Surgical options 

After failure of all conservative care [such as physical therapy, chiropractic care, acupuncture, epidural steroid injection, biofeedback and alternative medicine], surgical intervention is considered. 

Microdisctomy

Endoscopic Discectomy

Lumbar Decompression

Cervical Disc Replacement

Lumbar Disc Replacement

Cervical/Lumbar Fusion

Kyphoplasty

treatment options:

microdiscectomy 

Although not common, leg pain or sciatica that does not respond to conservative management may require surgical intervention.

Microdiscectomy allows your surgeon to remove small amount of disc material which is pushing against your nerve after a disc herniation. Excellent success has been reported with this procedure.

The images below show a white arrow pointing to the disc herniation on the MRI images; The red arrow shows the compression of the nerves in the back [may cause weakness, numbness or bowel and bladder problems]. The disc material is shown [left] when removed which looks like “crab meat”.

endoscopic discectomy

A newer procedure, endoscopic discectomy allows your surgeon to remove part or all of herniated discs which may be causing back and/or leg symptoms.

The procedure is performed with the patients awake under local anesthesia [similar to dental work]. The disc is visualized with a scope and camera [similar to knee arthroscopy]. A special tissue grasper can then be visualized in the disc space where the herniated disc can be removed.

After this type of surgery, the patients can usually go home the same day. The pain relief is usually immediate following the procedure allowing return to most of the patient’s daily activities wihtout a long delay.

Depending on the type of disc herniation, this procedure may be as successful as the open procedures. As this procedure is significantly less invasive than an open procedure, endoscopic discectomy may be the best option before extensive open surgery is attempted.  The white arrow is pointing to a disc herniation that can be removed with an endoscope.

lumbar decompression 

As we age, our spine develops arthritis and degeneration of the disc and adjacent joints. As arthritis develops, the area available for the nerve roots diminishes. The pressure on the nerve roots can cause both back and leg pain.

If conservative measures fail, lumbar decompression allows removal of the arthritic elements and taking away the pressure on the lumbar nerve roots.

The MRI shows the side view of the low back [lumbar spine] showing the narrowing of the spine where the fluid seems to be cutting off in the middle of the lumbar spine [marked with an ellipse].

cervical fusion

Anterior cervical discectomy and fusion, also known as ACDF, is the optimal surgical treatment of disc herniations, instability or degenerative changes in the cervical spine [neck].

A small incision is made in the front of the neck; the incision usually leaves minimal scarring depending on the number of levels requiring treatment. Disc material is removed and replaced with bone graft. This graft can be from the patient’s hip area or from a cadaver. Graft taken from the hip area has increased discomfort for the patient which may last an extensive amount of time. Graft taken from the cadaver is obviously less traumatic to the patient but carries additional risk of infection or rejection.

After placement of a graft in the disc space, a metallic plate is placed to lock the vertebrae and the bone graft. The plate helps increase the success of the fusion surgery.

Below, the red arrow point to bony plugs placed in between the vertebrae. The titanium plate is marked with the white arrows.

disc replacement technology

Disc replacements have now been approved for use in the United States. The replacement technology has gone through multiple revisions since its infancy in Europe. Disc replacements are ideal for the younger patient who has degenerative disc disease causing low back pain.

As with other spinal treatments, not everyone would benefit from this new technology. Its important to have a full work up of your spinal condition by a spine specialist to determine the best surgical approach to help you.

Disc replacement benefits:

  • Preservation of motion

  • Avoidance of surgery through the back [the discs are replaced through the abdomen]

  • Probable decrease likelihood of adjacent level problems in the future

Disc replacement pitfalls:

  • Revision [repeat] surgery is very difficult and dangerous

  • There is potential wear down of the disc and inflammatory reaction surrounding the disc

  • Long term results still not available compared to proven fusion technology.

lumbar fusion

Lumbar fusions are commonly performed on patients who complain of significant back or neck pain which has not responded to conservative treatment [such as medications, injection, physical therapy, etc]. As fusions are relatively larger surgeries with Increased Risk Factors, fusion surgery should always be considered as a last resort.

Fusions are most commonly used for patients with previous surgeries which have failed, unstable spine, or degenerated spinal segments. Fusions are also used in patients with tumors or fractures.

In order to fuse a spinal level, bone grafts [either from the patient or a cadaver] and some type of metallic holding device [such as screws, cages, etc.] is used.

The bone graft is placed in between the vertebrae and screws or cages are applied to hold the vertebrae together until a solid fusion forms.

The success rate of obtaining a fusion may be as high as 90% or more depending on the surgical approach taken. However, the success rate of pain relief in patients varies dramatically depending on the diagnosis of the patient. As the success rate of fusion is variable, fusions are usually only considered when the patient is completely disabled by their back or neck pain.

In the lumbar spine, vertebrae can be fused by going through the abdomen [ie, removing the disc and placing bone by opening the belly from the front!]. First 2 Figures below shows a anterior [front] fusion with cages only.

Fusions can also be performed from the back where screws can be placed. The figure below shows screws [marked by red arrows] and a cage [marked by white arrow] placed into the spine by going through the back side of the patient.

kyphoplasty

Vertebral compression fracture [VCF] is the most common complication of osteoporosis. Over 750,000 compression fractures are recorded per year at an average yearly cost of 750 million dollars. Fortunately, most compression fractures are benign. The acute pain of the fracture resolves with medical management; a few days of bed rest, Calcitonin and pain medications allow most patients to return to their activities of daily living.

