Spinal surgeries
 SPINAL FUSION
Abnormalities or degeneration (“wearing”) of the discs between vertebrae may lead to abnormal motions causing back and or leg pain. If this pain continues following attempts at rehabilitation, surgery may be recommended. Surgical treatments for this pain commonly involve eliminating motion between affected vertebrae by initiating new bone growth, ultimately joining the two vertebrae together. The surgical procedure is generally referred to as a spinal fusion procedure. In general, the procedure is completed to induce new bone growth into the space between the transverse processes (posterolateral fusion) or the vertebral bodies (anterior interbody fusion). The spinal column may be surgically approached via an incision from the back or through the abdomen. A fusion may be attempted either on the front or back side of the spine.
There are different types of spinal fusion.
Anterior interbody spinal fusion is performed via an incision in a patient’s abdomen. The vertebral bodies are approached from the front and a femoral ring (cadaver bone), or cylindrical cage, is placed between the two vertebral bodies. The femoral ring or cage instrumentation is filled with bone graft usually obtained from the patient’s hip (iliac crest). If fusion is successful, motion between the vertebrae will stop and any pain caused by abnormal motion between those vertebrae will no longer exist.
Posterior spinal fusion, sometimes referred to as a posterolateral spinal fusion, is performed from an incision made in the back. The procedure entails roughening the surfaces of the transverse processes and inserting bone graft between the transverse processes. The bone is usually obtained from a patient’s hip. If fusion is successful, motion between the vertebrae will stop and any pain caused by abnormal motion between those vertebrae will no longer exist.
Because of the limited supply of a patient’s own bone and possible donor site pain or morbidity, there is a continuing search for ideal bone graft substitute.
LAMINECTOMY
A laminectomy can be performed on all regions (lumbar, thoracic, and cervical) of the spinal column to relieve pressure on the spinal cord or the nerve roots. The lamina is the bony roof of the spinal canal. Laminectomy is the term used to refer to the process of removing the lamina (usually both sides). Removing the lamina increases the size of the spinal canal, giving more room for the spinal cord or nerve roots.
This procedure is also called a spinal decompression. Pressure on the nerve roots or the spinal cord can be caused by bony spurs or by a herniated or bulging disc. This pressure is often referred to as spinal stenosis and can cause pain and weakness. The pressure is relieved by removing the lamina as well as any other source of compression such as bone spurs, a herniated disc, or disc bulges. Decompression of the nerve roots and the spinal cord relieves pain and other symptoms.
LAMINAPLASTY
This procedure is used to relieve spinal cord compression in the cervical spine. Its most common use is in severe cases in which the spinal cord is compressed at multiple levels. This procedure is very similar to a laminectomy. However, instead of completely removing the lamina (bony roof), the lamina is hinged on one side and rotated away from the spinal cord – a procedure similar to cracking open a door. This procedure allows marked expansion of the spinal canal and relieves compression of the spinal cord. It also is a good alternative to an anterior cervical decompression and fusion. The laminaplasty is performed posteriorly and does not involve fusion of the spine. It allows for decompression of the spinal canal while maintaining good stability.
SELECTIVE DORSAL RHIZOTOMY
What is selective dorsal rhizotomy?
Selective dorsal rhizotomy is a surgical procedure performed to reduce leg muscle stiffness and spasticity in children who have cerebral palsy. For some children, reduced spasticity results in improved walking. For other children, surgery means the ability to function better in a wheelchair, sit more comfortably or for longer periods of time, or to bend at the waist and use the hands for play. In addition, selective dorsal rhizotomy sometimes results in better breathing, improved arm and head control and decreased leg spasticity.
Who is a candidate for the surgery?
Children most suitable for rhizotomy are between the ages of 3 and 10, but older children may be candidates for the surgery as well. Candidates for rhizotomy usually are already involved in an active physical therapy program. Because the procedure involves intensive follow-up therapy, children who can understand and follow directions generally are ideal candidates. There are two groups of children who benefit from selective dorsal rhizotomy:
- Spastic diplegics (also known as borderline ambulators) — children with this type of cerebral palsy also have some form of forward movement (usually walking up on their toes and bringing their legs together in a crossed position) and can take a few steps by themselves without falling. The goals of surgery for these patients include better gait and leg function. To make sure that spasticity isn’t masking muscle weakness, team members carefully test muscle power before surgery.
