Spinal surgery is a highly specialized medical discipline. It deals with the surgical treatment of patients with complaints and diseases of the spine and spinal cord.
The spine is the supporting element in the skeletal system. It enables an upright posture and connects the other parts of the skeleton with each other. The sensitive spinal cord is located in the spinal canal of the spinal column. This is why spinal surgery requires the utmost precision and a good spinal surgeon.
As a rule, spinal surgery requires an interdisciplinary approach. This means that specialists from a wide range of disciplines use their expertise to answer all questions that arise regarding the diagnosis and treatment of spinal disorders. These include, in particular, specialists in orthopaedics and trauma surgery as well as specialists in neurosurgery.
Spinal surgery is often also a sub-specialty of neurosurgery - because the spinal cord is the starting point of the peripheral nervous system. The therapeutic and scientific focus of this surgery is on degenerative and tumor-related diseases of the spine and spinal cord, so it is classically concerned with spinal cord injuries and spinal diseases. The most common reasons for operations are tumors or contusions.
The spectrum of surgical procedures ranges from the treatment of inflammation and paralysis to herniated discs - including in the cervical spine - and disc degeneration (discopathies) to instabilities of the cervical, thoracic and lumbar spine. Osteoporosis with neurological symptoms is also included in this area. Incidentally, operations on the spine and spinal cord are increasingly being performed using minimally invasive techniques.
The spine is exposed to extreme stresses on a daily basis. Corresponding signs of wear and tear - degenerative diseases of the spine - can be the result. These can be very painful at rest or under stress, such as a slipped disc or spinal canal stenosis. The following diseases of the spine are frequently treated by spinal surgery:
- Degenerative changes (e.g. herniated disc, spinal canal stenosis, osteochondrosis, spondylosis, spondylarthrosis and degenerative lumbar scoliosis or neuroforaminal stenosis),
- Instability of the spine(spondylolisthesis or spondylolysis),
- Inflammatory rheumatic diseases, such as ankylosing spondylitis, with corresponding deformities of the spine, or rheumatoid arthritis (chronic polyarthritis),
- Infections and inflammations in the area of the spine, such as infectious spondylodiscitis,
- Injuries to the spine, e.g. a vertebral fracture as a result of an accident or damage to the spinal cord running through the spinal canal, which can lead to paraplegia ,
- Tumor diseases of the spine, such as traspinal tumors or tumors in the spinal cord,
- scoliosis
The most widely used diagnostic method in spinal surgery is magnetic resonance imaging(MRI), which allows the vertebral bodies, nerves and intervertebral discs to be imaged in great detail.
In addition, X-ray images of the corresponding region of the spine in two planes in a standing position and a lateral X-ray image of the spine in a standing position, including the femoral heads, are necessary to assess sagittal balance.
The techniques used in spinal surgery can vary greatly and depend heavily on the disease in question. Today, an endoscopic-assisted, minimally invasive surgical technique is standard in many cases. This spinal surgery method is very gentle on the patient.
Below you can find out more about the various spinal surgery procedures for the most common spinal diseases.
In the case of a herniated disc, the fibrocartilage ring of the intervertebral disc tears or splits, causing disc tissue to protrude into the spinal canal. This compresses (squeezes) the spinal cord or nerve roots.
This leads to severe pain, which often radiates to one extremity, and to characteristic loss of sensitivity, motor function and reflexes in the area supplied by the pinched nerve root, but occasionally also to signs of paralysis.
The definitive diagnosis of a herniated disc is made using magnetic resonance imaging (MRI) or alternatively computer tomography (CT).
Disc surgery is not always necessary. If there are no neurological deficits, conservative treatment measures are often used. These include, for example
- Anti-inflammatory and pain-relieving medication,
- infusions,
- plexus analgesia and
- CT- or X-ray-guided periradicular infiltrations.
In the latter case, cortisone is injected into the affected nerve root under CT or X-ray control. The majority of patients are relieved of pain as a result.
As the complication rate for disc surgery is relatively high, surgical treatment of a herniated disc should only be considered if conservative measures have failed or if there is a clear indication. Common complications include
- Scarring,
- recurrence of the herniated disc,
- infections,
- leakage of cerebrospinal fluid (spinal fluid).
Symptoms that suggest immediate or early disc surgery are
- cauda equina syndrome (crushing of the nerve fibers in the cauda equina area) with symptoms of paralysis,
- bladder and rectal paralysis and
- increasing or acutely occurring severe muscle deficits.
Thestandard operation for herniated discs today is microsurgical discectomy using a surgical microscope, which has almost completely replaced open discectomy. Alternatively, a herniated disc can also be treated using minimally invasive procedures.
