Key Points Pressure on a nerve in the neck may variously cause pain the in the region of the shoulder blade, shoulder, upper chest and the associated arm or upper forearm. The pain often gets better within days or weeks without treatment but sometimes persists for months and sometimes never gets better without surgical treatment. In the lower spine the surgical incision is usually on the back but in the neck the surgical approach is usually through an incision on the front of the neck. In the neck the spine is closer to the front of the neck than the back of the neck. The approach through the front of the neck is easier, quicker and safer and the recovery shorter. Surgery is performed using optical magnification. It involves removal of the disc (the soft part between the vertebrae) and, working through the disc space, removal of any separated disc fragment or bone spurs to relieve pressure on the nerve. It is necessary to place a spacer (cage) into the gap and this is usually secured with a metal plate on the front of the spine. Nearly every patient has discomfort swallowing for a few days or a week or two. Occasionally this persists for longer. Surgery is very safe. The risk of an injury to a spinal nerve or the spinal cord is much less than 1% and should be almost 0%. Frequently Asked Questions I am still experiencing some pain in my shoulder or arm or numbness after my operation. Should I worry about this? No, providing the pain is less than it was prior to the surgery. Surgery relieves the pressure on the nerve but in some patients the nerve has a “memory” for the pain and remains slightly irritable. This usually resolves within a matter of weeks. The numbness usually resolves over weeks or months as the nerve recovers. Will fusion of the vertebrae make my neck permanently stiff? In the vast majority of patients, following a one or two level fusion there is no detectable stiffness in the neck once recovery is complete. What do I do with the dressing? The stitches are under the skin and will dissolve. The dressing is waterproof and you can shower in it. One week after leaving hospital simply peel it off as if it were a big “band aid”. Under the dressing you will find steri strips (tapes) holding the skin edges together. These may come off with the dressing but otherwise remove them one week later if they have not fallen off. General Information Pressure on a nerve in the neck may variously cause pain the in the region of the shoulder blade, shoulder, upper chest and the associated arm or upper forearm. Some patients experience numbness or tingling in one or more of the fingers and/or weakness in the arm or hand. Most commonly this occurs because as the discs and joints in the neck age bone spurs develop around the margin of the discs and narrow the space for the exiting nerve. Less commonly a piece of disc separates (disc protrusion or disc herniation) causing pressure on the nerve. The pain of a nerve compression in the neck can be very severe and unresponsive to painkillers and anti-inflammatory medication, even strong painkillers such as Morphine. The pain often gets better within days or weeks without treatment but sometimes persists for months and sometimes never gets better without surgical treatment. In the lower spine the surgical incision is usually on the back but in the neck the surgical approach is usually through an incision on the front of the neck. In the neck the spine is closer to the front of the neck than the back of the neck. The approach through the front of the neck is easier, quicker and safer and the recovery shorter. Surgical Procedure Surgery is performed under general anaesthetic and usually takes about two hours. The incision is on the front of the neck and usually heals to a fine line which is difficult to see. Surgery is performed using optical magnification. It involves removal of the disc (the soft part between the vertebrae) and working through the disc space removal of any separated disc fragment or bone spurs to relieve pressure on the nerve. It is necessary to place a spacer (cage) into the gap and this is usually secured with a metal plate on the front of the spine. The cage is filled either with a small amount of bone taken from the hip or alternatively a bone graft substitute such as a Tricalcium Phosphate product to fuse the vertebrae together.   Post Operative Course The day after surgery the drainage tube is removed from the neck, the urinary catheter is removed and patients commence walking. Nearly all patients go home on the second day after surgery. Most patients notice that the pain in the shoulder and arm goes immediately. In some patients the pain gradually resolves over days or weeks. Nearly every patient has discomfort swallowing for a few days or a week or two. Occasionally this persists for longer. Most patients have remarkably little pain in the neck but some residual discomfort and stiffness for several weeks up to three or four months. The surgery removes the pressure upon the nerve and quickly relieves the pain but numbness or weakness may take weeks or months to resolve and do not always resolve completely. Because the vertebrae are held with a plate it is not necessary to wear a cervical collar after the surgery but a minority of patients feel more comfortable in a collar. You will leave hospital with a waterproof dressing which should be removed one week later. Simply peel off this dressing as if it were a big “band aid” – the stitches under the skin resolve. No suture removal is necessary. Under the dressing you will find steri strips (tapes) holding the skin edges together. These may come off with the dressing but otherwise remove them one week later if they have not fallen off. Return to work is variable and may occur in as little as one to two weeks for sedentary works but make take up to two to three months for heavy manual workers. Driving is normally resumed as soon as it feels safe and comfortable. Complications Most patients have discomfort swallowing for a few days or a week or two. In the occasional patient this persists longer. A small proportion of patients notice an alteration in the quality of the voice which nearly always resolves completely within several weeks. Surgery is very safe. The risk of an injury to a spinal nerve or the spinal cord is much less than 1% and should be almost 0%. Infection almost never occurs with surgery on the front of the spine. The risk of the bones not fusing together (pseudarthrosis) requiring further surgery is approximately 1% to 2%. The risk of further surgery being required over the next ten years because of development of similar problems at an adjacent disc is approximately 5%. A few patients have persisting discomfort and stiffness in the neck but this usually gets better with time and physiotherapy treatment. Bone grafts are avoided if possible. Some patients find the bone graft donor site quite painful and very occasionally taking a bone graft causes numbness on the outer aspect of the thigh due to bruising of a nerve to the skin.

