Microdiscectomy means a small incision perhaps up to an inch long and visualization of the surgical field with an operating microscope.

Microdiscectomy has been relatively successful. We employ it in our practice. Assuming that you have an accurate diagnosis in the sense that the anatomic defect seen on the imaging corresponds well with your neurologic defect and pain pattern, the probability of you having relief from your pain is high. This does not return the disc to normal but removes a portion of the compromised disc. The wear and tear of degenerative changes present will continue.

There are risks involved in any procedure including microdiscectomy. The particular risks involved other than the general statement of risk to life and limb are injuries to the structures that live close to the operative site such as the nerve roots to the lower limbs, great vessels to the lower limbs, risk of infection and risk of arachnoiditis. Most patients are home from microdiscectomy in 24 hours, back to sedentary work in a week, back to moderate activity in a month, return to vigorous activity in 3 - 4 months.

Degeneration of the intervertebral discs can result from a variety of conditions, including aging, trauma, and several types of arthritic conditions. As we age, our tissues tend to lose water. That's why skin wrinkles with age, and various body parts begin to sag. When this occurs in the intervertebral disc, the disc tends to shrink, becoming thinner and less cushiony. The condition is fairly common in adults past middle age, and may be asymptomatic - causing no symptoms - other than occasional lower back pain, or stiffness. At other times, however, the associated collapse of the disc space, especially in the lumbar spine (lower back), can be the source of severe mechanical back pain, or radicular leg pain. Under these circumstances, surgical intervention may be appropriate.

The inner portion of the disc, the nucleus pulposis, is composed of proteoglycans - chemical combinations of sugar and protein. When the disc degenerates, small cracks or tears form in the outer annulus, allowing these chemical substances to leak out into the epidural space. Proteoglycans have been shown to cause irritation or inflammation of the nerves surrounding and adjacent to the damaged disc. Minimally invasive, endoscopic procedures, designed to remove the diseased or damaged portion of the disc, may be helpful in alleviating such pain.

Under other circumstances, collapse of the disc space can lead to a condition more recently termed "vertical instability". In this case, shrinkage of the disc allows abnormal movement across a motion segment (2 vertebrae and the intervening disc), and may result in mechanical back pain - pain which arises from changes in position, or attempts at strenuous activities. In such cases, fusion of the interspace may be the procedure of choice.

A myelogram is an injection of contrast material into the spinal canal in the space where the spinal fluid is. The purpose is to evaluate for neuro compression. Pain varies from minimal to moderate from patient to patient. Side effects are infrequent - range from headache due to CSF leak to rarely, seizures, to allergic reaction to the contrast material. With any invasive procedure there is risk to life and limb. In some cases, MRI is a good alternative.

The indications for lumbar spinal fusions are intractable pain or progressive neurologic deficits due to anatomical changes identified on MRI, plain x-ray, myelogram or discography. Every surgeon has a different post-op protocol and the recovery period depends on the extent of the procedure and the status of the patient preoperatively. For patients who are in good cardiovascular condition, the recovery is relatively brief. Typically, hospitalization for decompression and fusion procedure would be four to five days with the patient independent for self care but limited in endurance at the time of discharge. Some suggestions for successful lumbar fusions are: no smoking; no anti-inflammatory meds; low impact aerobics such as walking and swimming; avoid extremes of motion of the lumbar spine; use narcotics sparingly.

The hospital recuperation time for an anterior cervical fusion is significantly less than for a lumbar fusion. Typically, patients will stay overnight, and then be sent home wearing a neck brace. Oftentimes, this type of procedure can be done in an outpatient surgery center and patients can return home the same day.

The term "ruptured disc" is a catch-all, which encompasses a variety of related conditions affecting the structural integrity of the intervertebral disc, which is the cushiony material between the vertebrae, or back bones. The disc is a complex structure containing a gelatinous inner portion, called the nucleus pulposis; and a tough and fibrous outer portion, called the annulus fibrosis. In many ways, the disc is similar both in structure and function to a modern radial tire. The nucleus acts in much the same way as does the air in the tire, to dampen and absorb the forces applied to it. And the annulus also contains many layers of fibers, like the radial plies of a tire, to contain the nucleus and distribute the forces.

