SPINE PROCEDURE INFORMATION

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ANTERIOR CERVICAL FUSION

HERNIATED DISC

LAMINECTOMY

LUMBAR INSTABILITY

SCOLIOSIS

LAMINOPLASTY

SPINAL FUSION

SPINAL STENOSIS

PHYSIATRY PATIENT EDUCATION

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SPINE PROCEDURE INFORMATION

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The OrthoCarparaolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding anterior cervical fusion operations. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case.

What is anterior cervical fusion?

Anterior cervical fusion is a surgical procedure done to relieve neck and arm pain caused by disc herniation (ruptured disc), bones spurs from degenerative disc disease, or for vertebral instability.

The operation is done through a small incision on the front of the neck using a microscope. The disc rupture and bone spurs are removed. A bone graft is then inserted in the disc space. This graft can be taken from your iliac crest (hip) or more commonly, from a bone bank. This bone graft then solidifies (fuses) with the vertebra above and the one below. This “fusion” usually takes about three to six months. A plate and screws are typically used to prevent the bone graft from dislodging.

After surgery most people experience some neck discomfort, but this is usually minimal. There may be slight difficulty swallowing solid food, but it should pass within a few weeks. Patients usually spend one night in the hospital. A cervical brace or soft collar is occasionally worn after the procedure. The collar can be removed for bathing.

Time out of work varies according to your profession. If you have a sedentary occupation,

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you may be able to return when your symptoms permit. If your job requires heavy lifting, you may need 4 - 6 weeks out of work from the time of

your surgery. Most people can resume driving an automobile 1 - 2 weeks after surgery, but you should clear this with your physician before doing so. We recommend that you use a high head rest when either driving or riding.

What are the risks? Anesthetic

Complications: You must be fully anesthetized.

Infection: There is a chance of infection with any operation.

Spinal Damage: Damage to the spinal cord producing paralysis.

Nerve Damage: This can occur, but happens in less than one percent of our cases. If a nerve is damaged, it does

not mean paralysis. Each spinal nerve supplies only a small group of muscles.

Dural Leak:

This is the most common complication (5 - 10%). Because the spinal canal is so tightly bound to the spinal nerves (which are covered by a thin membrane called dura) the dura may be perforated or torn in the bone removal process. These dural tears are repaired at the time of surgery if possible. Occasionally the leakage of spinal fluid from the dural tear can prolong the patient’s hospital stay and may even require a second operation if the repair is not successful. This second operation is seldom necessary.

Hardware Complications:

In some cases where internal fixation devices (plates and screws) are to be used, there is always the possibility that one or more of the crews may break or the plate may come loose. This is a rare occurrence and if it does occur, in many cases it is not a problem.

Nonunion: In some cases, the fusion may not occur. If there is persistent pain, additional surgery may be

required.

Hematoma: A swelling from pooled blood

Expectations:

The final risk is that the surgery may not give you the results you hoped it would. We hope to give you significant relief from your spinal stenosis symptoms, but it is unrealistic to expect 100% relief. It would be wise to get a clear understanding of what you can expect from your surgery.

ANTERIOR CERVICAL FUSION

-2-Herniated or rup-tured disc putting pressure on spinal cord or nerve roots. Post-operative illustration of removal of disc, with bone graft replacing it.

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Additional risks include hoarseness (usually temporary), blood loss and difficulty swallowing. If the bone graft material is taken from a bone bank, there is a risk of transmission of blood-borne diseases, including hepatitis and AIDS. Bear in mind that anterior cervical fusion is a relatively safe procedure and all these risks are rare.

How successful is the operation?

No operation is guaranteed to be successful and there is the possibility the operation may not work. For the majority of patients, a successful operation results in the relief of about 90% of preoperative pain.

If one or two levels are fused, there is usually no more than minimal loss of motion in the neck. Physical therapy is sometimes necessary to help restore motion. Noticeable loss of motion with stiffness occurs if three or more levels are fused. Is a blood donation necessary?

Normally blood is not needed for an anterior cervical fusion unless there is some rare complication. In most cases, your surgeon will not order a blood donation for you.

How long will I be in the hospital?

This is an outpatient procedure for some patients. In those cases, you should expect to spend half a

day at the hospital. If you or your physician does not feel as though you are ready to leave, you will not be sent home.

Other patients will be admitted to the hospital the day of surgery and observed closely. The day after surgery, you will be encouraged to walk, and then will be discharged home. Some patients will have a drainage tube placed near the incision during the operation to drain away blood. The tube is removed before you go home. As you become more comfortable, you should be able to perform most of your daily tasks. Depending on how quickly you recover, you may require rehabilitation.

