Fusion Surgery
The more disc material that is removed or
the more simple discectomy surgery that is done increases
the instability of the spine, often necessitating fusion
surgery later as the disc continues to degenerate.
Posterior approach fusion surgery of the spine is a procedure
whereby the spinal column is entered from the back (posterior)
skin, the muscles are separated, the existing bony structures
are hammered away, and bone from other parts of the body
(such as the patient's pelvic bone) is harvested and applied
to the spinal bones. Also, the spinal column has its problem
disc cut out so that during the healing process, one vertebral
bone contacts and grows into the adjacent bone. In this
"classic" fusion, posterior elements of the vertebral
bones as well as the centers of the spinal vertebrae adjacent
to the problem disc are cut into, then the bone grafts are
placed between the vertebrae so that they grow together
into a solid mass. This was probably the most traumatic
surgical option; so, in an attempt to limit the severity
of treatment, fusion was usually not done as the first surgical
procedure (unless there was an existing spondylolisthesis
or other anatomical exception); but remained as the option
of last resort if diskectomy failed or repeated diskectomy
resulted in instability.
Considering the pain, the damage to associated
ligaments, muscle trauma, prolonged discomfort of recovery,
and potential for complications, this was considered the
most drastic of therapeutic options for disc disease
up until recently. It was not an option to be looked forward
to as anything other than the last alternative. This older,
open-type, posterior approach, fusion should still not be
considered anything but the last resort because there is
a newer, more effective procedure.
The newer, less traumatic procedure is accomplished
by an anterior approach through the abdomen. It is a procedure
that also involves attaching a cage-like apparatus to hold
the two vertebral bones together until they fuse. The entire
herniated disc is removed through the front of the disc
space between the vertebral bones and, usually, bone grafts
are inserted to fill the space.
Awaiting the results of the clinical trials
involving the artificial disc replacement option, the anterior
approach spinal fusion procedure is, to my mind, the best
choice among the surgical alternatives if one's pain cannot
be reasonably controlled by The O'Connor Technique (tm).
It is my belief that if your spinal problem is so significant
so as to require any type of surgery, you are wasting your
time with the simple discectomy. Eventually, it will deteriorate
further the pieces will move down the fissure and exit the
joint capsule through the scar created during the surgery
or from the original lesion. It makes little sense to me
to have a partial procedure performed. Either have the disc
replaced or fused on the first and hopefully the
last surgery.
If you approach the surgical alternatives
with a lackadaisical attitude that assumes you can ignore
The O'Connor Technique (tm) principles of back protection
and continue to abuse your discs by assuming that you can
always have the fusion done, if worse comes to worse,I would
advise you not to rely on fusion as the solution when "all"
else fails and, by a careless spinal protection attitude,
insure that all else does fail. Recent retrospective analysis
of published series of back pain surgeries, with and without
fusion, showed that fusion offered no statistically improved
benefit to the clinical outcome. In other words, just as
many people were no better after this surgery as those who
went through all the agony of having their back sliced open,
their muscles torn, and bone chiseled with
a hammer.
It is no small feat to direct a needle into a space deep
within the body. Nor is it easy to perform an operation
deep within the spine. I ask the reader not to interpret
my assertions as failing to respect the skills of spinal
or neuro-surgeons in general. I have the utmost respect
and frank awe of their skills and dedication to their patients.
The neurosurgeons I have had occasion to know work so hard
and get unfairly sued so often, that I often wonder what
could compel a person to subject themselves to such abuse.
Sure, the money is good; but, in reality, they are probably
underpaid when you take into consideration the sacrifices
they undergo by choosing that career (This probably could
apply to any physician, and does to most that I have had
occasion to work with). I'm glad someone does it. My back
would not have tolerated that laborious a career. Imagine
bending over for hours upon hours without a break, night
after night, day after day.
Those doctors deserve the utmost respect by their colleagues
and the public in general; however, their decisions should
not go without scrutiny, because they are human, too, and
not all of them make decisions solely based upon what is
best for the patient. Often, their needs and training impact
upon their decision process. For instance, if a surgeon
is up in his years, doesn't feel the need to acquire the
skill of percutaneous diskectomy, and prefers to stick with
the procedure he feels most comfortable with, he may be
inclined to convince a patient to go with an open operative
procedure when a percutaneous solution would have been better.
Given this scenario, it would require of him the largess
to refer the patient to another neurosurgeon. If it just
so happens that he hasn't been too"busy" (which
in medical parlance means making money), he may be reluctant
to offer that as an alternative. This is a consideration
which the wise patient should be aware of, yet not assume
to be the case unless definitive evidence exists to demonstrate
it. If you suspect yourself being put in such a situation,
it would behoove you to obtain a second opinion or a third
opinion from a different neurosurgeon who does both procedures.
It is unnecessary to be confrontational or accusatory, but
in the same vein, do not assume a totally submissive role.
My intent is not to alienate neurosurgeons by this choice
of words; however, if they are honest with their patients
and themselves--they have nothing to be offended by because
they are not of whom I make reference. Yet, they know, as
well as I do, that there are some surgeons out there (the
decided minority) that are motivated by something less than
altruism.
