Recent evidence suggests that physiotherapy and other exercise treatments are as good as surgical treatments in the majority of patients with chronic back pain, where there are no referred nerve root symptoms.
However, there remains a place for the surgical management of back pain either where non‐operative treatment has failed or where the situation is more complex with nerve root symptoms or other pathology such as spondylolisthesis.
This article on developments in spinal surgery has been written by Gavin Bowden, Consultant Spinal and Orthopaedic Surgeon, Oxford.
Fusion is the gold standard, but there are new devices which can stabilize the spine without fusion or using different kinds of fusion and many of these are being assessed at the moment (such as the Wallis device or Dynesys system).
Spinal decompression and discectomy
With the advent of microsurgery most patients with a disc prolapse can now be treated with an overnight stay if they are young and fit, some being able to go home on the day of surgery. Results of microdiscectomy are good with up to 90% of patients achieving acceptable results.
Spinal stenosis can cause difficulties with standing and walking. Decompressive surgery is effective in 70‐80% of patients. Consultant surgeons are seeing and treating older patients in greater numbers. This is largely attributable to the benefits of less invasive techniques but also patient preference and keenness to maintain more active lifestyles. A recent method for treating these patients is called Inspace where a spacer is placed in the interspinous region to stretch the spine, which indirectly results in the decompression of the appropriate level.
This is not suitable for all patients but it means that patients who are otherwise unfit for surgery can now be considered and can be treated either as day surgery patients or short stay.
Fusion surgery is still the mainstay in the management of patients with spinal deformity. Use of instrumentation with pedicle screws and titanium rods has improved our ability to correct deformity. It is now an uncommon necessity for anterior and posterior surgery on an individual patient with the majority of patients undergoing posterior surgery alone. In addition, non‐fusion devices are now also available for paediatric patients with scoliosis which allow the spine to continue growth. A device called VEPTR, short for Vertical Expandable Prosthetic Titanium Rib, is a system that allows lengthening of the spine with correction of the deformity.
The majority of cervical surgery is carried out for nerve root compression where there is arm pain with or without neurological signs. Most surgery is carried out in the anterior approach and hospital stays have reduced dramatically with typical stays of one or two nights. Bone grafting from the iliac crest has been used over the years, but with techniques where cages are used it has been possible to avoid using autograft from the patient with less post-operative pain and shorter hospital stays. Disc replacement has been introduced to avoid spinal fusion but the advantage of disc replacement has yet to be proven with results of long‐term data.
The management of spinal trauma has advanced significantly over the last few years. More rapid retrieval of patients has meant more survivors of major accidents. These patients are often best managed with early or emergency spinal stabilization to avoid later complications. By using advanced techniques, the surgeons are able to provide early stabilization of the spine with decompression of the spinal cord and nerve roots.
Patients with osteoporosis and fractures with persistent pain can now be treated with Vertebroplasty. Cement is injected into the painful ununited fracture as a day case under local anaesthesia and pain relief is usually rapid.
Advances in technology now give patients a wider range of treatment options for spinal tumours, whether primary or metastatic. Patients suffering from tumours affecting the spinal column can now benefit from a combination of surgical resection and reconstruction removing whole vertebral bodies. This type of surgery will provide relief from ingrowth into the spinal canal and improve or delay neurological symptoms. Combined with traditional cancer treatments such as radiotherapy or chemotherapy, this can keep patients mobile and asymptomatic for longer periods than ever before.