones together. A number of factors can increase the risk of a nonunion, such as nicotine use, motion at the fusion site, and other medical problems. Nicotine use is perhaps that biggest, correctable risk factor for spinal nonunion. Spinal implants are used to prevent motion at the fusion site to promote fusion. Finally, all medical conditions are optimized when possible prior to surgery to increase the chance of success after surgery. Treatment for spinal nonunion is almost always surgical, often time the spinal implants placed during fusion surgery break or become loose once a nonunion occurs. During nonunion surgery, both the fusion and implant portions of the procedure are redone.

Spondylolisthesis is a term to describe instability and malalignment between two vertebral bodies and the disc in between them, usually in the lumbar or low back region. These three parts, thee disc and the spine bone above and below it, are often referred to as a motion segment and are named by the bone above and below, for example L4-5. L4-5 is the most common level for degenerative spondylolisthesis. It means that there is enough degeneration or arthritis at the L4-5 level that the L4 bone that sits on top of the L5 bone is sliding off of L5. Commonly it will slide forward, which is called anterolisthesis, but it can slide to the side (laterally) or the back (retro). With degenerative spondylolisthesis, there is usually significant pinching or stenosis of the nerves at that level. Together with the instability from the sliding out of place of the bone and the nerve pinching, spondylolisthesis usually cause significant back pain and leg pain and numbness. Isthmic spondylolisthesis usually occurs at L5-S1, the bottom disc in the spine. This happens when there is a stress fracture in part of the spine bone called the pars. The fracture commonly occurs in childhood and adolescence, but it can be years or decades before spondylolisthesis occurs. Once it occurs, the symptoms are very similar to degenerative spondylolisthesis with components of back pain and leg symptoms.

Treatment of spondylolisthesis is driven by the number of symptoms there are, but ultimately definitive treatment involves stabilizing the bones so they do not continue to slide out of place and unpinching the nerves. This surgery is called a decompression and fusion, where laminectomy and foraminotomies are performed and implants are used to hold the two bones together allow bone to grow between them fusing them into one bone. Before symptoms are severe enough for surgery, physical therapy, medications and epidural steroid injections can be helpful to lessen the symptoms.

Stenosis is when there is pinching, pressure or compression on the spinal cord or nerves. The cervical and thoracic regions of your spine, the neck and chest area, contain not only your spinal cord, but also spinal nerves that branch off and spread to your body. The lumbar region, or low back, contains only spinal nerves. Stenosis of spinal nerves can cause pain, numbness and weakness in the arms and legs; the symptoms can be episodic or constant and can range in severity from mild to excruciating and debilitating.

Treatment for significant stenosis usually involves surgical decompression of the pinched nerves to relieve the pinching and provide the best environment for the nerves to heal. The technical name for these types of decompressive surgeries are laminectomy, foraminotomy and discectomy. These surgical techniques can be done in addition to other techniques used at the same time. Milder forms of stenosis and be treated with non-surgical techniques, such as physical therapy, medications and injections

Posterior spinal fusion is a technique back and spine doctors in Dallas use to treat spinal instability, degeneration and malalignment. In its simplest form, it is getting two bones to grow together to for one bone, taking away the motion between the two bones and making them stable. To do this a Dallas spine surgeon will remove the facet joints, at least partially if not completely, rough up parts of the spine bones and place bone graft in between the two spine bones. This bone graft acts a scaffolding for the body to grow new, living bone between the two spine bones, connecting and fusing them together. Over time, the bone graft is replaced with the patient’s own living bone that will hold those two spine bones together. To give the new bone growth the best chance to succeed metal implants are placed to hold the spine still without motion. By stopping the motion with the spinal implants this gives the best environment for bone to grow; if there is too much motion, the bone will not grow, scar tissue will form and there will be a nonunion.

Dallas spine doctors perform Anterior lumbar interbody fusion—or ALIF—by making an incision in the lower abdominal region and sliding the organs off the front of the lumbar spine. Once this is done, the discs and bones of the lower spine can be seen. The discs are then removed and a structural graft or support is placed. This helps the dallas back doctor to remove degeneration, realign the spine and fuse the spine. Commonly, a metal screw will be placed, sometimes with a plate to help secure the graft. The structural graft is often packed with bone graft to help with the fusion process. The ALIF is a powerful surgical tool back doctors in Dallas use to treat scoliosis, instability and malalignment of the spine.

Transforaminal lumbar interbody fusion, referred to as TLIF, is a technique Dallas spinal surgeons use to place a cage or structural graft to replace the disc from a posterior or back incision. This is a technique often used in our Dallas spine center in conjunction with posterior spinal fusion to increase the chances of fusing and to help realign the spine. First, a spinal surgeon makes a back incision to expose the spine. Then, the facet joint is removed and a decompression is done to un-pinch and visualize the nerves. The nerves are then slightly swept out of the way to protect them exposing the disc. An incision is made into the disc, and the disc material is removed. Next, the spine surgeon roughs up the bones above and below the disc to help them to fuse. Finally, bone graft and structural graft are placed where the disc used to be. The structural graft is hollow and packed with bone graft to hold that bone graft in a specific location. It is often times referred to as a cage. The cage inserted from a TLIF approach in our Dallas spine center is much smaller than the cage inserted from an ALIF approach due to the nerves limiting the space to work with a TLIF.