- Severe spastic quadriparetics — these children have spasticity in all extremities and trunk with very limited movement. Rhizotomy may increase their independence by allowing them to sit for longer periods of time, use a potty seat, or power a wheelchair on their own. For parents, surgery can ease the daily care of these children. When there is less spasticity, parents find it easier to change a diaper or use an adaptive feeding device, for example.
How will the doctor know if rhizotomy will work for my child?
Because rhizotomy is only effective for some children with cerebral palsy, the Spasticity Clinic’s multidisciplinary team of specialists and support staff can screen your child to determine if the surgery will help. It is important to note that one group of children with cerebral palsy can not be helped with this surgery. Children with athetosis or ataxia do not improve after selective dorsal rhizotomy but benefit from other interventions.
The Spasticity Team has extensive training and experience in treating spasticity. The team is committed to providing comprehensive care in a compassionate setting. The Spasticity Clinic team members include:
| Social worker | Occupational therapist | Physical therapist |
| Pediatric neurologist | Pediatric orthopaedic surgeon | Pediatric neurosurgeon |
| Nurse clinicians | Biomedical engineer/gait and movement analysis specialists |
Children who are not immediate candidates for rhizotomy may return in six months for a further evaluation. If your child is not a candidate for the procedure, you can still gain helpful information from the Spasticity Team evaluation.
The Spasticity Team’s recommendations are sent to you in the form of a letter for your records. Upon request, a letter can be sent to the doctor of your choice. In addition, the occupational and physical therapists can share their evaluation results with your child’s therapists.
How does surgery help mobility?
Muscle tone is controlled by a reflex of nerves located in the spinal cord. This reflex involves a sensory nerve which brings information from a muscle back to the spinal cord, and a motor nerve that goes back to the muscle, causing it to contract.
Normally, messages from the brain reduce this spinal reflex and control the way the muscles contract. But in children who have cerebral palsy, control over these spinal nerves is reduced and the brain signals no longer communicate with the motor nerves to stop muscles from contracting. This causes a state of continuous contraction in some muscles, resulting in involuntary spasms and increased muscle tone (the amount of tension in a muscle).
Selective dorsal rhizotomy can often release some of this muscle tightness (spasticity). By cutting only the sensory nerve rootlets causing the spasticity, muscle stiffness is decreased, but other functions are not lost. Relieving spasticity improves mobility and function to help prevent extreme muscle scarring (contractures) and joint and bone deformities.
Before the procedure
Once the Spasticity Team has determined that your child is a candidate for the selective dorsal rhizotomy procedure, additional tests and evaluations are performed to be sure your child will benefit from the surgery. Additional screening may include in-depth evaluations by physical and occupational therapists, testing by a musculoskeletal specialist, a magnetic resonance imaging test (MRI), neurological examinations and other evaluations, as necessary.
During the procedure
The procedure generally takes about 4 hours. During surgery, a 4- to 6-inch incision is made along the lower back to uncover and test small nerve rootlets that make up the sensory nerve fibers in the spinal cord. Using a surgical microscope, the neurosurgeon locates, divides and tests the rootlets of each nerve for abnormalities.
Certain sensory (dorsal) rootlets with abnormal responses to testing are cut because they increase muscle tone and cause a spastic response. Cutting these nerve rootlets reduces spasticity after the operation. All motor nerve rootlets are preserved so leg movement is not affected.
After the procedure
For the first 24 to 48 hours after surgery, your child must lie flat, usually on the stomach or back. Physical and occupational therapy begin on the first day after surgery to educate caretakers regarding proper positioning of the trunk, arms and legs. Generally the third or fourth day after surgery your child may sit up for short periods. Direct physical and occupational therapy begin on the fourth day after surgery to stretch muscles and facilitate movement. Therapy continues about 2 hours every day while your child remains in the hospital. Children generally recover in the hospital 5 to 7 days after surgery.
Before being discharged, your child’s therapists will discuss the appropriate follow-up therapy for your child. Other follow-up appointments will be scheduled with the neurosurgeon and other members of the Spasticity Team, if necessary.
