While most patients do not need surgery, many are still at least wondering about the type of spine surgical procedures that exist. These are some of my most frequent questions and responses below:

I threw out my back - do I need surgery?

Most patients do not need surgery for spine pain. Neck and back pain is very common, and most of the time, it is myofascial/muscular pain. Some sort of an inflammatory response occurred, perhaps from direct injury such as whiplash from a car accident or when lifting heavy boxes, or more commonly, from an underlying region of spinal arthritis that triggered the muscle. Regardless of culprit, the first stage of treatment is focused on calming the inflammatory response and muscle spasm - usually drastically improving the pain. While of course every patient is different, typically I recommend starting with prescription NSAIDs and muscle relaxants and also some physical therapy. The NSAIDs help cover up the pain, just like taking ibuprofen for a headache, but they also treat the inflammation - thus actually treating the pain, not just covering it up. The muscle relaxants are a chemical disruption of the muscle spasm that often causes much of the neck or back pain; and then physical therapy, especially with dry-needling or cupping, can be a physical disruption of the spasm. With these measures, most patients, even those with underlying spinal arthritis, can improve enough to get back to normalcy at home without surgery. For those patients with unusual signs/symptoms or not getting better with these first-line treatments, I often then recommend spinal imaging, such as MRI, to help get to the root cause of the pain.

What is an ACDF?

An “ACDF” stands for anterior cervical discectomy and fusion.

• The ‘anterior’ refers to going through the front of the neck (ie, anteriorly) through a small incision in the neck. While this often seems scary to patients, it is actually much safer and less painful than in the back of the neck because nearly all of the muscle in the neck is actually posterior - and cutting through muscle is what is most painful. Thus, going through the front avoids most of the muscle and decreases pain. As above, the surgery is also safer this way because the surgeon can reach the disc space before the spinal cord, in fact, completely bypassing the spinal cord which is found posteriorly. This approach is so safe that most patients can have this procedure as an outpatient

• ‘Cervical’ refers to the cervical spine, ie the neck

• ‘Discectomy and fusion’ - the discectomy is the removal of the disc component and any bone spurs to decompress the spine and nerve roots. Once this portion is done, the decompression is complete; however if nothing were put in the disc space, that space would likely collapse down again, causing more neck pain. The fusion component is putting in some sort of a spacer, usually metal like titanium, into the disc space to keep it propped open and a small plate across the space to allow the bones to heal, or fuse, together with proper alignment.

Then, what is an artificial disc replacement vs a fusion?

The difference between an artificial disc (aka arthroplasty) and a fusion is all about the type of spacer that goes into the disc space. An artificial disc has a joint that allows generally normal motion in the disc space - this is great for patients who have stenosis/pinching from a disc herniation but do not have arthritis in the joints. Other patients may have arthritis in the joints and every movement is painful. For these patients, placing a fusion-type spacer to keep the joints from moving might help their pain much more effectively. Both procedures utilize the same anterior approach and both are done under the microscope, often even as an outpatient procedure.

When is a lumbar microdiscectomy appropriate?

Lumbar discectomies are procedures done to cure herniated discs. Thankfully most patients (approximately 85% in fact) will improve without surgery - that timeline is typically 6-12 weeks. These first few weeks are about trying to get the pain under control to “buy time” for the body to heal itself. Typically I recommend prescription NSAIDs and muscle relaxants, physical therapy, and an epidural steroid injection. With these temporary measures, we can usually get the pain under very good control to allow the body the 2-3 months it needs to fully heal. Some patients with severe symptoms or signs of weakness should not wait that long, and timing for surgery is always an individualized decision. For patients with severe symptoms or others who have not improved enough with the conservative treatments over the previous 12 weeks, then microscopic surgery becomes a good option.

While always microscopic, these procedures are often done through a tiny incision in the back, almost always as an outpatient procedure.

What’s recovery after a lumbar fusion really like?

All patients (and surgeries) are different, so it is difficult to accurately give a recovery timeline, but because this is such a common question/worry, I wanted to address it. Recovery probably is affected most by the amount/type of surgery. Some patients with scoliosis require several levels of screws and rods to help straighten their spine, and they might need several days in the hospital. Some patients need “only” 1 level treated and may spend just one night in the hospital. In general, though, for most patients with 1-3 levels of disease that need to be treated surgically, I would expect around 2 nights in the hospital. They are typically walking around the same day of surgery but not feeling like doing much more than that because of wound pain and muscle spasm in their low back. Anti-inflammatories, muscle relaxants, some narcotics, and icepacks are the norm for these first few days. Typically by day 2, most patients are able to walk well and climb stairs and feel comfortable to recover at home. By around day 5-7, the peak swelling has decreased, and patients are thinking about light stretching and physical therapy. Typically by around 4-6 weeks, most patients are doing light aerobic exercises such as exercise bikes or swimming in a pool, and it is typically around 3 months before patients feels like resuming more aggressive exercise.