What should I do when I leave the hospital? Upon discharge, you will need a ride home from the hospital. You are encouraged to walk, and gradually increase your activities as tolerated. You may shower on the fifth day after surgery, or sooner if your incision has a waterproof dressing.

If there are any problems with fever, drainage, increased weakness, or return of the symptoms prior to your postoperative appointment, call your physician’s office right away.

ANTERIOR CERVICAL FUSION

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-3-PHY SIA TR Y PA TI ENT E D. SPI N AL STE N O SIS SP IN AL F U SI O N LAM INO PL AS TY SC O LI O SI S LU M BA R IN ST AB ILI TY LA MI NE CT OM Y HE RN IA TE D D ISC AN TE RI OR IC AL F U SI O N HE RN IA TE D D ISC

The OrthoCarolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding herniated discs. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case.

What is herniated disc?

Herniated discs occur when a disc is damaged by natural degeneration or an injury. The nucleus (gel like core) of the disc herniates (squirts out) through a tear in the annulus (outer covering of the disc). “Crushed” disc, although not a

correct term, is generally used to describe a deteriorated or degenerated disc. Degeneration of discs is a normal process of aging but if a disc becomes damaged, the process of degeneration is accelerated and may show up at a younger age. Subsequently, it may lead to herniation.

Herniated discs cannot be diagnosed by an x-ray and must be viewed by a myelogram, MRI (Magnetic Resonant Imaging) or CT scan. There are certain cases where one or the other of these three tests is more appropriate and this decision will be made by your physician and radiologist.

Herniated discs do not always cause pain. If there is pain associated with the condition, it can vary from person to person. The most frequent pain associated with a herniated disc is a result of the herniated disc “pinching” a nerve (see drawing #1). Some experience a sensation of numbness

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-2-and/or tingling in the lower leg and foot. Back and leg pain that extends to the buttock and calf may also be present.

Proper body mechanics, stretching (with the appropriate exercises) and staying fit can assist in avoiding aggravation of the herniated disc. It is also important not to smoke because people who smoke are much more likely to suffer disabling back problems.

What are the treatment options?

Not all herniated discs require surgery. Several studies have shown that years after surgery, there is very little difference between patients who chose to have an operation and those who did not. Given adequate time, most herniated discs will shrink down and produce less nerve pressure and irritation. In the early painful stage, several options are available to treat your symptoms. Steroid injections, pain medication, anti-inflammatory medication, muscle relaxants, physical therapy, and bed rest

may help to gradually relieve symptoms and allow you to gradually return to your normal activities. It is possible that you may get such good results that you think you have a “normal” back. In general, once a disc herniates and produces enough pain to require medical attention, non-surgical treatment will result in minor pain of the lower back and leg. This “off-and-on” discomfort generally does not significantly interfere with a person’s lifestyle unless a lot of heavy and/or awkward lifting is included.

However, there are clear indications for surgery including: loss of bowel and/or bladder control, increasing weakness in the involved leg, and severe pain that cannot be controlled by standard narcotic pain medications and non-surgical treatment methods. The other indications for surgery are less definite and involve the severity of pain and the length of duration without improvement (feeling as though you are not getting any better). The decision to have surgery is a personal one and many factors will weigh into your decision. What are the risks?

Anesthetic

Bleeding/

Blood Clots: There is always some blood loss and a chance of post-operative blood clots with any operation. Spinal Damage: Damage to the spinal cord producing paraplegia. This is extremely rare.

Nerve Damage: This can occur, but is very infrequent. If a nerve is damaged, it does not mean paralysis. Each

spinal nerve supplies only a small group of muscles.

Dural Leak:

This is the most common complication (5 - 10%). Because the spinal canal is so tightly bound to the spinal nerves (which are covered by a thin membrane called dura), the dura may be perforated or torn in the bone removal process. These dural tears are repaired at the time of surgery, if possible. Occasionally the leakage of spinal fluid from the dural tear can prolong the patient’s hospital stay and may even require a second operation if the repair is not successful. This second operation is seldom necessary.

Expectations:

The final risk is that the surgery may not give you the results you hoped it would. We hope to give you significant relief from your spinal stenosis symptoms, but it is unrealistic to expect 100% relief. It would be wise to get a clear understanding of what you can expect from your surgery.

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-3-How successful is the operation?

Surgery is not performed if another effective alternative can be used because no operation is guaranteed to be successful, and there is the possibility the operation may not work or the disc will herniate again (this happens when scar tissue that has replaced the removed disc material herniates). The reoccurrence rate is 1 in 10 (10%) after the first operation and 1 in 5 (20%) after the second operation. After the third herniation of the same disc (second reoccurrence) it is strongly recommended that a spinal fusion be performed (see companion literature on Spinal Fusions).