Key Points Pressure on the spinal cord in the neck may cause pain in the arms, numbness or weakness in the arms or hands and numbness, weakness or unsteadiness in the legs. This is a very serious condition and requires early surgical treatment so the weakness does not become permanent. Surgery usually stops the condition worsening and if performed early some patients experience excellent recovery of numbness, weakness or unsteadiness. Surgery is performed through a vertical incision on the back of the neck. No fusion is performed. Recovery of spinal cord function usually occurs progressively over weeks or months and can go on occurring for a year or more. Most patients inevitably worsen without surgical treatment. Up to 5% of patients may be temporarily weaker following surgery and perhaps 1% of patients permanently worse following surgery. Frequently Asked Questions The weakness and numbness in my arms and legs is not recovering as quickly as I would like. Should I worry about this? It is always good if recovery commences within days or a week or two of surgery. Don’t be too worried if there is no improvement within this time as there is the potential for the spinal cord to recover for up to a year or longer following surgery. What do I do with the dressing? The stitches are under the skin and will dissolve. The dressing is waterproof and you can shower in it. One week after leaving hospital simply peel it off as if it were a big “band aid”. Under the dressing you will find steri strips (tapes) holding the skin edges together. These may come off with the dressing but otherwise remove them one week later if they have not fallen off. Will I need physiotherapy treatment? Most patients will benefit from physiotherapy treatment to help regain strength in the arms and the legs and in the neck muscles once the cervical collar is no longer required. General Information Pressure on the spinal cord in the neck may cause pain in the arms, numbness or weakness in the arms or hands and numbness, weakness or unsteadiness in the legs. Pressure on the spinal cord in the neck occurs in a small proportion of people as the spine ages and the spinal canal narrows due to a build up of bone around the discs or the joints in the neck. This is a very serious condition and requires early surgical treatment so the weakness does not become permanent. Surgery usually stops the condition worsening and if performed early some patients experience excellent recovery of numbness, weakness or unsteadiness. Surgical Procedure Surgery is performed under general anaesthesia with the head secured in a clamp. It is performed through a vertical incision on the back of the neck. The bone on the back of the spine (lamina) is thinned on one side and divided on the opposite side then hinged away from the spinal cord to increase the cross sectional area of the spinal canal. The bone is held away from the spinal cord by tiny metal plates and screws. No fusion is performed. Post Operative Course The day after the surgery the drain is removed from the neck, the urinary catheter is removed and patients commence standing and walking. Patients go home after several days when they can get in and out of bed, up and down stairs and their pain is under control with oral medication. A soft cervical collar is worn for four to six weeks. Recovery of spinal cord function usually occurs progressively over weeks or months and can go on occurring for a year or more. Recovery of function is incomplete if the spinal cord is permanently damaged prior to surgery. Most patients will not feel safe driving for at least six weeks following surgery. Complications Most patients inevitably worsen without surgical treatment. Up to 5% of patients may be temporarily weaker following surgery and perhaps 1% of patients permanently worse following surgery. Occasionally weakness of the shoulder muscle develops post operatively (C5 nerve palsy). This can be severe and does not always recover completely. Stiffness and weakness in the neck usually resolves progressively over months or up to a year. Infection occurs in 1% to 2% of patients.

Key Points A disc protrusion (disc herniation) occurs when a piece of the intervertebral disc (the soft part between the vertebrae) separates or partially separates and compresses a nerve in the lower spine. Disc protrusion with pressure on a nerve causes sciatica which is pain down the leg in the line of the sciatic nerve and may also cause weakness or numbness. Sciatica often gets better within days or weeks without treatment but sometimes persists for months and sometimes never gets better without surgical treatment. Surgery is performed under general anaesthetic and usually takes 30 to 60 minutes. Surgery involves extraction of the disc fragment from under the nerve root through a 3cm to 4cm incision (longer in large patients). Some patients go home the day after surgery, some on the second day. Return to work is variable and may occur in as little as one to two weeks for sedentary workers who can get up and walk periodically or may take up to two to three months for heavy manual workers. Complications or post operative problems are rare with the exception of recurrent disc protrusion which occurs in 2% to 3% of patients in the first year after surgery and 10% at ten years from surgery. Frequently Asked Questions I am still experiencing some sciatica or numbness after my operation. Should I worry about this? Only a minority of patients experience complete relief of sciatica from the time of the surgery. Most patients notice that it is much improved but there is still some aching in the leg because the nerve has a “memory” for the pain and remains slightly irritable. This usually resolves within a matter of weeks. The numbness usually resolves over weeks or months as the nerve recovers. If the pain is no better than it was prior to the surgery or is getting worse and worse, please contact the office in case a further MR scan is