When the disc has been injured, there may be internal derangement of the disc architecture; there may be radial tears through the annulus, or delamination of the annular fibers. With further damage, nuclear material may protrude through these annular tears, resulting in disc protrusion, which may be contained, extruded, or sequestered (think of toothpaste being progressively squeezed out of the tube). Each of these different types of disc protrusion has implications for treatment, and different types of intervention, or surgery, may be appropriate, depending upon the exact nature of the damage to the disc, and the particular symptoms which you have been experiencing. In many instances, effective relief of symptoms may be accomplished by a period of relative rest, or avoidance of provocative activities. Prolonged bed rest is, however, not generally beneficial. Physical therapy and medication may be helpful in reducing inflammation and easing muscle spasm. However, protruding disc material may be toxic to the nerves, causing pain, or numbness and tingling. If the disc actually presses on the nerve roots - a so-called "pinched nerve" - the nerve may be damaged, and there may be symptoms of weakness, or even disturbances of bowel and bladder function.

A careful clinical examination is required, and appropriate tests, such as an MRI scan, should be performed, to clearly delineate the precise nature of the "ruptured disc". You should discuss this with your doctor, so that you have a thorough understanding of the exact nature of your condition, and the treatment options available to you.

Answer: There are many different types of procedures available to treat the various conditions affecting the intervertebral disc, and conditions affecting the cervical and lumbar spine. These are summarized below. Please bear in mind that the various descriptions are brief, and cannot substitute for a full discussion with your doctor, who has examined you and has access to the various X-rays and tests which have been, or will be performed.

Microsurgical Laminoforaminotomy and Disc Excision

Often referred to as the "gold standard", by which other treatment modalities are measured, the microsurgical removal of disc material, by means of an open, operative procedure, is the most commonly performed treatment for ruptured discs and related pathology. This technique permits the most unrestricted access to the area(s) of abnormality, and is suitable for the treatment of a wide variety of spinal conditions, and multiple levels of pathology.

Because the operating microscope permits great magnification, and the delivery of intense light to the depths of the operative field, handling of the nerves and other delicate tissues can be very precise, using fine, microsurgical instruments. The skin incision can be made very small, with minimal retraction of muscle, and postoperative healing is rapid. However, surgical manipulation of the nerve root(s) is required, and there may be some concerns about the postoperative development of epidural cicatrix (scar tissue).

The procedure is customarily performed in a hospital environment, under general anesthesia, although other variations have been reported. Patients are generally allowed up to walk within a few hours, and are usually hospitalized overnight.

Laminectomy and Decompression

Open surgical approach to the spine, with or without the use of magnification (loupes or operating microscope), is a traditional surgical procedure, dating to the earliest description of disc pathology, in the 1930's. Although less frequently used today for the surgical treatment of single level disc protrusion ("ruptured disc"), it may be the procedure of choice in more extensive surgical procedures for the treatment of spinal stenosis, spinal cord tumors, and incident to the placement of interbody fusion devices.

At present, use of prosthetic (artificial) disc replacements is under study in the United States, Europe, with further testing scheduled in Asia and South America. Preliminary reports are encouraging and several different mechanisms are under consideration, and are composed of widely varying materials and designs. At present, however, no prosthetic disc is FDA-approved, and usage must be considered investigational, only, under specific protocol.

There is no single surgical, or medical, treatment which is effective for all conditions affecting the spine, intervertebral discs, and nerves. And no procedure is entirely free of risk. The choice of the most appropriate approach to the treatment of any condition can only be arrived at following detailed examination of the patient and of the various diagnostic, clinical, radiographic, and laboratory tests which have been performed.