During surgery the herniated portion of the disc is removed (see drawing #1) and replaced with scar tissue. The chance of a good or excellent result with microscopic technique is about 90% assuming that the diagnosis is correct and there are no complications. The chance of the condition becoming worse after the surgery is about 1% and is almost always due to some complication. How long will I be in the hospital?

This is an outpatient procedure for most patients. You should expect to spend half a day at the hospital. Most patients see a significant decrease

in pain quickly, and you should be up and walking within 2 or 3 hours of the surgery. If you or your physician does not feel as though you are ready to leave, you will not be sent home.

What should I do when I leave the hospital?

You can recline, lie down and walk, but you should try to avoid bending at the waist, lifting objects, twisting at the waist, and prolonged sitting in upright chairs. These activities may increase pressure on the disc and thus, increase the chances of pain or the reoccurrence of herniation.

If you use common sense in your activities and follow physical therapy instructions regarding exercise and body mechanics, you should reach maximum improvement in 6 to 10 months. Over that time you will continue to improve gradually and your may not know your final result for up to a year. In order to achieve the best long-term results, you need to make the exercise program you will be taught a part of your daily routine.

If there are any problems such as fever, drainage, increased weakness or return of your symptoms prior to your appointment, do not wait – call your surgeon right away.

Fig. 1 above shows a healthy disc. Fig. 2 above shows a typical herniated disc. The herniation occurs when the nucleus (core) herniates (ruptures) through a defect (tear) in the annulus (casing).

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PHY SIA TR Y PA TI ENT E D. SPI N AL STE N O SIS SP IN AL F U SI O N LAM INO PL AS TY SC O LI O SI S LU M BA R IN ST AB ILI TY LA MI NE CT OM Y HE RN IA TE D D ISC AN TE RI OR IC AL F U SI O N LA MI NE CT OM Y

The OrthoCarolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding laminectomy operations. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case.

What is a laminectomy?

A laminectomy is an operation performed on individuals who have spinal stenosis (enlarged, thickened bone and ligaments that compress the nerves or spinal sack). The operation consists of removing part of the bone which is pressing against the nerve. Depending on the amount of

narrowing, varying amounts of bone may need to be removed. Also, if disc material presses on the nerve, it may need to be removed. For this reason, the term decompression is often interchanged. This bone removal may lead to instability which may require a fusion operation.

A small incision of one to three inches is made in the back (the length of the incision depends on the number of disc levels involved). The muscles are carefully moved away from the bone and a small hole is cut in the lamina and the ligaments between the laminae are moved away from the spinal sack. The herniated disc material that compresses the nerve, if present, is then removed, and the incision is closed.

What is a microdiscectomy?

Microdiscectomy is a newer procedure in which a small incision of approximately one inch is

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made over the involved area of the spine. The surgery is performed using an operating microscope or other magnification with special lighting. The disc material that has “squirted

out” is removed using special instruments. The indications for surgery, risks of the operation and outcome are essentially the same as with the standard laminectomy.

Bleeding/Blood Clots There is always some blood loss and a chance of post-operative blood clots with any _operation

Nerve Damage: This can occur, but happens in less than one percent of our cases. If a nerve is damaged, it

does not mean paralysis. Each spinal nerve supplies only a small group of muscles.

Dural Leak:

This is the most common complication (5 - 10%). Because the spinal canal is so tightly bound to the spinal nerves (which are covered by a thin membrane called dura) the dura may be perforated or torn in the bone removal process. These dural tears are repaired at the time of surgery if possible. Occasionally the leakage of spinal fluid from the dural tear can prolong the patient’s hospital stay and may even require a second operation if the repair is not successful. This second operation is seldom necessary.

Expectations:

The final risk is that the surgery may not give you the results you hoped it would. We hope to give you significant relief from your spinal stenosis symptoms, but it is unrealistic to expect 100% relief. It would be wise to get a clear understanding of what you can expect from your surgery.

No operation is guaranteed to be successful and there is the possibility the operation may not work. For the majority of patients, a successful operation results in the relief of about 90% of preoperative pain. Your recovery period can range from three weeks to three months, depending on your age, level of previous conditioning, and your ability to follow the postoperative regimen given to you by your physician.

Is a blood donation necessary?

Normally blood is not needed for a laminectomy unless there is some rare complication. In most cases, your surgeon will not order a blood donation for you.

This varies from patient to patient. Depending on the amount of surgical decompression necessary, you may be sent home the day of surgery or require hospital admission. The hospital stay can be as brief as 24 hours or as long as one week, with an average of two days. While you are in the hospital, you will be taught how to roll over in bed, get up and begin walking.

Upon discharge from the hospital, you should plan to ride home in a reclining position in a car or other vehicle. Pillows behind your back will serve to keep you in this position. If you

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are traveling a long distance, you should plan on spending at least part of the time lying down in the back seat.