Microsurgical discectomy: standard operation for herniated discs
In microsurgical discectomy, the protruding part of the disc (partial discectomy) or the entire disc as well as disc tissue that has slipped into the spinal canal is removed under general anesthesia and in a prone position via a small incision in the skin. This reduces the pressure on the spinal cord or nerve root.
Although this intervertebral disc surgery is only slightly stressful for the patient, complications can occur, as with any operation. In rare cases, for example, the nerve can be injured during the disc operation. As a result, the patient may suffer from paresthesia and motor, bladder and rectal dysfunction as well as sexual dysfunction. Some patients also develop what is known as failed back surgery syndrome. In this clinical picture, pain and numbness in the leg persist in the long term despite successful disc surgery.
Other surgical methods for herniated discs
In open discectomy, which is rarely used today due to the higher rate of serious complications (e.g. in the case of spinal malformations), the disc material is removed via a larger incision in the skin.
Another option for treating herniated discs is endoscopic discectomy. High-resolution endoscopes and video systems as well as micro instruments are used in this herniated disc surgery, which is performed under local anesthesia.
The surgical instruments and endoscope are inserted through small incisions in the skin and the disc tissue is carefully removed. However, this procedure cannot be used for every type of herniated disc (not for detached disc tissue located in the spinal canal) and at every point of the spine (not between the lumbar spine and sacrum).
Minimally invasive procedures are also used for herniated discs with an intact fibrous ring. Common procedures include
In these methods, the disc tissue is dissolved using heat, a chemical (chymopapain) or a laser.
If the entire intervertebral disc is removed during a herniated disc operation, an implant must sometimes be inserted to replace the disc .
Age- and stress-related degenerative changes (signs of wear and tear) to the spine develop in most people as they get older. However, they do not always cause clinical symptoms.
Bony outgrowths on the spinal canal, degenerative changes and protrusions of the intervertebral disc as well as arthrosis of the small vertebral arch joints can lead to spinal canal stenosis(narrowing of the spinal canal).
As a result, the spinal cord is irritated by the now too narrow canal or the nerve roots are no longer adequately supplied with blood, which leads to the typical symptoms of spinal canal stenosis: discomfort and pain that radiates into the legs and usually results in a shorter walking distance.
In addition to such signs of wear and tear, there are other acquired (e.g. operations on the spine) and congenital (e.g. malformations of the spine) reasons why spinal canal stenosis can develop.
Asymptomatic spinal canal stenosis does not need to be treated. If, on the other hand, spinal canal stenosis causes symptoms, it depends on the clinical picture, the extent of the narrowing and the level of suffering of the person affected as to whether treatment is necessary and, if so, what kind of treatment.
The treatment of spinal canal stenosis can consist of conservative measures (e.g. physiotherapy), drug therapy (for pain) or surgery.
However, only around 2% of patients with spinal canal stenosis have an absolute need for surgery.
Surgery for spinal canal stenosis
There is an absolute indication for surgery for spinal canal stenosis if
- a significantly reduced pain-free walking distance,
- in the case of unbearable pain,
- acute, severe neurological deficits (signs of paralysis) or bladder-mast bowel disorders and
- for Kauda syndrome.
However, surgery is also strongly recommended in cases of therapy-resistant pain with limited mobilization.
During spinal canal stenosis surgery, the parts that constrict the spinal canal are removed. This reduces the pressure on the nerves (pressure relief or decompression). Minimally invasive surgical techniques are standard today.
The following procedures are available in spinal surgery:
- Decompression with fusion involves widening the spinal canal and then connecting the vertebrae together using screws and rods, thereby stiffening them. Destroyed intervertebral discs are removed and a so-called cage (titanium basket) is implanted as a placeholder.
- In ventral nucleotomy with fusion , the intervertebral disc is removed microsurgically, the affected vertebrae are fused together and a placeholder is inserted.
- In ventral uncoforaminotomy with fusion, the vertebral body is milled out in the area of the spinal canal, thereby widening it and stabilizing the spine in this section by fusing the vertebrae involved.
- In intradiscal electrothermal therapy (IDET), the nerve fibers in the intervertebral disc are destroyed by slow heating, thereby strengthening the collagenous tissue in the disc.
- Decompression with implantation of a disc prosthesis involves widening the spinal canal and replacing the defective disc with an implant.
- In corpectomy with spondylodesis, a vertebra is removed, the adjacent vertebrae are joined together and an implant made of a titanium basket is inserted into the gap as a placeholder.
- In straightening spondylodesis with fusion, several vertebrae are fused together.
In motion-preserving surgical procedures (e.g. flexible spinal stabilization), a dynamic implant is used. It stabilizes the vertebrae and maintains their mobility at the same time.
Scoliosis is a deformity of the spine in which the spine is laterally displaced, the vertebrae are twisted (rotated) and the vertebral bodies are twisted.