required to be sure a recurrent disc protrusion has not occurred. What do I do with the dressing? This stitches are under the skin and will dissolve. The dressing is waterproof and you can shower in it. One week after leaving hospital simply peel it off as if it were a big “band aid”. Under the dressing you will find steri strips (tapes) holding the skin edges together. These may come off with the dressing but otherwise remove them one week later if they have not fallen off. Will I need physiotherapy treatment? Most patients undergoing a discectomy operation do not have physiotherapy treatment, they simply increase their walking progressively and ease back into normal activity as their symptoms subside over a period of weeks. Some patients, however, prefer to work with a physiotherapist and you should feel free to arrange physiotherapy if that is your preference. General Information A disc protrusion (disc herniation) occurs when a piece of the intervertebral disc (the soft part between the vertebrae) separates or partially separates and compresses a nerve in the lower spine. A protrusion only occurs at a disc which is beginning to age of wear (degenerate). Disc protrusion occurs at any age from 12 years upwards and is most common in the fourth decade of life (30s). Disc protrusion with pressure on a nerve causes sciatica which is pain down the leg in the line of the sciatic nerve and may also cause weakness or numbness. Sciatica can be very severe and unresponsive to pain killers and anti-inflammatory medication, even strong pain killers such as Morphine. Sciatica often gets better within days or weeks without treatment but sometimes persists for months and sometimes never gets better without surgical treatment. Improvement in sciatica occurs if the disc fragment dissolves away, gradually shrinks back into the disc or if the nerve stretches over the disc fragment. Disc protrusion causing sciatica may be treated by surgical removal of the disc fragment if it is not resolving naturally. Micro discectomy operation should be undertaken as an emergency if there is an alteration in bladder or bowel control and semi urgently if there is major muscle weakness. Surgical Procedure Surgery is performed under general anaesthetic and usually takes 30 to 60 minutes. It is performed used optical magnification (microsurgery). Surgery involves extraction of the disc fragment from under the nerve root through a 3cm to 4cm incision (longer in large patients). Any other loose or unstable disc fragments are also removed. In a small proportion of patients the disc fragment compresses the nerve as it exits the spine rather than in the spinal canal (extra foraminal disc protrusion). In these patients a larger incision is required and the surgery takes a little longer. The image intensifier (mobile X-ray machine) is used to confirm the correct level. Post Operative Course Patients stand out of bed and walk to the toilet on the day of surgery. Some patients go home the day after surgery, some on the second day. Most patients notice an immediate reduction in the nerve pain down the leg. In some patients all the nerve pain goes immediately but in most patients it is greatly reduced and tails off over three to six weeks. Some patients are more aware of residual pain in the leg after they leave hospital when the effects of the anaesthetic and pain relieving drugs are wearing off. If the pain in the leg becomes severe please contact the office in case a repeat MR scan is required. There is discomfort and stiffness at the site of the incision for several weeks, particularly when seated, tailing off over a month or two. The surgery removes the pressure from the nerve and quite quickly relieves the pain in the leg but numbness or weakness may take weeks or months to resolve and do not always recover completely. Walking is the only exercise that is necessary when recovering from micro discectomy. Walking is increased progressively, with the aim of walking 1km to 2km outside within two weeks of surgery. Some patients also like to have physiotherapy treatment but this is not necessary for most patients. Sitting or standing in one position can be uncomfortable for several weeks – simply move about or change position. You will leave hospital with a waterproof dressing which should be removed one week later. Simply peel off this dressing as if it was a big “band aid”. The stitches under the skin dissolve. No suture removal is necessary. Return to work is variable and may occur in as little as one to two weeks for sedentary workers who can get up and walk periodically or may take up to two to three months for heavy manual workers. Driving is normally resumed within one to two weeks when it feels safe and comfortable. Complications Complications or post operative problems are rare with the exception of recurrent disc protrusion which occurs in 2% to 3% of patients in the first year after surgery and 10% at ten years from surgery. Patients who experience a recurrent disc protrusion are not necessarily those who do too much too soon but rather patients whose remaining disc is unstable. Micro discectomy is undertaken to relieve nerve pain but cannot prevent a further disc fragment from separating (occasionally this occurs within days or weeks of surgery). A small number of patients experience recurrent or persistent backache due to damage to the remaining disc which occurs when the disc fragment, usually a large fragment, separates from the disc causing sciatica. A very small proportion of these patients have a fusion operation later to address this problem. Other complications include nerve injury, deep infection or spinal fluid leak requiring further surgery but these almost never occur. In over 2000 micro discectomy operations one of my patients had a nerve injury which recovered completely, there were two deep infections requiring prolonged antibiotics or surgical treatment and no spinal fluid leaks requiring further surgery.