You may shower on the fifth day after surgery, sooner if your incision has waterproof dressing. The third week after your surgery, if your back condition and pain permit, you should begin gentle exercises as directed by your physician.

Sexual activity is of concern to most patients. You may begin within a few days of leaving the hospital, but you should be the passive partner, on your back at the beginning of relations.

Housework and yard work are generally difficult to do right after surgery and should be avoided until your physician gives you

permission. Driving, returning to work and other activities vary depending on the individual’s condition and recovery rate. Your physician can guide you in these matters.

You should walk on a daily basis (preferably outside if the weather permits). You should gradually work up to a goal of at least one mile a day. Avoid lifting, bending or stooping until allowed to do so by your surgeon. In addition, sitting should gradually be increased as your tolerance allows.

If there are any problems such as fever, drainage, increased weakness or return of your back symptoms prior to your postoperative appointment, do not wait – call your surgeon right away.

LAMINECTOMY

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The OrthoCarolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding lumbar instability. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case.

What is a lumbar instability?

The spine is like a 25-story skyscraper, vertical, strong and stable. It is also responsible for supporting the trunk and limbs. (Fig. 1)

Unlike a skyscraper, the spine has also been designed to be flexible.. By virtue of “hinges”, the spine is able to move in multiple directions.

Each hinge is made of the disc and two joints. Like all moving parts, these “hinges” may wear out over time or suffer an injury or malfunction.

The most vulnerable portion of the spine is the disc. Structurally, it resembles a jelly donut with a gel center (nucleus) containing large water binding molecules. The outer covering (annulus) is composed of intertwined fibers which support or corset the softer center. Near the outside of this

corset, there is a nerve, Fig. 1

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which encircles the disc making it pain sensitive. Unlike other structures in the spine, the disc is “avascular” - it does not contain a blood supply. This makes healing more difficult when an injury affects the disc.

Following an injury, nerves which course around the disc or other nearby structures, including the joints and nerve roots, become sensitized either by inflammation or by chemical irritation from the gel material in the disc itself (torn annulus, herniated nucleus pulposus). This irritability creates sensitivity such that a weakness caused by injury or “worn-out hinges” can now be appreciated and recognized by the patient. This weakness is conveyed to the brain as pain.

If you think of a bicycle as a model, the bike tends to fall over when perfectly still. (Fig. 2) However; the bike balances when moving and is stable when laid on its side on the ground. Most low back pain is like the unstable bicycle with pain and symptoms that are worse when sitting or standing perfectly still and improved when walking, changing position or lying down.

Additionally, the spine must support much of the body weight and bear forces generated by the arms and legs. Simple machines known as levers are often

used to enhance the force required to lift heavy objects. So the spine, particularly the lower back, acts as a fulcrum for multiple lever systems including the arms, legs and upper spine. Leverage causes small forces to be markedly enlarged or accentuated in the low back area. Activities such as vacuuming, sweeping, working overhead or cleaning the car or bathtub are markedly stressful for the low back and often cause a worsening of pain.

One day, physicians may be able to block the chemical message which allows our brains to feel the mechanical forces which the spine experiences. Until that time arrives, we must work “from the outside” by strengthening the spine through exercise.

Back injuries affect our lives in many ways, interfering with our ability to work, play and be a productive member of the family. Stabilization exercises strengthen the muscles that support the spine. Stretching can reduce the pull of muscles, which attach to the spine. (Fig. 3) Manual therapy helps to align the spine so that it is more stable and balances more efficiently. Stronger arms and legs protect the spine. Proper body mechanics

(Fig. 4) protect us from re-injury and allow time

for the spine to heal. Lumbar Instability

-2-OrthoCarolina Spine Center - 2001 Randolph Rd. Charlotte NC 28209 - 704.323.2225 www.orthocarolina.com

Back injuries af

Back injuries affect our lives in many ways, interfering with our ability to work, play and be a productive member of the family. Stabilization exercises strengthen the muscles that support the spine. Stretching can reduce the pull of muscles, which attach to the spin

which attach to the spine. Manual therapy helps to align the spine so that it is more stable and balances more efficiently. Stronger arms and legs protect the spine. Proper body mechanics protect us from re-injury and allow time for the spine to heal.

Unlike other structures in the spine, the disc is “avascular” - it does not contain a blood supply. This make healing more difficult when an injury affects the disc.spine, the disc is “avascular”– it does not contain a blood supply. This makes healing more difficult when an injury affects the disc.

FFollowing an injury, nerves which course around the disc or other nearby structures, including the joints and nerve roots, become sensitized either by inflammation or by chemical irritation from the gel material in the disc itself (torn annulus, herniated nucleus pulposus). This irritability creates sensitivity such that a weakness caused by injury or “worn-out hinges” can now be appreciated and recognized by the patient. This weakness is conveyed to the brain as pain.

