Think of back surgery and you think of someone who is out of action for at least six weeks. Or surgery that, at best, brings limited relief, but no real healing. But new technology in spinal surgery is changing that.

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Titanium vertebrae, laser surgery, disc replacement, keyhole surgery and minimal recovery periods – sounds like something from a science fiction movie, doesn't it? The good news for those with back problems is that these things are real and they're being used by doctors as we speak.

Types of back surgery The three main types of back surgery are laminectomy (in which back part of the bone over the spinal column is removed to relieve pressure on a nerve), a diskectomy (in which a portion of a disc is removed to relieve pressure on a nerve, and a spinal fusion (in which two or more vertebrae are joined together).

Most of these operations would require several days in hospital and a lengthy recovery period of six or more weeks.

But now, with new techniques, the discomfort and recovery period can be reduced substantially.

What are these new techniques?
In the case of disc degeneration or displacement, there are several possibilities:

• Nucleolysis - a minimally invasive disc procedure in which a portion of the displaced invertebral disc is dissolved. This is done by the direct injection of an enzyme into the diseased disc, which makes the portion of the disc, which causes the problem, to dissolve.
• Nucleoplasty - the herniated disc is heated up using a special probe in order to get it to heal. This procedure reduces the volume of the spongy nucleus within the herniated disc to relieve pain. The disc usually returns to a more natural shape, and the source of the pain is either minimised or eliminated in most cases. This procedure avoids the trauma associated with open surgery, allowing the patient to resume normal life activities faster. The procedure takes 20 – 30 minutes, is done and local anaesthetic and requires no hospital stay.
• Non-fusion instrumentation - a device or spacer is inserted in order to try and get the disc to heal. This nucleus replacement helps the surgeon reconstruct the disc with natural or synthetic materials and it prevents the further deterioration of the disc. By using endoscopes and special instrumentation, laparoscopic spinal fusion requires only a small incision in the back. There are numerous benefits including reduced hospital stay and recuperation time. Patients undergoing laparoscopic surgery are hospitalised for just under 2 days, versus the 4 to 6 days required for patients undergoing open surgery.
• Microdiscectomy – this is a minimally invasive procedure done with the help of magnification. The spinal muscles are not damaged and the slipped disc is removed. The success rate with this operation is greater than 90%. A microdiscectomy spine surgery is performed through a small (2 – 3 cm) incision in the midline of the low back. First, the back muscles are lifted off the bony arch of the spine. The surgeon then enters the spine by removing a membrane over the nerve roots. Often, a small portion of the inside facet joint is removed both to facilitate access to the nerve root and to relieve pressure over the nerve. The nerve root is then gently moved to the side and the disc material is removed from under the nerve root.
• Disc replacement - two metal plates and a plastic sleeve are inserted in the place of the damaged disc. Because this is done from the front of the body, a vascular surgeon is usually present during the operation. The design of most prosthetic discs is similar, with two metallic endplates separated by a more pliable inner core designed to imitate the biomechanical properties of the disc. The implantation of the prosthetic discs involves a small cut below the belly button. The diseased disc is partially or fully removed.

In the case of damaged vertebrae, there are also several surgical possibilities:

• Vertebroplasty - the injection of bone cement into a fractured or collapsed vertebra. The hardened cement will seal and stabilise the fracture and relieve pain. People suffering from severe pain as a result of a compression fracture will be benefit from this procedure. This is often done in the case of elderly patients who have osteoporosis.
• Kyphoplasty – the insertion of a "balloon" to expand a compressed vertebra and the injection of bone cement. Kyphoplasty is a type of vertebroplasty (to fix a fracture) in which the vertebral body is first prepared by using a balloon to inflate and reposition the vertebra. The cement is then put in place in order to fix the vertebral body, and helps it resume a more normal shape. Kyphoplasty is minimally invasive, requiring only a very small incision in the back.
• Total vertebral replacement using a "cage". This is most often used in the case of cancer and trauma patients. The surgeon goes in through the front of the spine and replaces the damaged or diseased vertebra with a titanium cage. When performed by well-trained spine surgeons titanium cages offer the following advantages: It is less invasive to surrounding tissue; there is less blood loss; patients recover more quickly and there are fewer post-operative problems.

Many of the new techniques use so-called keyhole surgery, or to use its medical name, endoscopical or image guided procedures. Because large surgical cuts are not made, the recovery periods of the patients can be substantially reduced.

Does this mean that anyone who suffers from back pain as a result of worn-out discs should rush off and have an operation?

"Absolutely not," says Dr Pradeep Makan, part-time lecturer in the Department of Orthopaedic Surgery at the University of Cape Town. "Surgery is only considered as a last resort when all other conservative measures have been exhausted."

These include seeing one's GP, taking anti-inflammatories and other pain medication, going to the physiotherapist, seeing the chiropracter, going for acupuncture and body stress release classes.

In which cases would surgery be considered?
Simple back pain results from normal wear and tear, which can include a disc protrusion or an annular tear, muscle sprains or facet joint strains. Surgery is not usually considered in these cases until these conservative measures have been tried.

So-called "red flags" indicate a possible serious underlying cause for the back pain, according to Dr Makan and include the following:

• Back pain in someone who has/had Cancer
• Persistent back pain in those under 25
• Persistent back pain in those over 55
• Non-mechanical pain e.g. pain at night
• Back pain resulting from trauma e.g. following a motor accident
• A feeling of illness in addition to the back pain
• Thoracic back pain (upper back pain)
• Bowel and bladder disturbances
• Weakness in the legs

Basic investigations that are done before the decision to operate is made, include X-rays and blood tests. MRI scans are the answer, according to Dr Makan, but because of their high cost, are often not recommended as a starting point in the investigation of the origin of the backache.

"But, also, MRI scans often show too much, giving doctors ammunition to operate – even in cases where other treatment options might have been beneficial," says Dr Makan.

Preventing back pain
Everyone knows the basics: picking things up the right way, wearing a seatbelt, watching your posture, your weight, your calcium level and your fitness level. What else does an expert advise you to do in order to prevent back pain in later life?

• Make sure your car or truck has a good suspension, especially if you're a long-distance driver. Bad suspension wears out the discs in your back.
• Don't choose a profession where you work with vibratory tools or where you have to carry heavy stuff. Don't become a baggage handler, a road builder or a clothing factory worker. Nurses also often hurt their backs when moving patients.
• Choose your type of sport carefully. Golf, squash and cricket (especially if you are a fast bowler) are hard on the back.
• Do as much exercise as you can, as improved muscle tone in your back prevents many back problems.
• Get the company you work for to invest in decent office chairs. Cheap ones can do real damage to your spine. And remember to sit with your knees lower than your hips and your feet flat on the floor.

Susan Erasmus(Health24)
 

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