Key Points Normal ageing of the spine leads quite commonly to a narrowing of the spinal canal. As the spinal canal continues to narrow, a point may be reached where nerve pain develops in the lower extremities, sometimes precipitated by injury. Early symptoms may subside with time but more often tend to recur, persist or worsen with progression of spinal canal narrowing. Spinal stenosis, when it causes symptoms, may cause constant sciatica or sciatica which occurs with standing and walking and is relieved only by resting or sitting down. In most cases it is necessary to remove the joints at the back of the spine and the spine is then stabilised by insertion of two screws into each vertebrae (pedicle screws) joined by rods. Patients usually rest in bed the day after surgery and stand to take a few assisted steps on the second day after surgery. Surgery for spinal stenosis is performed to address an existing problem in an ageing spine. Surgery has an 85% to 90% success rate but does not stop the spine ageing and, depending upon the age of the patient, up to 5% - 10% of patients may require further surgery in the future as other segments of the spine continue to age. Frequently Asked Questions I am still experiencing some sciatica or numbness after my operation should I worry about this? Only a minority of patients experience complete relief of sciatica from the time of the surgery. Most patients notice that it is much improved but there is still some aching in the leg because the nerve has a “memory” for the pain and remains slightly irritable. This usually resolves within a matter of weeks. What do I do with the dressing? The stitches are under the skin and will dissolve. The dressing is waterproof and you can shower in it. One week after leaving hospital simply peel it off as if it were a big band aid. Under the dressing you will find steri strips (tapes) holding the skin edges together. These may come off with the dressing but otherwise remove them one week later if they have not fallen off. Will I need physiotherapy treatment? Most patients undergoing a decompression operation do not have physiotherapy treatment; they simply increase their walking progressively and ease back into normal activity as their symptoms subside over a period of weeks or months. Some patients however, prefer to work with a physiotherapist and you should feel free to arrange physiotherapy if that is your preference. When can I resume activities such as lifting? The spine is held together by very strong screws and rods and cannot be damaged by activity, even lifting. Heavy lifting should obviously not be undertaken until your back feels strong enough. The patients who make the best recovery simply listen to their body and exercise common sense. As the weeks pass activity is increased progressively but not to the point where it causes excessive pain which can slow your progress. Full recovery takes at least three to four months and sometimes six months or more. General Information Normal ageing of the spine leads quite commonly to a narrowing of the spinal canal. The spinal canal narrows as a result of changes in multiple tissues but particularly degenerative arthritis involving the joints at the back of the spine (facet joints) resulting in enlargement of the joints and encroachment into the spinal canal. In some patients degenerative arthritis of the facet joints results in a loss of their restraining function and a slippage of the spine (degenerative spondylolisthesis). Narrowing of the spinal canal with ageing does not usually cause symptoms in the early stages because of spare capacity in the spinal canal and because the spinal nerves can, up to a point, tolerate a smaller space. As the spinal canal continues to narrow, a point may be reached where nerve pain develops in the lower extremities, sometimes precipitated by injury. Early symptoms may subside with time but more often tend to recur, persist or worsen with progression of spinal canal narrowing. Spinal stenosis, when it causes symptoms, may cause constant sciatica or sciatica which occurs with standing and walking and is relieved only by resting or sitting down. In severe cases patients can walk only short distances and are disabled to the same degree as patients requiring joint replacement surgery because of hip or knee arthritis. Patients often adopt a stooped posture in an attempt to open up the spinal canal and create additional space for the spinal nerves. Surgical Procedure Surgery is performed under general anaesthetic. Optical magnification (microsurgery) is used to remove bone and tissue and to create space for the nerves. The operative time varies from one to four hours, depending upon the number of levels requiring decompression and whether or not instrumentation (stabilisation of the spine with screws and rods) is required. In most cases it is necessary to remove the joints at the back of the spine and the spine is then stabilised by insertion of two screws into each vertebrae (pedicles screws) joined by rods. Pedicle screw stabilisation of the spine is a very safe and routine procedure which has been performed for over twenty years and is performed most weeks by committed spine surgeons. It is always accompanied by a fusion (joining the vertebrae bone to bone). In spinal stenosis the bone removed from the spine to create space for the nerves is used to perform the fusion, often supplemented by a Tri calcium Phosphate or collagen product. Bone grafts from the pelvis (hip) are avoided. Post Operative Course Patients usually rest in bed the day after surgery and stand to take a few assisted steps on the second day after surgery. On day three patients are usually walking to the toilet and the urinary catheter is removed. Patients usually go home on day four or five when their pain is under control with oral tablets, when they are able to get in and out of bed and up and down stairs. Walking is the only exercise that is necessary when recovering from surgery for decompression of lumbar spinal stenosis. Walking is increased progressively with the aim of walking 1km to 2km outside within two weeks of surgery. Some patients might also have physiotherapy treatment but this is not necessary for most patients. Sitting or standing in one position can be uncomfortable for several weeks – simply move about or change position. Most patients notice almost immediately that there is a marked improvement in the nerve pain in the lower extremities, but in some patients there is some residual pain which slowly resolves over a month or two. Obviously there is lower back pain and stiffness created by the surgery which resolves over weeks, tailing off over several months. You will leave hospital with a waterproof dressing which should be removed one week later. Simply peel off this dressing as if it was a big "band aid”. The stitches under the skin dissolve. No suture removal is necessary. Driving is normally resumed within three to six weeks when it feels safe and comfortable. Surgery for spinal stenosis is performed to address an existing problem in an ageing spine. Surgery has an 85% to 90% success rate but does not stop the spine ageing and, depending upon the age of the patient, up to 5% - 10% of patients may require further surgery in the future as other segments of the spine continue to age. Complications Infection or nerve injury can occur during surgery for spinal stenosis but are extremely uncommon in my Practice. A dural tear can occur because in spinal stenosis the dura (the membrane containing the spinal nerves and spinal fluid) can be very thin and adherent to the walls of the spinal canal. Dural tears occur occasionally and when they occur need to be repaired watertight with fine stitches. If this repair does not hold a headache or leakage of fluid out of the incision can occur and this may require further surgery. In my practice a second operation to repair a dural tear occurs approximately once every five years. Note that I perform three to four hundred spinal operations per year. The screws which stabilise the spine (pedicle screws) are occasionally misplaced with the result that the screw contacts a nerve and causes sciatica pain. Approximately once every five years in my practice a second operation is required to remove a pedicle screw. Patients are often elderly with co-existing medical problems such as heart problems which could present anaesthetic risks or lead to post operative complications.

