THORACIC SPINE DECOMPRESSION
Thoracic spine decompression is a procedure to relieve pressure on the spinal nerves in the middle portion of the back. Spine decompression surgery is indicated in treating spinal stenosis. Spinal stenosis is the narrowing of the spinal canal caused by degeneration of the facet joints and the thickening of the ligaments. These thickened ligaments narrow the spinal canal and compress the nerves causing chronic pain, numbness and tingling sensation or weakness in your arms or legs. Thoracic decompressive surgery is recommended when your pain is not relieved with conservative treatments such as physical therapy or medications.
The following are common techniques for decompression:
Laminectomy: During a laminectomy the entire lamina, a part of the enlarged facet joints and the thickened ligaments are removed to relieve pressure.
Laminotomy: During a laminotomy, just a section of the lamina and ligament is removed.
Foraminotomy: A foraminotomy is increasing the space where the spinal nerve roots leave your spinal canal to avoid compression.
Laminoplasty: Laminoplasty is a surgical procedure indicated in conditions such as cervical spinal stenosis to relieve the pressure off the spinal canal by increasing the space within the spinal canal. This is achieved by creating a hinge on one side of vertebrae and cutting a portion of vertebrae on another side. This forms the swinging vertebrae and the portions or vertebrae are held in place using small wedges. These spacers are then held in place using tiny plates and secured with screws. This widens the space of the spinal canal and relieves the pressure off the spinal cord.
These surgeries are performed under general anesthesia and your surgeon makes an incision down the middle of your back and the muscles overlying the vertebrae are spilt and moved to the side exposing the lamina of the vertebra. The lamina is the bone that makes the back of the spinal canal and forms a protective roof over the back of the spinal cord. Then the entire bony lamina and ligament is removed (laminectomy). In some cases, only a small opening of the lamina is made by removing bone of the lamina above and below the spinal nerves to relieve compression (laminotomy). Next, to remove the bone spurs and the thickened ligament the protective sac of the spinal cord and the nerve root are retracted. Then the facet joints are trimmed to create more space for the nerve roots. If compression is caused from a slipped disc, your surgeon will perform a discectomy- the removal of a portion of a slipped disc.
This surgery makes the spine unstable and therefore another procedure, spinal fusion, is performed to stabilize the spine. Spinal fusion uses bone grafts, rods, plates or screws to join two separate vertebrae in the spine.
THORACIC SPINE FUSION
Thoracic spine fusion is a surgical procedure in which two or more bones (vertebrae) of the thoracic spine are joined together to eliminate the movement between them. The thoracic spine is the center part of the spine and is formed of 12 vertebrae. Thoracic spine fusion is done by placing bone grafts or bone graft substitutes in between the affected vertebrae. This promotes bone growth and eventually fuses the vertebrae into a single, solid bone.
Spinal fusion surgery is recommended in certain conditions that cause persistent back pain even after conservative treatment. The surgery is indicated in the following conditions:
Injury or fracture of the vertebra
Instability of the spine caused by infections or tumors
Abnormal spinal curvature (kyphosis)
Degenerative disc disease
Spinal stenosis (combined with foraminotomy or laminotomy)
To perform a spinal fusion the spine may be approached and graft can be placed either from posterior approach (back), anterior approach (front) or a combination of both (anterior and posterior). Thoracic fusion is usually performed by posterior approach. The aim of the surgery is to fuse the two vertebrae into a single solid bone.
Posterior approach – The approach is made through the back while the patient lies on his or her stomach. The incision is made down the middle of the back.
Usually, small pieces of bone graft material are filled into the space between the vertebrae to promote bony fusion. A bone graft stimulates bone healing by increasing bone production.
Bone grafts can be taken from the patient’s own hip bone. This is called as autograft. It can also be obtained from a donor (allograft). Several artificial bone grafts such as demineralized bone matrices (DBMs), bone morphogenetic proteins (BMPs), and ceramics may also be used.
Immobilization of the vertebrae after the surgery helps in the fusion process. Your surgeon may suggest a brace to be worn or internal fixation with plates, screws and rods may be done to hold the spine still.
Risks and Complications:
It is important to be aware of the potential risks and complications before undergoing the surgery. As with any surgery, there are some possible complications after thoracic spinal surgery which includes:
Infection: Antibiotics will be prescribed before, during, and often after surgery to decrease the risk of infections.
Bleeding at the site of surgery
Persistent pain at bone graft site
Pseudoarthrosis: This is a condition in which there is no enough amount of bone formed and this is more likely in patients who smoke
Formation of blood clots in the legs
The recovery period for spinal fusion varies among individuals and depending on the procedure. You may need to stay in the hospital for 3 to 4 days after surgery. You will be given pain medicines in the hospital and will be taught about the right way of mobilization, postures while sitting, standing, and walking. You may have to wear a brace or a cast when you leave the hospital.
You can resume normal daily activities only after 2-3 weeks of rest period during which the spine heals. Follow your doctor’s instructions and maintain a healthy lifestyle to achieve better outcomes.
Osteoporosis is a “silent” disease characterized by weakening of bones, making them more susceptible to fractures, typically in the hip and spine. Elderly people and especially post-menopausal women are at greater risk of developing osteoporosis.