A finite number of patients, however, are left with long term sequelae from their VCF. The kyphotic deformity [i.e., stooped over position] commonly seen with multiple thoracic VCF can lead to chronic thoracic and low back pain. The abnormal kyphoses increases the work load of the paraspinal muscles which leads to chronic pain and fatigue.

Furthermore, deformity causes compression of the viscera; this compression results in early satiety and weight loss in this population. The lung’s functional capacity is also significantly reduced; each VCF causes a 9% loss of forced vital capacity. Patients with multiple VCFs are at significantly increased risk of pneumonia as well.

Finally, multiple studies have confirmed the increased mortality risk associated with VCF. When compared to controls, patients with VCF had a 5 year survival of 61% compared to 76% for their matched peers. A study of 9,575 women followed for over 8 years demonstrated a 23% increased mortality rate compared to patient without VCF.

A technique of percutaneous stabilization of vertebral fractures [Kyphoplasty], however, allows for restoration of the vertebral body height with injection of cement to stabilize VCFs. A balloon is utilized to inflate and “jack up” the vertebrae to its normal, non compressed height. Subsequently, cement is injected into the void to prevent future collapse. [See Figure showing cement in two vertebrae].

What our patients are saying:

Richard H: Dr Hannani has operated on me twice…once for my neck and once my lower back. Both surgeries were very successful and returned me to work. Waits can be long but I’m not concerned with that, I’m concerned with the quality of the surgeon should my injury result in actually needing surgery…and you couldn’t be in better hands if that’s the case.

Pablo G: Incredibly friendly Doctor and staff. I was dealing with horrible lower back and leg pain but was hesitant to go through with surgery and Dr. Hannani was very accommodating. When I finely went with surgery it was possibly the best decision I ever made. He explained everything thoroughly and the surgery went well… Now I have no back or leg pain anymore and the post op therapy has helped me get back to a normal routine. Ultimately that decision [surgery] turned out for the best and I can continue living normally without any pain.

Jaime T: I don’t think that there is a more compassionate caring and trustworthy doctor out there. Dr. Hannani has changed my life since the day I started seeing him. Because of him I was able to get back up on my feet again and walk. There are not enough thank you’s in the world to show my gratitude for all that Dr. Hannani has done for my health. If you are looking for a doctor that you can trust this is the place to go.

Jaime T: I don’t think that there is a more compassionate caring and trustworthy doctor out there. Dr. Hannani has changed my life since the day I started seeing him. Because of him I was able to get back up on my feet again and walk. There are not enough thank you’s in the world to show my gratitude for all that Dr. Hannani has done for my health. If you are looking for a doctor that you can trust this is the place to go.

Gregory E: Dr. Hannani is a straight forward and down to earth surgeon. He explained my condition and my options very clearly. He and his entire staff are friendly and accommodating. My spine was slipping at S1-L5 and pinching my sciatic nerve. After the surgery the pain was immediately gone. The hospital staff were amazing. I had meet with another surgeon and reviewed at least 20 others. After meeting with Doctor Hannani I felt confident I would not find anyone more focused in his profession. Or in who’s care I would be better treated.

What our patients are saying:

Richard H: Dr Hannani has operated on me twice…once for my neck and once my lower back. Both surgeries were very successful and returned me to work. Waits can be long but I’m not concerned with that, I’m concerned with the quality of the surgeon should my injury result in actually needing surgery…and you couldn’t be in better hands if that’s the case.

Pablo G: Incredibly friendly Doctor and staff. I was dealing with horrible lower back and leg pain but was hesitant to go through with surgery and Dr. Hannani was very accommodating. When I finely went with surgery it was possibly the best decision I ever made. He explained everything thoroughly and the surgery went well… Now I have no back or leg pain anymore and the post op therapy has helped me get back to a normal routine. Ultimately that decision [surgery] turned out for the best and I can continue living normally without any pain.

Jaime T: I don’t think that there is a more compassionate caring and trustworthy doctor out there. Dr. Hannani has changed my life since the day I started seeing him. Because of him I was able to get back up on my feet again and walk. There are not enough thank you’s in the world to show my gratitude for all that Dr. Hannani has done for my health. If you are looking for a doctor that you can trust this is the place to go.

Jaime T: I don’t think that there is a more compassionate caring and trustworthy doctor out there. Dr. Hannani has changed my life since the day I started seeing him. Because of him I was able to get back up on my feet again and walk. There are not enough thank you’s in the world to show my gratitude for all that Dr. Hannani has done for my health. If you are looking for a doctor that you can trust this is the place to go.

Gregory E: Dr. Hannani is a straight forward and down to earth surgeon. He explained my condition and my options very clearly. He and his entire staff are friendly and accommodating. My spine was slipping at S1-L5 and pinching my sciatic nerve. After the surgery the pain was immediately gone. The hospital staff were amazing. I had meet with another surgeon and reviewed at least 20 others. After meeting with Doctor Hannani I felt confident I would not find anyone more focused in his profession. Or in who’s care I would be better treated.

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