Key Points Surgery is recommended only for selected patients with persistent or recurrent pain causing significant interference with quality of life and after a period of non-operative (physical therapy, pain management) treatment. Surgery for low back pain is a reasonably major undertaking. The recovery period can be prolonged – recovery is usually 90% complete at three to four months but some patients continue improving for six to twelve months. Surgery for low back pain is generally considered to give good or excellent results in 70% to 80% of carefully selected patients. A spine fusion is performed at one or two levels if the painful level can be determined with confidence and the remainder of the lumbar spine is relatively free of degenerative change and can take over the function. Patients who undergo a one or two level fusion do not generally notice any stiffness or loss of movement and their lumbar spine may in fact feel more mobile because of a reduction in pain. There are many techniques for obtaining a lumbar fusion but broadly, fusion can be achieved through a Posterior Approach (the incision is on the lower back) or an Anterior Approach (the incision is on the abdomen). Sometimes one approach is preferable over another depending upon the MR findings and the age, sex and build of the patient. Some patients improve slowly, others quickly, but improvement is progressive. Most patients have returned to sedentary work at 4 to 6 weeks, light manual work at 2 to 3 months and heavy manual work at 4 months.   Frequently Asked Questions Will the surgery stiffen my back? Patients who undergo a one or two level fusion do not generally notice any stiffness or loss of movement and their lumbar spine may in fact feel more mobile because of a reduction in pain. Will the fusion put more stress on other parts of my spine leading to further problems? Theoretically this can occur. However, the vast majority of degenerate discs and joints were not caused by surgery. Surgery is recommended for selected patients where the damage is over a limited segment of the spine and the remainder of the spine is healthy. The aim of the surgery is to improve pain and function over a period of 10 to 20 years while the patient wishes to be active but ultimately the remainder of the spine continues to age and can be a source of symptoms in the future. However, it is uncommon to need a further fusion because of adjacent segment damage. What do I do with the dressing? The stitches are under the skin and will dissolve. The dressing is waterproof and you can shower in it. One week after leaving hospital simply peel it off as if it were a big “band aid”. Under the dressing you will find steri strips (tapes) holding the skin edges together. These may come off with the dressing but otherwise remove them one week later if they have not fallen off. You will notice a swelling on the left side of the incision. What is the cause of this? Quite commonly swelling develops on the left side of the incision on the back because this is where the bone graft is taken from and fluid accumulates between the incision and the back of the pelvis. This nearly always goes away within three or four weeks. This is a fairly common occurrence, is much more obvious in thin patients and does not mean there is an infection. Will I need physiotherapy treatment? Walking is the only exercise which is necessary in the first six weeks following lumbar fusion surgery. Walking is increased progressively with the aim of walking 1km to 2km outside within two weeks of surgery. Patients may swim if desired after two weeks. After six weeks most patients will benefit from an exercise programme, often gym based, supervised by a physiotherapist. When can I resume activities such as lifting? The spine is held together by very strong screws and rods and cannot be damaged by activity, even lifting. Heavy lifting should obviously not be undertaken until your back feels strong enough. The patients who make the best recovery simply listen to their body and exercise common sense. As the weeks pass, activity is increased progressively but not to the point where it causes excessive pain which can slow your progress. Full recovery takes at least three to four months and sometimes six to twelve months. General Information The most common cause of low back pain is degeneration (“wear and tear”) associated with normal ageing and injuries to the spine.Low back pain is common and requires surgical treatment in only a small minority of patients (see spine surgery for treatment of neck or back problems). Surgery is recommended only for selected patients with persistent or recurrent pain causing significant interference with quality of life and after a period of non-operative (physical therapy, pain management) treatment. Surgery for low back pain is a reasonably major undertaking. The recovery period can be prolonged – recovery is usually 90% complete at three to four months but some patients continue improving for six to twelve months. It is generally considered to give good or excellent results in 70% to 80% of carefully selected patients. Patient selection is all important – consistently good results are only obtained when the correct operation is performed on the correct patient for the correct reason. For the vast majority of patients the recommended surgical procedure is a lumbar fusion (joining the lumbar vertebrae together “bone to bone”). In a very small minority of patients with disc pathology only and normal facet joints (the joints at the back of the spine), disc replacement is an option. Disc replacement has the theoretical advantage of maintaining some motion in the disc and better protecting the adjacent discs. A spine fusion is performed at one or two levels if the painful level can be determined with confidence and the remainder of the lumbar spine is relatively free of degenerative change and can take over the function. Patients who undergo a one or two level fusion do not generally notice any stiffness or loss of movement and their lumbar spine may in fact feel more mobile because of a reduction in pain. A good or excellent result does not mean the patient will never experience some lower back pain but rather there will be very useful or marked improvement in the pain with improved quality of life and function. A good or excellent result implies that 1 to 2 years later the patient considers the procedure was very worthwhile and would undergo it again under similar circumstances. This should occur in 70% to 80% of carefully selected patients. With modern techniques fusion can be achieved reliably in 95% of patients (less in smokers) but achievement of fusion does not always translate to a good or excellent result. There are many techniques for obtaining a lumbar fusion but broadly, fusion can be achieved through a