The mid to lower back area of the spine is mainly involved in weight- bearing, making these regions of spine more prone to collapse when bone weakness is present. This can lead to spinal (vertebral) compression fractures in these patients. Many of these vertebral compression fractures occur by minimal trauma or by no trauma at all. They can even occur while doing simple activities, like bending or twisting. Symptoms range from severe pain in the back, arms and legs to no pain at all. Most patients suffering from such a fracture may believe that their back pain is just a part of ageing, letting these vertebral compression fractures go undiagnosed. However, a single vertebral fracture significantly increases a person’s risk of further fractures. When multiple fractures occur, it causes the spine to become rounded and bent forward resulting in loss of height and a hunchback appearance. This forward curvature of the spine negatively affects the quality of life of the patient and makes it more difficult for them to breathe, eat, walk, or sleep. Vertebral compression fractures can also occur in patients suffering from conditions such as metastatic tumor, multiple myeloma, and vertebral hemangioma.
Vertebroplasty is a minimally invasive procedure which is performed to reduce or eliminate pain caused by vertebral compression fracture. It stabilizes the fracture and prevents further collapse of the vertebra averting deformity. The vertebroplasty procedure involves injection of bone cement into the fractured vertebra under high pressure. The procedure is done under general or local anesthesia. You will be lying face down on the operating table. Your doctor will make a very small 1/2-inch incision in the skin over the fracture site. Under live X-ray guidance, a hollow needle called a trocar is introduced through the back and is positioned within the fractured vertebrae. Next, bone cement is injected into the area through the trocar under high pressure. After the vertebral body is filled completely with the bone cement, the needle is withdrawn before the cement hardens. X-rays or CT scans may be done to confirm the effective spread of the bone cement into the fractured vertebra. The skin incision is closed using steri-strips.
The procedure cannot be performed under the following situations:
Compression fracture is stable and does not cause any pain
A fractured fragment or tumor is present in the spinal canal
Presence of a bone infection or bleeding disorder
Risks and Complications:
As with any surgery, some risks can occur. General complications include bleeding, infection, blood clots and reactions to anesthesia. The specific complications following a thoracic vertebroplasty include leakage of the bone cement into surrounding soft tissues or veins and damage to the spinal cord or spinal nerves leading to numbness or paralysis.
The human spine provides support to the body allowing you to stand upright, bend, and twist. The spine can be broadly divided into cervical, thoracic and lumbar spine. Thoracic spine lies in the mid back region between the neck and lower back and is protected by the rib cage.
24 spinal bones called vertebrae are stacked on top of one another to form a spinal column. Between two vertebrae there is a disc of cartilaginous tissue called intervertebral disc. Intervertebral disc acts as a shock absorber and protects the spine from the strong forces of movement during activities such as jumping, running and lifting.
Wear and tear can occur in the disc with age and may cause the soft spongy tissue in the center of the disc to squeeze (herniate) from a tear on the side of the disc. Disc herniation may also occur due to an injury such as during a car accident or a fall; a sudden and forceful twist of the mid-back or disease of the thoracic spine such as Scheuermann's disease.
The herniated disc protrudes into the hollow tube of the spinal column called the spinal canal and directly pushes against the spinal cord passing through the spinal column. This can injure the spinal cord. Herniated discs can also block blood flow from the one and only blood vessel going to the front of the spinal cord in the thoracic region of the spine, causing nerve tissues in the spinal cord to die.
Symptoms of thoracic disc herniation vary depending on the position and size of the disc herniation, nerve irritation or nerve injury, and damage to the spinal cord. Symptoms may include mid-back pain, pain around the front of the chest that may mimic heart problems, groin pain or pain, numbness and weakness in the legs and arms. It may even affect bowel and bladder function.
Usually thoracic disc herniation is treated conservatively with rest, back brace, medication and physical therapy. Surgery is considered when long term conservative treatment does not relieve pain or the condition is rapidly getting worse or is affecting the spinal cord.
The goal of the surgery is to remove all or part of the herniated disc pressing on the nerve root or spinal cord and is called discectomy. Thoracic discectomy can be performed either through the anterior approach (front side) or posterolateral approach (behind and to the side).
Anterior approach: This approach usually involves open thoracotomy in which the herniated disc is accessed through the chest cavity. An alternative to open thoracotomy is Video Assisted Thoracic Surgery (VATS). VATS is a minimally invasive surgery that is done through several small incisions and involves the use of a thoracoscope, a surgical tool with a tiny camera. Thoracoscope is inserted into the side of the thorax through a small incision to provide real images of the surgical area on a TV screen. These images guide the surgeon to remove the herniated disc using instruments inserted through other small incisions. VATS is minimally invasive and results in quicker recovery than open thoracotomy.
Posterolateral approach: This approach is also called as costotransversectomy. The herniated disc is accessed through an incision on the back of the spine. A window through the bones that cover the herniated disc is created by removing a small part of rib where it connects to the spine (costo means rib) and transverse process (a small bone attached to the spine). The discectomy is then performed with the small instruments.