Epidural steroid injections mean that the steroid, which is an anti-inflammatory chemical, is placed into the space in the spine around the sac containing the nerves (dura). So epidural means around the dura. To be sure that the injection of the steroids is placed in the epidural space, the needle is inserted under x-ray control (fluoroscopy) and the doctor performing the injection confirms that he or she is in the correct location before injecting the steroid medicine.

Smoking affects the probability of fusion. The statistics involve smokers and non smokers, not ex-smokers. Published studies report a 6 - 8 times higher nonunion rate in smokers. Many surgeons have concluded that for best results patients should not smoke. The surgery can still work in spite of smoking but the probability of failure is higher. The risk of infection is also higher among smokers as is the risk of perioperative pulmonary problems. There was a recent article in Orthopedics Today entitled "Confirmed: Smoking delays bone union" which you might want to read. A Medline search which can be done at your local library or on AOL will provide you with many articles on the subject.

Neck pain with intermittent numbness and pain in the arms suggest a nerve compression syndrome in the neck which could be a herniated disc. Sometimes the level can be located by the pattern of the pain and numbness. If the pain is to the thumb side of your hand, it is probably the C5-6 level. If it is to the long finger of your band, it is probably the C6-7 level and if it is to the little finger side of your hand it is probably the C7-Tl level. If you have those symptoms, or symptoms of a myelopathy (more general symptoms related to spinal cord compression) that have not responded to a reasonable trial of non-operative treatment then you are a candidate for surgery. Most people will not require surgery. The technique for surgery is controversial. The particular procedure involved would depend on the individual pathology and the surgeon's preferences. In our hands it is usually anterior decompression with discectomy or corpectomy and fusion with auto graft - your own bone. Long term studies suggest that the symptoms will get better with time. In general, there has been a fairly high satisfaction rate in patients who have painful herniated cervical disc who undergo anterior cervical fusions. The usual treatment is time, activity modification such as avoiding overhead work or extremes of motion of the neck and vibratory stresses, occasional use of splinting and traction and pain medicines. Risks involved in non-operative treatment are continued pain. There is a small risk of progression of the neurologic deficit but it is very small.

The technique of doing a discogram is to sedate the patient, although the patient is still awake, insert a needle into the disc space under fluoroscopy and inject the disc space with contrast material. The purpose is to see the volume of material the disc will accept, the pattern of the contrast material on x-ray image and, most importantly, the sensation of the patient as the injection occurs. In general, the injection is painless or is described as a pressure sensation. If the injection reproduces the same discomfort as the patient feels at home, then it is an indication that the level being injected is the source of the pain. If every level that is injected hurts, there is not a surgery to fix it. If no level hurts, then you must look further for the source of the pain.

Spinal stenosis means a narrowing of the spinal canal. Some individuals have a lower than normal diameter of the spinal canal that they are born with. Most of us develop spinal stenosis with time just as the joints in your fingers and wrists become larger with age and wear and tear - the joints in the spine do as well. In the case of the spine, this enlargement of the facet joints and the intervertebral joints results in the narrowing of the neural foramina and of the spinal canal.
Most individuals with spinal stenosis live normal lives. In fact, I suspect that all of us over 50 have it to some degree. It is only those patients who have intractable symptoms that have treatment. The usual treatment is activity modification, anti-inflammatory drugs, and pain medications. If the pain is intractable, epidural steroids are frequently used and finally, surgery.
Surgical treatment involves making the spinal canal bigger by removing the bony elements that are compressing the nerves. In our hands, we frequently add fusion surgery in the patients that have significant longevity. This is a controversial issue as there is a strong difference of opinion. The reason we would recommend a fusion would be that we feel the instability is part of the genesis of the arthritic changes and we find that surgery without fusion, done on the people with significant stenosis, adds to the instability problem by removing a portion of the spinal joints. Lastly, we find that in the long term follow-ups of greater than three years, the patients do better. In general, patients with severe stenosis say the postoperative pain is not a whole lot worse than the preoperative pain as we typically do not operate on folks unless they are essentially housebound before the surgery.