Posterior Approach (the incision is on the lower back) or an Anterior Approach (the incision is on the abdomen). Sometimes one approach is preferable over another depending upon the MR findings and the age, sex and build of the patient. Posterior Approach Surgery is performed under general anaesthetic and using optical magnification (microsurgery). The operative time varies between 2 and 4 hours. Surgery always involves insertion of 2 screws into each vertebrae (pedicles screws) joined by rods and the laying of bone graft (taken from the pelvis through the same incision) up and down each side of the spine. Surgery often also involves removal of the inter vertebral disc and insertion of a spacer (cage) containing bone graft into the disc space. Sometimes additional products (e.g. BMP) are used to assist fusion. Anterior Approach Surgery is performed under general anaesthetic with an incision on the lower abdomen. It is necessary to mobilise the large vessels (aorta, vena cava, common iliac arteries and veins) on the front of the spine to access the inter vertebral disc. If difficulties are anticipated a vascular surgeon may help with the procedure. A spacer (cage) is inserted into the disc space. Usually the cage is filled with a bone graft substitute to assist fusion – bone grafts are avoided if possible. Post Operative Course Patients usually rest in bed the day after surgery then stand to take a few assisted steps on the second day after surgery. On day 3 patients are usually walking to the toilet and the urinary catheter is removed. Patients usually go home on day 4 or 5 when their pain is under control with oral tablets, when they are able to get in and out of bed and up and down stairs. Walking is the only exercise which is necessary in the first six weeks following lumbar fusion surgery. Walking is increased progressively with the aim of walking 1km to 2km outside within two weeks of surgery. Patients may swim if desired after 2 weeks. After 6 weeks most patients will benefit from an exercise programme, often gym based, supervised by a physiotherapist. Sitting or standing in one position can be uncomfortable for several weeks – simply move about or change position. Some patients improve slowly, others quickly, but improvement is progressive. Most patients have returned to sedentary work at 4 to 6 weeks, light manual work at 2 to 3 months and heavy manual work at 4 months. It is difficult to damage the fusion but excessive activity undertaken too early can result in pain and slower progress. The patients who make the best recovery gradually increase their level of activity as the days and weeks pass. You will leave hospital with a waterproof dressing which should be removed one week later. Simply peel off this dressing as if it was a big “band aid”. The stitches under the skin dissolve. No suture removal is necessary. Driving is normally resumed within 3 to 6 weeks when it feels safe and comfortable. Complications As with any spine surgery, infection, nerve injury or spinal fluid leak requiring further surgery occur in less than 1% of patients (and closer to 0% in my Practice). Failure of the spine to fuse occurs in up to 5% of patients and in some of these further surgery may be required. Incomplete pain relief is the most important “complication” to be discussed prior to lumbar fusion surgery. With further ageing or injury to the spine painful degeneration can occur at adjacent levels and sometimes further surgery is required in the future. Complications Related to the Anterior Approach Injury to the vessels on the front of the spine can result in significant bleeding and if difficulties are anticipated a vascular surgeon will assist with the procedure. In males there is the theoretical risk of interference with sexual function.

Key Points An isthmic spondylolisthesis is present in approximately 1 in 20 people. Only a minority of patients with spondylolisthesis ever require surgical treatment. During childhood or adolescence surgery may be required because of progression of the spondylolisthesis. During adulthood surgery is most often required because of the onset of sciatica (nerve pain in the lower extremities) due to narrowing of the exit zone for one of the spinal nerves. Usually this occurs in the 30s or 40s. Surgery involves the removal of bone from the back of the spine to create space for the spinal nerves and stabilisation of the two vertebrae by means of two pedicle screws in each vertebra joined by rods. A fusion is performed taking bone from the back of the pelvis through the same incision and laying it up and down each side of the spine. In most patients the inter vertebral disc is also excised and a spacer (cage) filled with bone graft inserted into the space between the vertebrae to assist fusion and creation of space for the exiting spinal nerves. Patients usually rest in bed the day after surgery and stand to take a few assisted steps on the second day after surgery. Frequently Asked Questions I am still experiencing some sciatica and numbness after my operation. Should I worry about this? Only a minority of patients experience complete relief of sciatica from the time of the surgery. Most patients notice that it is much improved but there is still some aching in the leg because the nerve has a “memory” for the pain and remains slightly irritable. This usually resolves within a matter of weeks. The numbness usually resolves over weeks or months as the nerve recovers. What do I do with the dressing? The stitches are under the skin and will dissolve. The dressing is waterproof and you can shower in it. One week after leaving hospital simply peel it off as if it were a big “band aid”. Under the dressing you will find steri strips (tapes) holding the skin edges together. These may come off with the dressing but otherwise remove them one week later if they have not fallen off. I have noticed a swelling on the left side of the incision. What is the cause of this? Quite commonly swelling develops on the left side of the incision because this is where the bone graft is taken from and fluid accumulates between the incision and the back of the pelvis. This nearly always goes away within three or four weeks. This is a fairly common occurrence, is much more obvious in thin patients and does not mean there is an infection. Will I need physiotherapy treatment? Most patients who undergo surgery for isthmic spondylolisthesis do not have physiotherapy treatment; they simply increase their walking progressively and ease back into normal activity as their symptoms subside over a period of weeks or months. Some patients however, prefer to work with a physiotherapist and you should feel free to arrange physiotherapy if that is your preference. When can I resume activities such as lifting? The spine is held together by very strong screws and