Nevertheless, if, after you have devoted a legitimate and
conscientious effort to rehabilitating and protecting your
back, studied and practiced The O'Connor Technique (tm)
on a daily basis, and you unfortunately are caused to resort
to surgery, then you cannot be seen to have sold yourself
short. Be aware, too, that often a surgeon's decision to
operate or not depends upon the pressure put on the surgeon
to operate. Patients who unrealistically believe that surgery
is the answer, can influence a physician to decide in favor
of surgery simply due to the patient's plaintive encouragement.
If you accidentally fall in flexion and your condition
worsens, of course, no one can blame you; however, putting
yourself in a position that would cause you to be in flexion
when you fall can be seen as a failed opportunity to prevent
future pain and problems. If you are constantly conscious
about the mechanisms of injury, you will judiciously avoid
situations in which you put yourself at risk of a flexed
fall that could result in a disc herniation. If you fall
while playing football, its not exactly an "accident"
because, if you have a bad back, you shouldn't be engaging
in a sport that has such a high probability of flexion falls.
An equivalent situation would be if one were to leave home
without one's glasses and drive to the store. Not being
able to read a one-way sign causes one to get into an "accident."
Well, sure, it was an auto "accident," but by
putting oneself knowledgeably into that circumstance, the
person actually can be seen to have caused the "accident".
Same with the bad back, if you carry packages up wet steps
knowing that if you lose your balance you will be unable
to grab the hand rail to prevent a backwards fall in flexion,
you have just set yourself up for a prolonged period of
pain. Sure, the fall was an "accident" in that
you didn't plan it to happen, but you have pushed the probabilities
that if something untoward did happen, the worse possible
consequence for you would occur. It is better to think about
these considerations in advance, and make several trips
up and down the stairs so that you have a free hand to catch
yourself in case you fall backwards. It may sound like an
imposition, but if you ever have to experience the grinding
agony of a surgical fusion procedure, looking back on whether
you would have desired to sustain that inconvenience if
you knew you could prevent it, I'm willing to bet you would
choose the less traumatic option.
Finally, if you undergo a surgical procedure, you are at
just as much risk of damaging the same disc unit as you
were before surgery if you don't intentionally change the
mechanical forces on your back. A diskectomy usually only
removes the herniated volume or a portion thereof. There
probably is loose disc material remaining, that with the
same forces applied, will probably eventually migrate along
the path the other material took on its exiting of the central
area. This residual material has a good chance of returning
you to the same pain you were in before the surgery. I believe
that the above described mechanisms are the major cause
of surgeries that do well in the immediate post operative
period but, later, end up as long-term failures.
One concept that must be understood following surgery,
a fusion or, for that matter, the prolonged wearing of a
back brace to stabilize a painful segment of the spine,
is that the damaging flexion forces that originally caused
the affected discs to deteriorate will be communicated to
the adjacent disc if you continue to commit the same flexion
mistakes. If you persist in making the same mechanical mistakes
as before the surgery, put damage inducing stresses on the
disc level that had to be surgically or mechanically corrected,
and you do not alter your motion behavior, you can expect
the same herniations to happen again at either the repaired
level (if it is not fused) or the level above or below the
fusion. If for no other reason, knowledge of the operant
mechanical forces and the protective measures elaborated
in The O'Connor Technique (tm) is of value for any stage
of disc disease or repair because it manages the problem
on a minute-to-minute basis to prevent further damage from
occurring. It is this ongoing damage that contributes to
the surgical failure rates and, I believe, is largely preventable.
The point to remember is that, even if you have to resort
to surgery, the basic mechanical problems are still lifelong
and still have a profound effect up the surgically treated
unit and other adjacent discs. Surgery does not alleviate
that reality. Surgery may temporarily end the pain, but
it has a good chance of returning unless you actively work
to prevent it. The O'Connor Technique (tm) is, in part,
designed to eliminate that event or at least forestall the
eventuality if it should exist as your ultimate predictable
destiny
1. Spencer DL, Lumbar intervertebral disc surgery In: Bridwell
KH, De Wald RI, eds. The Textbook of spinal surgery. Vol
2. Philadelphia, Lippincott, 1991:675-93.
2. Vlok, GJ, Hendrix MR, The lumbar disc: evaluating the
causes of pain. Orthopedics, 1991;14:419-25.
3. Spencer DL, Lumbar intervertebral disc surgery In: Bridwell
KH, De Wald RI, eds. The Textbook of Spinal Surgery. Vol
2. Philadelphia, Lippincott, 1991:675-93.
4. Kambin P, Gellman H. Percutaneous lateral discectomy
of the lumbar spine; a preliminary report. Clin Orthop.
1983;174:127-129.
5. Mooney V, Percutaneous discectomy. Spine, State of the
Art Reviews. 1989;3:103-112.
6. Overmyer R, Herniated disk: New laser therapy is more
efficient and rapid than standard technique, Modern Medicine,
June 1990;58:32-34.
7. Turner JA, Ersek MN, Herron L, et al., Patient outcomes
after lumbar spinal fusions. The Journal of the American
Medical Association, 1992;268:907-11.
Further Reading
Introduction
TENS (Transcutaneous Electrucal Nerve
Stimulation)
Ice and Heat
Acupuncture
Trigger Point Point
Injections
Epidural Steroid / Aneshetic Injections
Chemonucleolysis
Surgery
Percutaneous Diskectomy
Microdiskectomy
Laminectomy
Artificial Discs
Fusion
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