ACDF, or Anterior cervical discectomy and fusion, is a very common technique spine surgeons use on the neck region of the spine. It has been performed for decades and generally has very good results. It starts with an incision on one side of the front of the neck, and then the space is made between muscles to allow the trachea and esophagus, also known as the windpipe and the muscular tube connecting your mouth to your stomach, to be held to the side out of the way and protected. This allows the Dallas spinal surgeon to see the front of the spine. Then the disc is removed, and a microscope is used to un-pinch the nerves and spinal cord by removing the disc herniation and any bone spurs. In the space left by removing the disc and cage, a structural graft is placed by the spine surgeon, followed by a small plate and screws, to hold everything stable and allow the spine to fuse following surgery at our spine center in Dallas.

Surgical decompression of the spine is when a spine surgeon removes bone spurs, disc and degeneration to un-pinch the nerves in our Dallas spine center. An incision is made in the back, and the muscles are pushed off the spine. Then the spine doctor her in Dallas removes part of the lamina, which is part of the spine bone, to see the nerves and gain access to the disc and bone spurs that need to be removed. This is called a laminectomy. Once access to where the nerves are in the spine, called the spinal canal, has been achieved the nerves in the spinal canal can be decompressed, and the stenosis will be treated. As well, the spine surgeon can also decompress the nerve in the foramen, the left and right side-tunnels at each level of the spine where the spinal nerves exit the spine and go to the rest of the body. This is called a foraminotomy. These two techniques are almost always done together, because stenosis in the central canal is usually accompanied by stenosis in the foramen. These techniques are also used in all three regions of the spine, the lumbar, thoracic and cervical areas at our Dallas spine center.

Discectomy, which some people call shaving the disc, is the surgery spine doctors use for a lumbar disc herniation when there is not signs of instability. Since this technique is in the lumbar spine and involves the use of a microscope, it is called micro lumbar discectomy (MLD). During this procedure at our spine center in Dallas, a back doctor makes a small incision on the back over the level of the disc herniation. The muscle is swept aside exposing the top of the spine bone called the lamina. A small hole is made in the lamina to visualize through a microscope the nerves and disc herniation. The back doctor then removes the disc herniation along with any damaged disc material left in the disc space. Most people will go home the same day from our Dallas back and spine center.

Cervical laminoplasty is a technique back and spine doctors use to treat cervical stenosis of the spinal cord here at our Dallas spine center. It cannot be performed for all cases of cervical central stenosis, but it is a possible alternative to a fusion and decompression that can preserve some motion. To perform this technique, a back surgeon makes an incision on the back of the neck, and the left and right muscles of the spine are slide to the sides exposing the lamina and some of the lateral masses of the spine bones. Then a "door" is created using the lamina by completely cutting one side of the lamina and creating a hinge on the opposite side, allowing the lamina to be pulled back. This “opening of the door” increases the room for the spinal cord in the central canal at multiple levels. Then a small metal plate an screws are used to hold the door open. In order to preserve motion and spinal alignment, specific cervical extension physical therapy is ordered after a few weeks of recovery.

Osteotomy is the medical term for a bone cut, and posterior column refers to the three column model for spinal stability. In the three column model for spinal stability, the disc and vertebral body compose the anterior and middle column and the facet joints and ligaments in the back of the spine are considered the posterior column. By cutting the bone and ligaments of the posterior column, a posterior column osteotomy, a spine surgeon here in our Dallas spine center can make the spine more flexible to realign it during a fusion surgery. These osteotomies can only be done with a fusion, because they make the spine unstable and must be fused. Posterior column osteotomies are sometimes referred to as Ponte or Smith-Peterson osteotomies after spine surgeons who pioneered the different types of osteotomies. Here at our spine center in Dallas, these osteotomies are commonly done during surgeries for scoliosis, kyphosis, deformity and sometimes even spondylolisthesis.

The pedicle subtraction osteotomy (PSO) is a powerful and sometimes technically demanding surgical tool the spinal surgeons in our spine center use that involves the removal of the majority of one of the spine bones. Like the posterior column osteotomy, the PSO is always done with a fusion. Spine surgeons use the PSO almost exclusively to address kyphosis and flat back syndrome after prior fusion surgeries. The PSO is performed by extensively decompressing the nerves and isolating the pedicle, a part of the spine bone that connects the back of the bone to the front or body. The pedicle is the common place for screws to be placed during fusion surgery, the case of the PSO it is removed on both sides. Once the spine surgeon removes the pedicle, a wedge is cut from the vertebral body, allowing it to compress. This compression after removing the wedge corrects kyphosis and aligns the spine so that the back patient can stand up straight again. The back surgeries with a PSO are quite involved, but can make a dramatic improvement in a patient’s symptoms and quality of life.