rods and cannot be damaged by activity, even lifting. Heavy lifting should obviously not be undertaken until your back feels strong enough. The patients who make the best recovery simply listen to their body and exercise common sense. As the weeks pass, activity is increased progressively but not to the point where it causes excessive pain which can slow your progress. Full recovery takes at least three to four months and sometimes six months or more. General Information An isthmic spondylolisthesis is present in approximately 1 in 20 people. It occurs because of the development of a bone defect at the back of the spine (the Pars) because of a stress failure of the bone in susceptible individuals. A Pars defect is never present at birth but develops during childhood once walking commences, or during adolescence. Most patients with an isthmic spondylolisthesis have no symptoms and do not realise they have the condition. In a very small proportion of patients the spondylolisthesis can worsen during growth and development and rarely results in a complete slippage of the spine. Further slippage of the spine (progression of spondylolisthesis) only occurs to a minimal degree after the completion of growth, as the spine ages or degenerates. Only a minority of patients with spondylolisthesis ever require surgical treatment. During childhood or adolescence surgery may be required because of progression of the spondylolisthesis. During adulthood, surgery is most often required because of the onset of sciatica (nerve pain in the lower extremities) due to narrowing of the exit zone for one of the spinal nerves. Usually this occurs in the 30s or 40s. Isthmic spondylolisthesis is very rarely caused by an injury but an injury may result in a nerve compression and the onset of symptoms. Once nerve symptoms are established surgery is usually required. Surgical Procedure Surgery is performed under general anaesthetic and usually takes approximately three hours. Surgery is performed using optical magnification (microsurgery) and involves the removal of bone from the back of the spine to create space for the spinal nerves and stabilisation of the two vertebrae by means of two pedicle screws in each vertebra joined by rods. A fusion is performed taking bone from the back of the pelvis through the same incision and laying it up and down each side of the spine. In most patients the inter vertebral disc is also excised and a spacer (cage) filled with bone graft inserted into the space between the vertebrae to assist fusion and creation of space for the exiting spinal nerves. Post Operative Course Patients usually rest in bed the day after surgery and stand to take a few assisted steps on the second day after surgery. On day three patients are usually walking to the toilet and the urinary catheter is removed. Patients usually go home on day four or five when their pain is under control with oral tablets, when they are able to get in and out of bed and up and down stairs. Walking is the only exercise that is necessary when recovering from surgery for isthmic spondylolisthesis. Walking is increased progressively with the aim of walking 1km to 2km outside within two weeks of surgery. Some patients might also have physiotherapy treatment but this is not necessary for most patients. Sitting or standing in one position can be uncomfortable for several weeks – simply move about or change position. Most patients notice almost immediately there is a marked improvement in the nerve pain in the lower extremities but in some patients there is some residual pain which slowly resolves over a month or two. Obviously there is lower back pain and stiffness created by the surgery which resolves over weeks, tailing off over several months. Complete recovery may take 6 months or longer. You will leave hospital with a waterproof dressing which should be removed one week later. Simply peel off this dressing as if it was a “band aid”. The stitches under the skin resolve. No suture removal is necessary. Driving is normally resumed within three to six weeks when it feels safe and comfortable. Complications A small proportion of patients develop a swelling to the left of the incision related to the bone graft. This nearly always resolves within three to four weeks. Infection, nerve injury, spinal fluid leak requiring further surgery, or misplacement of pedicle screws requiring further surgery or failure of fusion requiring surgery are possible complications but occur in much less than 1% of patients and closer to 0% than 1%.

Key Points The exact cause of idiopathic scoliosis is unknown but probably has a genetic basis in most patients. Surgery is generally recommended when a curve is going to progress beyond 40° to 45°. Surgery nearly always involves insertion of implants (screws and rods) onto the spine and fusion (joining one vertebra to the next, bone-to-bone). The incision is over the length of the curve and generally heals to a fine line but sometimes spreads slightly at the base of the neck or the bottom of the spine. On average, patients spend five nights in hospital after surgery and leave hospital when their pain is under control with tablets, when they are able to get in and out of bed and up and down stairs. Patients usually return to school at about four weeks, on half-days for the first two weeks. Considering the extent of the surgery, complications are very rare. Injury to a spinal nerve or the spinal cord occurs in less than 3 patients out of 1000. Frequently Asked Questions Will the rods stop the spine growing? This spine will not grow significantly over the length of the rods. However, after the age of 10 years 80% of spinal growth is complete and at that the usual time of surgery for adolescent idiopathic scoliosis there is generally only a few millimetres of spinal growth left. This growth simply deforms the spine and shortens it rather than adding to height. The unfused part of the spine and the lower extremities keep growing. Therefore, patients generally end up taller with surgery than without surgery. Do the rods need to be removed? It is extremely unusual for the rods or a portion of the rods to require removal. This would only occur if there is an infection or if the rods are prominent under the skin and with current techniques that virtually never occurs. Will other surgery be required later? The surgery aims to straighten the spine and protect the unfused parts of the spine above and below the rods. It is very unusual for further surgery to be required. Straightening the major curve at a younger age can at times prevent the need for a longer fusion when the patient is older. Posterior Correction & Fusion for Scoliosis General Information Scoliosis is a lateral (sideways) curvature of the spine. There are multiple causes for scoliosis. The three major categories