In most cases, the cause of the development of scoliosis is unknown (idiopathic scoliosis). Only in around 10% of patients with scoliosis can the cause be attributed to a congenital disorder (congenital scoliosis) or a consequence of another disease (secondary scoliosis, e.g. after exposure to violence or muscular dystrophy).
Mild scoliosis is not that rare. It either causes no symptoms at all or remains stable with physiotherapeutic measures. However, if the scoliosis progresses further, it can manifest itself, for example, as a rib hump, sloping head posture and back problems.
Further progression can lead to massive movement restrictions and degenerative changes in the vertebral bodies, including severe deformation of the rib cage.
Surgery for scoliosis
Around 90 % of all patients with scoliosis do not require surgery. In these cases, scoliosis can be treated conservatively with physiotherapy and, if necessary, corsets. However, if the heart and lungs are constricted by the deformation of the rib cage, then surgery can no longer be avoided.
The principles of scoliosis surgery
- Straightening the curvature as far as possible
- Elimination of the rotation
- Maintaining the result of the correction with implants
- Stiffening of the spine.
Scoliosis surgery can be performed from the front (ventral), from the back (dorsal) or from both sides (dorsoventral or ventrodorsal). The following procedures can be used:
- In dorsal scoliosis straightening, the lateral curvature of the spine is eliminated by inserting screws and hooks into the vertebrae of the affected section, which in turn are connected to a rod system. However, this stiffening of the spine restricts the overall mobility of the vertebral apparatus.
- In ventral derotation spondylodesis, the spine is exposed via the thoracic or abdominal cavity, the intervertebral discs in the affected area are removed and screws are inserted into the vertebral bodies to be corrected. The screws are then connected to a rod. It is often necessary to wear a corset after the operation.
- Ventrodorsal surgery is performed for some severe forms of scoliosis (e.g. double curves). The dorsal and ventral approach can be used in one or two sessions.
A vertebral fracture (vertebral fracture) can occur at the vertebral body, the spinous process and the vertebral arch. A vertebral fracture usually occurs as a result of an accident, fall or physical violence. Due to bone splinters or displacement of the spine, the spinal canal is often also affected by a vertebral fracture. There is then a risk of a spinal cord syndrome.
In older people, a vertebral fracture can also be caused by osteoporosis. A stable vertebral fracture can be asymptomatic.
However, the following symptoms may also occur:
- Sudden onset of back pain
- Unnatural reflexes
- Sensory disturbances
- signs of paralysis
- Restricted movement
- Paraplegia
A stable vertebral fracture can often be treated conservatively. This includes
- pain treatment,
- mobilization with physiotherapeutic measures,
- improving posture and
- back-friendly movement,
- possibly also the wearing of a corset.
An unstable vertebral fracture in which the spinal cord and/or internal organs are also affected must be operated on by means of spinal column stabilization (usually by means of kyphoplasty or spondylodesis).
All spinal surgery should be performed by a specialist. The focus is on spinal stabilization by dynamically or statically connecting the vertebrae in the affected segment of the spine. Spinal stabilization relieves already damaged or constricted structures and prevents further damage to the spinal cord and nerves.
The following surgical methods are frequently used for vertebral fractures:
- Spondylodesis (vertebral body fusion): Stiffening of two or more vertebral bodies. Spondylodesis is a common spinal stabilization procedure in which screws are inserted into the vertebrae and connected with rods. The procedure is also used for spondylolisthesis.
- Kyphoplasty: minimally invasive procedure in which either a balloon is inserted into the collapsed vertebra and the resulting cavity is then filled with bone cement or the fractured vertebra is stabilized using only a special bone cement.
Spine specialists are usually specialists in the fields of orthopaedics and trauma surgery as well as neurosurgery, with the medical specialization being spinal surgery.
The specialty of neurosurgery includes the diagnosis, surgical and conservative treatment, aftercare and rehabilitation of diseases, injuries and malformations in the central nervous system, the vascular system and the peripheral and autonomic nervous system.
The training period is currently six years, whereby five years should generally be spent on inpatient care and six months on the intensive medical care of neurosurgical patients. A half or full year can currently be recognized, for example, as part of specialist training in related surgical disciplines such as trauma surgery, orthopaedics, general surgery or a conservative discipline such as neurology. In addition, as mentioned above, many specialists in spinal disorders also hold the specialist title of orthopaedist and trauma surgeon.
It is not possible to designate a clinic or spine center as the "best clinic" or "top clinic" for spine surgery. There are indeed spinal surgeons who have specialized in certain procedures and have a great deal of experience. You can find these spinal surgery experts in the Leading Medicine Guide.
Leading Medicine Guide only presents highly qualified specialists from Germany, Austria and Switzerland. Each specialist must meet the strict LMG quality guidelines. In addition, all listed spine surgeons have a high level of professional expertise and excellent experience in the field of spine surgery.