If

If you think of a bicycle as a model, the bike tends to fall over when perfectly still. However; the bike balances when moving and is stable when laid on its side on the ground. Most low back pain is like the unstable bicycle with pain and symptoms that are worse when sitting or standing perfectly still and improved when walking, changing position or lying down.

A

Additionally, the spine must support much of the body weight and bear forces generated by the arms and legs. Simple machines known as levers are often used to enhance the force required to lift heavy objects. So the spine, particularly the lower back, acts as a fulcrum for multiple lever systems including the arms, legs and upper spine. Leverage causes small forces to be markedly enlarged or accentuated in the low back area. Activities such as vacuuming, sweeping, working overhead or cleaning the car or bathtub are markedly stressful for the low back and often cause a worsening of pain

Lumbar Instability

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“avascular”– it does not contain a blood supply. This makes healing more difficult when an injury affects the disc.

If

A

Lumbar Instability

Back injuries af

Unlike other structures in the spine, the disc is “avascular” - it does not contain a blood supply. This make healing more difficult when an injury affects the disc.spine, the disc is “avascular”– it does not contain a blood supply. This makes healing more difficult when an injury affects the disc.

If

A

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PHY SIA TR Y PA TI ENT E D. SPI N AL STE N O SIS SP IN AL F U SI O N LAM INO PL AS TY SC O LI O SI S LU M BA R IN ST AB ILI TY LA MI NE CT OM Y HE RN IA TE D D ISC AN TE RI OR IC AL F U SI O N SC O LI O SI S

The OrthoCarolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding scoliosis. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case. What is scoliosis?

Scoliosis is a deformity of the spine and ribs characterized by:

1. Lateral curvature (a side-to-side curve in the spine); and

2. Vertebral rotation (an abnormal rotation of the body that causes one side

of the chest to be higher and protrude more than the other side).

When viewed from behind, the normal spine looks perfectly straight, but with scoliosis, the side-to-side curvature is evident. In some cases, it is very slight. In more severe cases the spine resembles an “S” or a long “C”. A person with scoliosis may appear to slump or lean to one side. Other suggestive signs may be a shoulder or hip that appears higher than the other.

As the spine curves it can rotate, affecting the ribs and causing one side of the chest to be higher and protrude. When a person with scoliosis bends forward, this one-sided rib prominence and lateral curvature of the spine is usually noticeable.

In most cases, scoliosis begins in mid or late childhood and is more often seen in girls (10% of teenage girls may have mild scoliosis), but its complications may be seen in adult patients.

In children, scoliosis is not painful, and can be difficult to detect. Sometimes the first warning

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signs are clothes that don’t fit or hang properly, or continuous problems in adjusting the length of a skirt or slacks. There are three forms of scoliosis seen in children – idiopathic, congenital and paralytic. Idiopathic scoliosis is the most common, occurring more often in adolescent girls. Congenital scoliosis is present at birth, characterized by malformed vertebrae and is much less common. Paralytic scoliosis is associated with various neurological diseases such as cerebral palsy or spina bifida, and can occur at any time in life.

In adults, scoliosis may bring on a worsening of a curvature which was present in adolescence. If severe and untreated, it may lead to significant symptoms such as back pain, and can increase susceptibility to disabling lung disease. Adults, as they develop degenerative disc disease, may also develop a degenerative scoliosis. These usually develop in the lumbar spine, rarely affecting heart or lung function. Treatment of degenerative scoliosis is therefore treated on the symptoms it produces.

Scoliosis is detected by physical examination or an x-ray. School screenings to detect scoliosis early have been implemented for over 20 years and are highly recommended. Unfortunately, based on the current medical research, scoliosis cannot be prevented. However, when detected early, treatment can be more effective and the need for surgery lessened.

What causes scoliosis?

A spinal muscle imbalance occurs, and this causes the spine to curve by tightening the muscles on one side and relaxing them on the other side of the spine. Recent studies of idiopathic scoliosis show evidence of a middle balance abnormality, no other causes have been proven.

We do know that scoliosis frequently runs in families and may be influenced by heredity. Therefore, when one family member has been diagnosed with scoliosis, it is essential that the other members also be examined, especially growing children around ages 11 – 13.

What are the treatment options?

Fortunately, most patients with scoliosis have mild curves which can be treated with exercises and careful medical follow-up. Only 10% require treatment such as a brace or surgery. Brace treatment has been used for decades to control curves which progress beyond an acceptable limit (curvature over 25 degrees). The brace is usually worn until a child’s growth has stabilized and the spine is mature. The braces used today are closely molded to the body and are well concealed by clothing. They allow much more freedom of movement than braces once did. Other treatment methods (electrical stimulation, physical therapy, chiropractic) have not been shown to alter curves.