To obtain full text:
http://www.espineinstitute.com/handler.cfm?event=practice,template&cpid=14005
http://www.clevelandclinic.org/health/health-info/docs/0300/0368.asp?index=4591&src=news
 SPINAL FUSION
Abnormalities or degeneration (“wearing”) of the discs between vertebrae may lead to abnormal motions causing back and or leg pain. If this pain continues following attempts at rehabilitation, surgery may be recommended. Surgical treatments for this pain commonly involve eliminating motion between affected vertebrae by initiating new bone growth, ultimately joining the two vertebrae together. The surgical procedure is generally referred to as a spinal fusion procedure. In general, the procedure is completed to induce new bone growth into the space between the transverse processes (posterolateral fusion) or the vertebral bodies (anterior interbody fusion). The spinal column may be surgically approached via an incision from the back or through the abdomen. A fusion may be attempted either on the front or back side of the spine.
There are different types of spinal fusion.
Anterior interbody spinal fusion is performed via an incision in a patient’s abdomen. The vertebral bodies are approached from the front and a femoral ring (cadaver bone), or cylindrical cage, is placed between the two vertebral bodies. The femoral ring or cage instrumentation is filled with bone graft usually obtained from the patient’s hip (iliac crest). If fusion is successful, motion between the vertebrae will stop and any pain caused by abnormal motion between those vertebrae will no longer exist.
Posterior spinal fusion, sometimes referred to as a posterolateral spinal fusion, is performed from an incision made in the back. The procedure entails roughening the surfaces of the transverse processes and inserting bone graft between the transverse processes. The bone is usually obtained from a patient’s hip. If fusion is successful, motion between the vertebrae will stop and any pain caused by abnormal motion between those vertebrae will no longer exist.
Because of the limited supply of a patient’s own bone and possible donor site pain or morbidity, there is a continuing search for ideal bone graft substitute.
LAMINECTOMY
A laminectomy can be performed on all regions (lumbar, thoracic, and cervical) of the spinal column to relieve pressure on the spinal cord or the nerve roots. The lamina is the bony roof of the spinal canal. Laminectomy is the term used to refer to the process of removing the lamina (usually both sides). Removing the lamina increases the size of the spinal canal, giving more room for the spinal cord or nerve roots.
This procedure is also called a spinal decompression. Pressure on the nerve roots or the spinal cord can be caused by bony spurs or by a herniated or bulging disc. This pressure is often referred to as spinal stenosis and can cause pain and weakness. The pressure is relieved by removing the lamina as well as any other source of compression such as bone spurs, a herniated disc, or disc bulges. Decompression of the nerve roots and the spinal cord relieves pain and other symptoms.
LAMINAPLASTY
This procedure is used to relieve spinal cord compression in the cervical spine. Its most common use is in severe cases in which the spinal cord is compressed at multiple levels. This procedure is very similar to a laminectomy. However, instead of completely removing the lamina (bony roof), the lamina is hinged on one side and rotated away from the spinal cord – a procedure similar to cracking open a door. This procedure allows marked expansion of the spinal canal and relieves compression of the spinal cord. It also is a good alternative to an anterior cervical decompression and fusion. The laminaplasty is performed posteriorly and does not involve fusion of the spine. It allows for decompression of the spinal canal while maintaining good stability.
SELECTIVE DORSAL RHIZOTOMY
What is selective dorsal rhizotomy?
Selective dorsal rhizotomy is a surgical procedure performed to reduce leg muscle stiffness and spasticity in children who have cerebral palsy. For some children, reduced spasticity results in improved walking. For other children, surgery means the ability to function better in a wheelchair, sit more comfortably or for longer periods of time, or to bend at the waist and use the hands for play. In addition, selective dorsal rhizotomy sometimes results in better breathing, improved arm and head control and decreased leg spasticity.
Who is a candidate for the surgery?
Children most suitable for rhizotomy are between the ages of 3 and 10, but older children may be candidates for the surgery as well. Candidates for rhizotomy usually are already involved in an active physical therapy program. Because the procedure involves intensive follow-up therapy, children who can understand and follow directions generally are ideal candidates. There are two groups of children who benefit from selective dorsal rhizotomy:
- Spastic diplegics (also known as borderline ambulators) — children with this type of cerebral palsy also have some form of forward movement (usually walking up on their toes and bringing their legs together in a crossed position) and can take a few steps by themselves without falling. The goals of surgery for these patients include better gait and leg function. To make sure that spasticity isn’t masking muscle weakness, team members carefully test muscle power before surgery.