are:- A) Neuromuscular (a condition of nerve or muscle such as poliomyelitis) B) Congenital (the vertebrae are abnormally formed at birth e.g. half a vertebra or vertebrae fused together) C) Idiopathic scoliosis (affects otherwise normal children or teenagers, most commonly females). Most often patients with neuromuscular scoliosis are in a wheelchair. Congenital scoliosis is apparent on the X-ray because of abnormal vertebrae. The exact cause of idiopathic scoliosis is unknown but probably has a genetic basis in most patients. Idiopathic scoliosis tends to progress (worsen) during growth. It may progress after the end of growth if moderate (greater than 45°) or severe. Exercise has not been shown conclusively slow the progression of scoliosis. In selected cases a brace may slow the progression of scoliosis but does not correct it. Approximately one third of patients with scoliosis have significant pain, although not usually severe. This is usually, although not always, helped by surgery. The primary aim of the surgery is to correct the curve and stop it progressing. Surgery is generally recommended when a curve is going to progress beyond 40° to 45°. Surgery nearly always involves insertion of implants (screws and rods) into the spine and fusion (joining one vertebra to the next, bone-to-bone). The most common surgical procedure involves making an incision over the back of the spine (posterior approach). Surgical Procedure Surgery usually takes 4 to 6 hours. The incision is over the length of the curve and generally heals to a fine line but sometimes spreads slightly at the base of the neck or the bottom of the spine. Surgery usually corrects the curvature by about two thirds and the rib prominence by about two thirds. Occasionally segments of rib are removed to further correct a severe rib prominence. These grow back later. Surgery involves inserting screws into the vertebrae (or sometimes attaching hooks) and joining the screws to two rods shaped to the normal contour of the spine to straighten the curve. Bone is removed from the spine and sometimes the back of the pelvis (hip) and laid in the joints on the back of the spine and over the back of the spine to create a fusion. Sometimes bone graft substitutes are used in addition to bone from the spine to assist fusion. In large, rigid curves there is a small risk the spinal cord may be stretched and spinal cord monitoring or a wake-up test are performed to ensure this has not occurred. The wake-up test is performed towards the end of the procedure once the spine has been straightened. The anaesthetic is lightened while the pain killing drugs are working and the patient is asked to move the toes and feet then the anaesthetic is deepened again. This is a safe, routine procedure and patients have no recollection of it later. Post Operative Treatment Patients rest in bed the day after the surgery. For the first two to three days pain relief is from a self-regulated Morphine pump following by oral analgesics (painkillers). On the second day after surgery the surgical drain is removed and the patient stands out of bed. On the third day after surgery patients are usually walking to the toilet with assistance and the urinary catheter is removed on the third or fourth day. On average, patients spend five nights in hospital after surgery and leave hospital when their pain is under control with tablets, when they are able to get in and out of bed and up and down stairs. There is no particular need to rest after surgery but obviously patients will feel tired for the first several weeks. Over the six weeks following surgery patients ease back into normal activity. The only exercise necessary is a progressive increase in walking which should be performed regularly. If desired, swimming can commence two weeks following surgery. Patients usually return to school at about four weeks, on half-days for the first two weeks. Return to sport usually takes four to six months. Complications Considering the extent of the surgery, complications are very rare. Infection occurs in 1% of patients and is often very low grade and may not show up for many months. In 1% to 2% of patients the bone does not fuse, leading to pain or breakage of the rods – further surgery may be required. 1% of patients have significant ongoing pain caused by the surgery. Injury to a spinal nerve or the spinal cord occurs in less than 3 patients out of 1000. In a very small proportion of patients the spine above or below the rods curves and requires surgery later.

General Information Back or neck pain occurs at some stage in the life of most people. Pain may be simply due to a muscle strain but, if persistent, usually arises from the discs and/or joints of the spine which are beginning to degenerate (develop “wear and tear”) as a result of normal ageing. Episodes of pain may be caused simply by loading the spine through normal activities of daily living, or precipitated by injuries (falls, lifting, sport etc). If pain or tingling extend down the arm or the leg this is usually due to compression of a spinal nerve. While degeneration (ageing in the discs or joints of the spine) is the most common cause of neck or back pain, less commonly persistent neck or back pain is due to slippage of the spine (spondylolisthesis), fracture (especially in osteoporosis) and very occasionally infections of the spine or cancer of the spine. Treatment Painful episodes often resolve within a few days or a few weeks with no treatment, simply the passage of time. Painful episodes can sometimes be shortened by: Physical therapy Physiotherapy Osteopathy Chiropractic treatment Pain management includes: Analgesic and anti-inflammatory medication Acupuncture Massage Spinal cortisone injections Preventative measures: Weight reduction Improved aerobic fitness (walking, jogging, cycling, swimming etc) Core muscle strengthening For some patients with nerve pain (pain/tingling extended down the arm or the leg) physical therapy may worsen their symptoms. These patients should stop treatment and proceed to imaging tests (e.g. MRI). My expertise is in diagnosis and surgical management - I do not get involved extensively in non-surgical treatment which can be directed through your General Practitioner. Surgery is recommended only for selected patients with persistent or recurrent pain causing significant interference with quality of life and after a period of non-operative (physical therapy, pain management) treatment. For selected patients with severe nerve pain, surgery may be necessary within days or weeks of the onset of symptoms for adequate pain relief. Surgery is only recommended when the chances of a successful outcome (good or excellent result) are at least 70% to 80% and usually higher. Surgery for treatment of nerve pain usually achieves 85% to 95% good or excellent results.