Surgical Options and Recovery
Who Needs Surgery - There is only one circumstance where surgery is an emergency: cauda equina syndrome. This is a condition where the nerve roots within the spinal canal are severely compressed. The end result is loss of bowel or bladder control, severe leg pain, and numbness in the genital region. If the pressure on the nerves is not released immediately, control of bowel and bladder may never be recovered. For this reason, we consider cauda equina syndrome a surgical emergency.
For all other patients with spondylolisthesis, there is no emergency. Surgery is planned when symptoms or circumstances warrant it. Reasons to consider surgery include:
- Back pain failing to improve with conservative care
- Leg pain failing to improve with conservative care
- Progressive leg or foot numbness or weakness
- Progression in the amount of vertebra slippage
- High grade spondylolisthesis (grades 3 - 5)
- Signs, symptoms, and presence of nerve compression failing conservative care
"What If I Don't Have Surgery?"
Since surgery is usually done for relief of pain, the decision to postpone surgery is essentially a decision to live with the pain a bit longer. Most patients know very clearly when they are ready to have their spinal problem surgically corrected. Their pain is intrusive and constant, work is difficult, social life or hobbies are impossible, family life is compromised, and the level of function is in every way sub-optimal.
Risks of Surgery - As with any surgery, there are risks with spinal surgery to correct spondylolisthesis. The risks depend on the procedure being performed, the complexity of the spinal problem, and the health of the patient. Some of the more common problems with posterior surgery (surgery from the back) include infection (1-3%), failure of fusion (3-15%), nerve root injury (1%), dural leak (1-5%), hardware failure (1%), and excessive blood loss (5%).
Complications unique to anterior surgery (surgery through the abdomen) include prolonged resumption of bowel function, injury of blood vessels or bowel, incisional hernia, and retrograde ejaculation in males (1-3%).
General complications that can occur with any surgery include blood clots, deep vein thrombosis, pulmonary embolus, heart attack, pneumonia, urine infection, incision infection, virus transmission through blood transfusion, and many others. The general health risk from surgery depends on the health of the patient. A complete physical is recommended for anyone with health problems before undergoing major spinal surgery.
Possible Surgical Approaches
POSTERIOR SPINAL FUSION - This approach involves placing bone graft on the back and/or sides of the slipped vertebra and the one below. When the bone heals, it will fuse and stabilize the slipped vertebra. Fusion rates in children are excellent. In adults, failure of fusion can approach 60% if spinal instrumentation is not used. As in all cases of spondylolisthesis, if nerves are compressed, a LAMINECTOMY is also performed. Performing a laminectomy and fusion without instrumentation is the historic approach for this disease and still has a place in current surgical practice for low-grade slips in children, and in degenerative listhesis in adults who do not have much back pain.
POSTERIOR SPINAL FUSION with INSTRUMENTATION - This is the most common technique used today to address the instability caused from spondylolisthesis. Adding spinal instrumentation (screws in the vertebrae linked together with rods to immediately stabilize the spine) greatly increases the success of the fusion. Postoperative pain is improved and long term outcomes are better than with fusions without instrumentation. Fusion rates when instrumentation is used are about 95%.
ANTERIOR INTERBODY FUSION - This technique was renewed in the mid 1990's and involves placing a titanium or plastic cage into the disk below the slipped vertebra. This is done through an incision in the abdomen. The cage or dowel contains the patient's own bone. Success rates are good if the procedure is limited to vertebrae that are not slipped more than a few millimeters in patients without significant nerve compression. Fusion rates are likely in the 85% range when bone is used and 95% or better if Bone Morphogenetic Protein is used. The rehab after surgery is quicker than with posterior procedures.
POSTERIOR INTERBODY FUSION - The spine is approached from the back and anything pinching the nerves is removed. The disc below the slip is removed from the same approach and a cage is inserted into the disc to fuse it. This technique has a higher fusion rate than the two above techniques, since it combines fusions on both the front and back of the spine. Spinal instrumentation is used to further stabilize the spine and add to the success rate.
COMBINED ANTERIOR AND POSTERIOR - In complex cases involving revision surgery, or in instances of marked instability, there is an advantage to fusing the spine both from the front and from the back. When the spine is fused from the front, the disk can be distracted better than from the back. Distracting the disk maintains or improves the natural arch in the low back and allows patients to stand erect effortlessly. Spinal instrumentation is used posteriorly (in the back) to stabilize the spine. With bone in the front and back of the spine, fusion rates approach 98%. The tradeoff is in the increased complication rate from 2 different surgeries (front and back).
REDUCTION OF THE SLIPPED VERTEBRA - With high grade or severe spondylolisthesis, there is significant trunk shortening, arching of the low back, and instability. Correction of the slip in these cases is generally thought to be superior to fusing the spine in the deformed position. Reduction is accomplished from posterior, and instrumentation is always required. In experienced hands, this technique provides very good results with few complications.
Recovery From Surgery
Most patients leave the hospital 2 to 4 days after surgery. Help is needed at home for a few weeks with some of the more common activities of daily living. For patients who do not have help at home, a short stay at a rehabilitation center can be helpful in becoming more independent. From the first day home from the hospital, patients should be able to get in to the bathroom, and get in and out of bed or a chair on their own.
If a patient wants to get back to work at a sedentary job, this can be done as soon as 4-6 weeks in a part-time status. During the first 3 months, walking is the only exercise permitted. After 3-4 months, physical therapy is started in an effort to regain trunk strength and stamina. Therapy usually lasts 4-8 weeks, culminating in a home exercise program to be done on a daily basis. By 6 to 9 months, most people are safe to release to unrestricted activities.
Patients are followed on a yearly basis for several years. This is necessary to make certain the fusion is solid, and to watch for degenerative changes that can develop next to the fusion (15% risk).
To call or request an appointment:
Use the Appointment Request Form
Sonoran Spine Offices:
Total Body Physical Therapy:
1255 W. Rio Salado Pkwy., Suite 105
Tempe, AZ 85281
Web site: tbphysicaltherapy.com
Sonoran Spine Research and
1255 W. Rio Salado Pkwy., Suite 107,
Tempe, AZ 85281
Mesa Phone: (602) 443-4169
Phoenix Phone: (602) 443-1424
Web site: www.spineresearch.org