Spinal surgery

Although back and neck pain episodes are frequent, few patients require surgery. None the less, a small minority undergo such procedures. This chapter will briefly describe the most common spinal surgical procedures.

Surgery for lumbar nerve root compression

The commonest indication for surgery in the lumbar spine is neurological compression, which has two main causes—prolapsed intervertebral disc (PID) and spinal stenosis.

The management of the patient with lumbar neurological compression starts with a clear definition of sciatica. Pain radiating into the leg and foot cannot be considered sciatica unless evidence of neurological dysfunction is also present. Over 70 years ago Kellgren injected hypertonic saline into the supraspinous ligament and described pain referral patterns exactly mimicking dermatomal distribution More recently, studies of patients with mechanical back pain have shown that pain referred below the knee is quite common. To diagnose sciatica, in addition to pain radiating in a dermatomal distribution, some corresponding sensory or motor symptoms and signs must be present.

Asymptomatic disc prolapse can be found in some 20-30 per cent of subjects of working age on MRI scans.56 The unfortunate patient with a referred pain into the leg and a coincidental asymptomatic disc prolapse on an ill-advised MRI scan is at risk of unnecessary and ineffective surgical treatment.

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