- Severe spastic quadriparetics — these children have spasticity in all extremities and trunk with very limited movement. Rhizotomy may increase their independence by allowing them to sit for longer periods of time, use a potty seat, or power a wheelchair on their own. For parents, surgery can ease the daily care of these children. When there is less spasticity, parents find it easier to change a diaper or use an adaptive feeding device, for example.
How will the doctor know if rhizotomy will work for my child?
Because rhizotomy is only effective for some children with cerebral palsy, the Spasticity Clinic’s multidisciplinary team of specialists and support staff can screen your child to determine if the surgery will help. It is important to note that one group of children with cerebral palsy can not be helped with this surgery. Children with athetosis or ataxia do not improve after selective dorsal rhizotomy but benefit from other interventions.
The Spasticity Team has extensive training and experience in treating spasticity. The team is committed to providing comprehensive care in a compassionate setting. The Spasticity Clinic team members include:
| Social worker | Occupational therapist | Physical therapist |
| Pediatric neurologist | Pediatric orthopaedic surgeon | Pediatric neurosurgeon |
| Nurse clinicians | Biomedical engineer/gait and movement analysis specialists |
Children who are not immediate candidates for rhizotomy may return in six months for a further evaluation. If your child is not a candidate for the procedure, you can still gain helpful information from the Spasticity Team evaluation.
The Spasticity Team’s recommendations are sent to you in the form of a letter for your records. Upon request, a letter can be sent to the doctor of your choice. In addition, the occupational and physical therapists can share their evaluation results with your child’s therapists.
How does surgery help mobility?
Muscle tone is controlled by a reflex of nerves located in the spinal cord. This reflex involves a sensory nerve which brings information from a muscle back to the spinal cord, and a motor nerve that goes back to the muscle, causing it to contract.
Normally, messages from the brain reduce this spinal reflex and control the way the muscles contract. But in children who have cerebral palsy, control over these spinal nerves is reduced and the brain signals no longer communicate with the motor nerves to stop muscles from contracting. This causes a state of continuous contraction in some muscles, resulting in involuntary spasms and increased muscle tone (the amount of tension in a muscle).
Selective dorsal rhizotomy can often release some of this muscle tightness (spasticity). By cutting only the sensory nerve rootlets causing the spasticity, muscle stiffness is decreased, but other functions are not lost. Relieving spasticity improves mobility and function to help prevent extreme muscle scarring (contractures) and joint and bone deformities.
Before the procedure
Once the Spasticity Team has determined that your child is a candidate for the selective dorsal rhizotomy procedure, additional tests and evaluations are performed to be sure your child will benefit from the surgery. Additional screening may include in-depth evaluations by physical and occupational therapists, testing by a musculoskeletal specialist, a magnetic resonance imaging test (MRI), neurological examinations and other evaluations, as necessary.
During the procedure
The procedure generally takes about 4 hours. During surgery, a 4- to 6-inch incision is made along the lower back to uncover and test small nerve rootlets that make up the sensory nerve fibers in the spinal cord. Using a surgical microscope, the neurosurgeon locates, divides and tests the rootlets of each nerve for abnormalities.
Certain sensory (dorsal) rootlets with abnormal responses to testing are cut because they increase muscle tone and cause a spastic response. Cutting these nerve rootlets reduces spasticity after the operation. All motor nerve rootlets are preserved so leg movement is not affected.
After the procedure
For the first 24 to 48 hours after surgery, your child must lie flat, usually on the stomach or back. Physical and occupational therapy begin on the first day after surgery to educate caretakers regarding proper positioning of the trunk, arms and legs. Generally the third or fourth day after surgery your child may sit up for short periods. Direct physical and occupational therapy begin on the fourth day after surgery to stretch muscles and facilitate movement. Therapy continues about 2 hours every day while your child remains in the hospital. Children generally recover in the hospital 5 to 7 days after surgery.
Before being discharged, your child’s therapists will discuss the appropriate follow-up therapy for your child. Other follow-up appointments will be scheduled with the neurosurgeon and other members of the Spasticity Team, if necessary.
To obtain full text:
http://www.espineinstitute.com/handler.cfm?event=practice,template&cpid=14005
http://www.clevelandclinic.org/health/health-info/docs/0300/0368.asp?index=4591&src=news