Surgery is performed when brace treatment has failed or for severe curvature that cannot be managed in a brace (curvatures over 40 degrees).

The specialists at OrthoCarolina’s Spine Center and Pediatric Center, long recognized for their expertise in the field of scoliosis, now provide a Scoliosis Clinic for the comprehensive evaluation and treatment of patients with this condition. Our physicians participate in a number of spine research societies, dedicated to researching causes and treatments of conditions such as scoliosis.

Rib prominence becomes more apparent when the child bends forward

Scoliosis

Side-to-side or lateral S-shaped

curve in Scoliosis Rib prominence becomesmore apparent when the child bends forward

Scoliosis

Side-to-side or lateral S-shaped curve in Scoliosis

Side-to-side or lateral S-shaped curve in Scoliosis

Rib prominence becomes more apparent when the child bends forward

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PHY SIA TR Y PA TI ENT E D. SPI N AL STE N O SIS SP IN AL F U SI O N LAM INO PL AS TY SC O LI O SI S LU M BA R IN ST AB ILI TY LA MI NE CT OM Y HE RN IA TE D D ISC AN TE RI OR IC AL F U SI O N LAM INO PL AS TY

The OrthoCarolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding laminoplasty. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case.

What is a Cervical Laminoplasty?

A laminoplasty is a surgical procedure intended to relieve pressure on the spinal cord while maintaining the stabilizing effects of the back part of the neck. This procedure is used to treat a painfully restricted spinal canal in the neck. It creates more space for the spinal cord and nerve

roots, immediately relieving pressure from the pinched spinal cord. This technique is often called “open door laminoplasty” because the back of the vertebrae is made to swing open like a door. What are the reasons for surgery?

Spinal stenosis is a narrowing of the bony spinal canal causing spinal cord compression. This may lead to pain, weakness, numbness, clumsy hands, and difficulty walking.

How is the Operation Performed?

The surgeon creates an incision on the back of the neck. A groove is cut down one side of the cervical vertebrae to create a hinge. The other side of the vertebrae is cut all the way through.

See Figure 1. Courtesy of Cleveland Clinic Foundation.

The tips of the spinous processes may be removed to create room for the bones to swing

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open like a door. The back of each vertebra is opened, taking pressure off of the spinal cord and nerve roots. Small wedges of bone and/or small plates are placed to “hold the door open” and allow room for the spinal cord and nerve roots to rest comfortably. See Figure 2a and 2b. Courtesy of

Cleveland Clinic Foundation.

In addition to opening the spinal canal, the surgeon may perform a foraminotomy if indicated. This involves using instruments to remove small pieces of bone surrounding an exiting nerve root that travels to the arm.

Bleeding/Blood Clots: There is always some blood loss and a chance of post-operative blood clots with any _operation.

Nerve Damage: This can occur, but happens in less than one percent of our cases. If a nerve is damaged,

it does not mean paralysis. Each spinal nerve supplies only a small group of muscles.

C5 Nerve Palsy:

Approximately 2 – 4% of patients will develop C5 nerve root palsy (weakness of the shoulder muscles). In almost all cases, this weakness will improve within 6 months, but some patients will require a full year to recover.

In some cases where internal fixation devices (plates and screws) are to be used, there is always the possibility that one or more of the screws may break or the plate may come loose. This is a rare occurrence and if it does occur, in many cases it is not a problem.

Expectations:

The final risk is that the surgery may not give you the results you hoped it would. We hope to give you significant relief from your Spinal Fusion symptoms, but it is unrealistic to expect 100% relief. It would be wise to get a clear understanding of what you can expect from your surgery.

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You will be admitted to the hospital the day of surgery and observed closely. The day after, you will be encouraged to walk, and will begin range of motion exercises for the neck and shoulder. As you become more comfortable, you should be able to perform most of your daily tasks. Most patients are discharged between 2-3 days, though this is variable. Depending on how quickly you recover, you may require rehabilitation to get full recovery.

What outcome can I expect from this operation?

Cervical spinal stenosis with spinal cord compression, or myelopathy, has a natural history of step-wise progression, with gradual decline in function. The goal of the operation is to prevent progression of myelopathy and further functional decline. However, most people experience an improvement in their symptoms.

Upon discharge, you will need a ride home from the hospital. You are encouraged to walk, and gradually increase your activities as your tolerance allows. You may shower on the fifth day after surgery, or sooner if your incision has a waterproof dressing. If there are any problems with fever, drainage, increased weakness, or return of the symptoms prior to your appointment, call your physician’s office right away.

