Lower Back Pain Surgical Management - Indications, Types, and Risks

Introduction

Back pain, especially lower back pain, is a very common condition. Most lower back pain can be treated without surgery. People experience back pain at least once in their lifetime. Most of them recover on their own. A few percent of such individuals develop chronic pain and require surgical intervention. Musculoskeletal injuries or nerve compressions require surgery as a viable option.

What Is Chronic Lower Back Pain?

Chronic lower back pain is defined as continuous lumbar, sacral, or lumbosacral spinal pain that occurs for 12 weeks or due to low-level pain caused by acute pain exacerbations. Back pain is diagnosed after a thorough physical examination to assess the factors leading to the pain. The evaluation aims to identify the causes of lower back pain and individuals at risk of developing delayed improvement because of neurological impairment. A physical examination is usually required for individuals without any other grave disorders. All other organs are also thoroughly examined in others with a systemic or visceral cause of lower back pain.

What Are the Indications of Back Surgery?

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) has laid down the following indications for surgical intervention for lower back pain:

Ruptured or herniated disks, in which one or a few disks are damaged.

• Spinal Stenosis - The spinal canal narrowing that puts pressure on the spinal cord and nerves.

• Spondylolisthesis - A condition in which one or more spinal bones move out of their place.

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• Vertebral Fractures - It is caused due to injury to the spinal bones or osteoarthritis.

• Degenerative Disk Disease - Damage to the spinal disk with age.

• Cauda Equina Syndrome - Back pain due to a tumor, infection, or a problem in the nerve root.

What Are the Different Types of Lower Back Surgeries?

Vertebroplasty and Kyphoplasty:

These are minimally invasive surgical procedures that are used to repair vertebral fractures due to osteoporosis. During the procedure, a hollow needle known as a trocar is inserted through the skin into the vertebra, guided with the help of an X-ray (fluoroscopy). After the trocar is in place, either cement (vertebroplasty) or a balloon-like device (kyphoplasty) is inserted into the vertebra via the trocar. As the balloon is inflated, it creates a space that can be filled with bone cement, thus strengthening the bone.

Spinal Laminectomy or Spinal Decompression:

This procedure is performed in cases of spinal stenosis. Spinal stenosis leads to spinal canal narrowing, resulting in pain, numbness, or weakness. In this procedure, a part of the lamina or a piece of the back of the vertebra is removed. Laminectomy enlarges the spinal canal to relieve pressure on the nerves.

Discectomy:

This procedure surgically removes the disk when some part of the soft part of the disk bulges out through an opening, causing pressure on the nerve root or spinal cord. This leads to compression of the nearby nerves, causing pain, numbness, and weakness. Laminectomy and discectomy are generally carried out together.

Foraminotomy:

This procedure involves the enlargement of the hole (foramen) where the nerve exits the spinal cord to prevent the bulging of the disks or joints from pressing on the nerve.

Nucleoplasty:

Nucleoplasty is also known as plasma disk decompression. This laser surgery uses radiofrequency to treat back pain associated with a mildly herniated disk. A needle is inserted into the disk along with a plasma laser device. The needle's tip is heated, vaporizing the disk tissue, reducing its size, and thus relieving the pressure on the nerves.

Spinal Fusion:

This procedure removes the spinal disk between two or more vertebrae. The adjacent vertebra is then fused with bone grafts or metal devices with the help of screws. This procedure may lead to some loss of flexibility in the spine. The recovery takes longer for the bone grafts to grow and fuse the vertebra.

Artificial Disk Replacement:

This is an alternative procedure used in place of spinal fusion for the treatment of individuals with damaged disks. In this procedure, the disk is removed and replaced by a synthetic disk.

Injection Therapy:

Injection therapy is used when painkillers and physiotherapy fail to curb the symptoms. In this therapy, local anesthesia and steroids are inserted in and around the joint with the help of a needle. This leads to a momentary suppression of the inflammation, thus reducing the pain. Injection therapy is a temporary measure and can be used to manage acute pain exacerbations.

This temporary pain management gives time for the patient to undergo physiotherapy. However, injection therapy is not meant for individuals with a progressive degenerative process. The area, level, and type of injection therapy depend on the symptoms and the area of pain. Injection therapy is not carried out more than three times a year.

Non-Fusion Stabilization:

This procedure is an alternative to traditional fusion. In this procedure, an artificial ligament is attached to the spine with the help of screws to stabilize the spine, limiting only the flexion movement. However, a study found a higher recurrence rate post-surgery. The device was then modified, limiting both flexion and extension. This led to removing the load from the intervertebral disc. The recurrence rate was low with such devices, but they had their share of limitations.

What Are the Risks Involved With Lower Back Surgery?

Lower back surgery has associated risks, like any other surgery. Being closer to the nervous system involves greater risk. Paralysis (loss of one's ability to move any body part) and infection are the two major risks of lower back surgery.

Conclusion

Chronic lower back pain is common and can be managed with or without surgery. The non-surgical approach includes physiotherapy, medications, or alternate hot and cold fomentations. Surgery comes into the picture only if these procedures have yielded no positive results.

Various procedures, from steroid injections to decompressions, remove pain by preventing movement between the two vertebrae. Like any other surgery, lower back surgery has its share of complications. No treatment is completely error-free. Further research is required in this field for a better understanding of the physiology and pathology of the disc and the development of a universal treatment strategy.