MRI images before and after a laminoplasty The MRI images at right show the difference in the amount of space for the spinal cord. The white around the spinal cord is the spinal fluid. The more white there is, the more space for the spinal cord. On the postoperative image, the plate creates in artifact that appears to come into the space for the spinal cord. This is all artifact.

LAMINOPLASTY -3-BEFORE LAMINOPLASTY Spinal fluid Spinal cord Spinal fluid Spinal cord AFTER LAMINOPLASTY

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PHY SIA TR Y PA TI ENT E D. SPI N AL STE N O SIS SP IN AL F U SI O N LAM INO PL AS TY SC O LI O SI S LU M BA R IN ST AB ILI TY LA MI NE CT OM Y HE RN IA TE D D ISC AN TE RI OR IC AL F U SI O N SP IN AL F U SI O N

The OrthoCarolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding spinal fusion. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case.

What is spinal fusion?

A spinal fusion can be likened to “cementing” two or more of your vertebrae (back bones) together. The reason for your pain is instability in one or more segments of your spine. The fusion is done to stabilize the unstable segments. The operation is

done with various techniques, depending on the individual case, and the preference of the surgeon. The aim is to achieve a solid fusion which bridges the unstable segment of your spine. The procedure can last anywhere from 2 – 4 hours, perhaps as many as 5. An average case with the insertion of hardware takes about 3 hours.

It is impossible to give a detailed description of the exact technique, but the basic principle is that there are 2 components to the surgery. The first is placement of hardware. The unstable segment of the spine is bridged by placing metal screws above and below the unstable segment and connecting these screws with metal plates or rods (there are other types of hardware that may be used depending on the preference of the surgeon). In general, there will be two screws and one plate or rod on each side. The rods are

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then secured to these screws using metal nuts, providing immediate stability. The hardware holds the vertebrae in position to allow the fusion of the bone to occur. In the rare instance that the plates or screws cause irritation to a patient, they can be removed once the fusion becomes solid. There are occasions where metal is not used.

The second component is the spinal fusion. This is the most important part of the procedure as the fusion ultimately takes the stress off of the hardware once the the verterbrae have fused. The unstable segment is bridged by a bone graft. The bone graft (in strips or small pieces) is placed next to the bone of the spine where the fusion is to take place. Once the incision is closed, the grafted bone begins to heal to the bone and ultimately forms a solid bar of bone, cementing one vertebra to another so that there is no motion. The bone

graft may come from the pelvis of the patient, although banked bone or bone substitute is often used to decrease pain from the bone graft site. In some rare instances, the bone graft may have to come from the bone bank or other substitute when the patient does not have enough bone available to provide and adequate graft (most likely due to multiple surgeries and/or severe osteoporosis). As a rule, the bone graft would be expected to be solid in 24 weeks or less.

Before surgery, some patients are fitted with a “chairback” brace and will be required to wear it for a time period of 3 to 6 months. This is a removable brace that does not have to be worn in bed or during short intervals (nighttime bathroom break, getting a snack). It is required for patients who are going to be up for an extended period of time.

Bleeding/ Blood Clots:

There is always some blood loss and a chance of post-operative blood clots with any operation.

Spinal Damage: Damage to the spinal cord producing paraplegia. This is extremely rare.

Nerve Damage: This can occur, but is very infrequent. If a nerve is damaged, it does not mean paralysis. Each

spinal nerve supplies only a small group of muscles.

Dural Leak:

This is the most common complication (5 - 10%). Because the spinal canal is so tightly bound to the spinal nerves (which are covered by a thin membrane called dura), the dura may be perforated or torn in the bone removal process. These dural tears are repaired at the time of surgery, if possible. Occasionally the leakage of spinal fluid from the dural tear can prolong the patient’s hospital stay and may even require a second operation if the repair is not successful. This second operation is seldom necessary.

In some cases where internal fixation devices (plates and screws) are to be used, there is always the possibility that one or more of the crews may break or the plate may come loose. This is a rare occurrence and if it does occur, in many cases it is not a problem.

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Nonunion: In some cases, the fusion may not occur. If there is persistent pain, additional surgery may _{be required.}

Expectations:

The final risk is that the surgery may not give you the results you hoped it would. We hope to give you significant relief from your Spinal Fusion symptoms, but it is unrealistic to expect 100% relief. It would be wise to get a clear understanding of what you can expect from your surgery. If you are taking aspirin, anti-inflammatory drugs or pain pills, these should be discontinued two weeks before surgery. Smoking can increase your chances of developing complications during and after surgery and decrease your chances of achieving a good fusion.

No operation is guaranteed to be successful and there is the possibility the operation may not work. For the majority of patients, a successful operation results in the relief of about 50 - 75% of preoperative pain.

Is a blood donation necessary?

In almost all cases, it is necessary to have blood available for transfusions during and after surgery. In addition a “cell saver” is used to collect the blood during from expected bleeding during surgery and about 50% of that blood can be given back to the patient during surgery in order to further reduce the requirement for a transfusion. How long will I be in the hospital?

This varies from patient to patient. The stay averages about 3 - 5 days depending on how extensive the surgery is. Elderly patients often need to stay longer.

Upon discharge from the hospital, you should plan to ride home in a station wagon or van where a small mattress or pad can be put in the back of the vehicle for you to lie down (particularly for patients who will be traveling more than 20 miles). For short distances, patients may ride in a care with a reclining seat.

Most patients are able to handle 2 or 3 steps to get in their home. If you will be required to go

up a flight of stairs, you will need to be assisted by two people. It is recommended that you set up sleeping quarters and remain on one floor for at least a week after arriving home.

The level of independence varies greatly by patient, but most are able to take care of their personal needs. If you have stitches or staples, you should not shower until they are removed. If your incision has been closed with buried stitches, you will have adhesive strips on your back. If there is no drainage when you leave the hospital, you may shower right away (do not try to sit down in a bathtub). When there is drainage, you will need to change the dressings and take sponge baths.

It is helpful to have some assistance with meals, household chores and child care. Do not bend over to pick up anything – bend at the knees with one hand on a piece of furniture for support. You may pick items up from tabletop height as long as they weigh no more than 15 pounds and you don’t have to carry them long.

Sexual activity is of concern to most patients. You may begin within a few days of leaving the hospital, but you should be the passive partner, on your back at the beginning of relations.

All patients will be started on some type of exercise program promptly after being discharged from the hospital. Depending on the magnitude of your surgery and your physical employment requirements, your therapy may consist of anything from exercises at home under the supervision of a physical therapist

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-3-PHY SIA TR Y PA TI ENT E D. SPI N AL STE N O SIS SP IN AL F U SI O N LAM INO PL AS TY SC O LI O SI S LU M BA R IN ST AB ILI TY LA MI NE CT OM Y HE RN IA TE D D ISC AN TE RI OR IC AL F U SI O N SPINAL FUSION

-4-to intense rehabilitation programs followed by work hardening. Walking is strongly encouraged for those who can tolerate it, any other physical activities may be restricted and should be discussed with your surgeon.

If your job does not involve manual labor, lifting or bending, you should be able to return to work part-time in about 4 to 6 weeks. If your job requires a significant amount of manual labor, it will be several months before you will be able to return (and require that you go through an

intensive rehabilitation program).

Do not allow anyone to massage the surgical area until you see your surgeon for the first post-discharge visit (1 to 2 weeks after surgery). If your incision is not draining when you leave the hospital but starts to drain after you get home, you should call your surgeon or nurse.

If there are any problems such as fever, drainage, increased weakness or return of your symptoms prior to your appointment, do not wait – call your surgeon right away.

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PHY SIA TR Y PA TI ENT E D. SPI N AL STE N O SIS SP IN AL F U SI O N LAM INO PL AS TY SC O LI O SI S LU M BA R IN ST AB ILI TY LA MI NE CT OM Y HE RN IA TE D D ISC AN TE RI OR IC AL F U SI O N SPI N AL STE N O SIS

The OrthoCarolina Spine Center provides the highest level of care to patients

suffering from all spine related conditions, from the neck to the lower back. Our

surgeons and physiatrists work with a highly skilled team of physician assistants and

nursing professionals to provide patients with state-of-the-art spine care.

The following is a series of the most frequently asked questions regarding spinal stenosis. The answers are for the average case, with the understanding that there may be unusual circumstances, which would cause any one of these answers to be changed significantly. You need to understand from your orthopedic surgeon whether there is anything unusual about your particular case and have him/her explain why the answers to some of these questions might be different in your case.

What is spinal stenosis?

Stenosis indicates a narrowing or constriction of any opening in the body and may involve blood vessels, the bowel, or other structures in the body. Spinal stenosis is a narrowing of the spinal canal, which surrounds the spinal sack and nerves. The illustration on left is a normal spine; the right is a

stenotic spine. You can readily see the difference in the size of the normal spinal canal and the spinal canal with stenosis.

There are a number of conditions that can lead to spinal stenosis, but the most common are degenerative disc disease and arthritis of the spine. Degenerative disc disease of the spine is usually age related, and spinal stenosis is usually seen in patients over 55 years of age, although it can occur much earlier. As the spinal degeneration worsens, the joints of the spine enlarge and the ligaments of the spine get thicker. This tends to cause narrowing of the spinal canal and the exit foramina (the opening through which nerves leave the spinal canal). Eventually, the narrowing process gets so severe that it begins to compress the nerves and the symptoms appear. Heredity and smoking may also hasten spinal degeneration and arthritis.