Spine surgery is surgery performed near or on the spinal cord, which controls the body's motor function. Spinal surgery is typically reserved for serious spinal conditions, as well as for some conditions that may cause chronic back pain.

The spine is composed of bones called vertebrae that usually number 33 at birth but total 26 in adulthood because some of them fuse. It connects with the skull, shoulders, ribs and pelvis. Many diseases, conditions and trauma make the spine subject to pain and disability. For most spinal conditions, treatments such as physical therapy, medications and injection therapy are attempted before surgery.

Conditions treated with spinal surgery include several forms of arthritis and spinal stenosis, a narrowing of the nerve openings in the spinal column. Herniated discs, degenerative disc disease, unresolved sciatica, severe scoliosis and some cases of pinched nerves may also be treated surgically. Vertebral compression fractures, which may occur among patients with osteoporosis, can be treated with newer surgical procedures such as vertebroplasty and kyphoplasty.

Spinal surgeries vary, depending on the condition treated. Some are minimally invasive and can be performed at a physician's office under local anesthetic. Others may require general anesthesia and an extended hospital stay and rehabilitation. Patients typically undergo a physician’s evaluation prior to surgery to minimize the risk of complications. In addition, instructions are often given to patients after surgery to aid in recovery and minimize pain.

Spine surgery is typically reserved for serious spinal conditions of the back and neck such as compression injuries and for some conditions that cause severe pain. The structure of the spine and its role as a pathway for nerves make it vulnerable to many painful conditions and susceptible to serious consequences if the pain is left untreated.

The spine provides the axis of the human skeleton. It attaches to the skull, shoulders, ribs and pelvis. The spinal anatomy includes at birth about 33 bones called vertebrae. Some of the lower vertebrae fuse so that an adult has 24 vertebrae lined up atop two other bones. The spine can be divided into four areas:

• The cervical spine in the neck has seven vertebrae.
  
  
• The thoracic spine in the upper back includes 12 vertebrae.
  
  
• The lumbar spine in the lower back features five larger vertebrae.
  
  
• The base of the spine includes the fused sacrum and the fused tailbone (coccyx).

Most vertebrae are ring-shaped, with the thicker part of the ring located facing the front of the body. Separating the vertebrae are thick discs of cartilage called intervertebral discs that help cushion the vertebrae from everyday stresses. The spinal cord and the nerves that attach to it pass through the vertebrae as they branch out from the brain to the body.

The spine has two primary forward curvatures in the thoracic and sacral regions. There are compensating backward curves in the cervical and lumbar vertebrae. These curves provide the spine with resilience and flexibility.

The regions most prone to injury are the cervical spine, which has the greatest range of motion, and the lumbar spine, which supports a lot of weight and is subject to much stress.

Many sources of spinal neck pain and back pain can be treated with nonsurgical pain management methods, such as:

• Physical agents such as thermotherapy, cryotherapy, hydrotherapy or electrical therapy
  
  
• Physical therapy, manipulation therapy or acupuncture
  
  
• Medications such as analgesics or anti-inflammatories
  
  
• Spinal bracing
  
  
• Injection therapy such as facet joint injections or epidural injections.

Usually spine surgery is not performed for only pain. There have to be changes in diagnostic tests (e.g., CAT scan, MRI), along with pain or weakness, before a surgeon is going to perform the surgery.  For only pain, patients are usually referred to pain specialists. However, some conditions (such as spinal stenosis) cannot be cured through nonsurgical treatments.

When surgery is recommended, it may be conventional (also called open) or minimally invasive (endoscopic or arthroscopic). Conventional surgeries require a longer incision and longer recovery period as compared to minimally invasive procedures, in which incisions are often 1 to 2 inches in length. However, not all conditions or patients are appropriate for minimally invasive surgery.

Spine surgery typically involves a posterior approach with incisions in the back, but some use an anterior approach through the abdomen or the front of the neck.

Some spinal surgeries are performed to remove unusual growths. Other surgical procedures may be effective at relieving spinal pain caused by injury or illness.

Some surgeries are minimally invasive (e.g., arthroscopy) and can be performed at a physician’s office under a local anesthetic. More serious procedures may require the patient to be unconscious and have an extended hospital stay. Rehabilitation involving physical therapy and sometimes occupational therapy may be needed.

Some of the more common spinal surgeries include:

• Discectomy. Removal of all or part of an intervertebral disc. This procedure is one of the more common ways to relieve pain and nerve pressure in the back or neck caused by a herniated disc or bone spur. Percutaneous discectomy, a recently improved variation using a thin tube inserted through a smaller incision, has been found to be effective in relieving some cases of disc herniation and sciatica.
  

• Spinal fusion. Used to strengthen spinal function while preventing painful movements. During this procedure, spinal discs between two or more vertebrae are removed and the bordering vertebrae are fused together by bone grafts and/or devices such as bone screws. Spinal fusion may decrease mobility and usually requires an extended period of recovery. It may be used for conditions including osteoarthritis (OA), rheumatoid arthritis, spinal stenosis, herniated discs and degenerative disc disease.
  
  
• Laminectomy (spinal decompression). The lamina (arched roof of the spinal canal) of one or more vertebrae is removed. By increasing the size of the spinal canal, this procedure may reduce pain by helping alleviate spinal cord and nerve pressure. It may be used for spinal stenosis. Partial removal of a lamina is known as laminotomy.
  
  
• Foraminotomy. Enlarging of the foramen (bony hole) where a nerve root exits the spine. Discs or joints can thicken as people age, causing the place where the spinal nerve exits to narrow. This can press on the nerve, causing pain, numbness or weakness. During this procedure, surgeons cut away the blockage to relieve pressure on the nerve to help conditions such as pinched nerves or sciatica.
  
  
• Vertebroplasty and kyphoplasty. Minimally invasive procedures used to treat vertebral compression fractures, notably those caused by osteoporosis. For both procedures, a type of bone cement is injected into the fractured bone. For kyphoplasty, a balloon is inserted first and inflated to restore the original height of the vertebra, followed by cement. Patients may recover from these relatively new procedures more quickly, with reduced risk of future fractures in the treated bone.
  

• Radiofrequency lesioning. The use of electrical impulses to interrupt pain signals in the body. A needle is inserted into nerve tissue in the pained area with the help of x-rays. The tissue is then heated and temporarily interrupts the nerve’s transmissions. This procedure may be effective at reducing pain for up to 12 months.
  
  
• Rhizotomy. The cutting of spinal nerve roots. Sometimes used to relieve severe chronic pain, this procedure blocks all senses from the affected area.
  
  
• Cordotomy. Disabling of certain pain conductors in the spinal cord to reduce pain and temperature perception. This procedure may be performed on patients with severe cancer pain.
  
  
• Dorsal root entry zone operation (DREZ). Spinal neurons that transmit pain are destroyed surgically. This procedure may be used on patients suffering from paraplegia or experiencing phantom limb pain after an amputation.
  
  
• Implantation of a spinal pump. In severe cases, a pump that delivers pain medication around the spinal cord can be surgically attached to the back.
  
  
• Implantation of a spinal cord stimulator.  In severe cases, especially with nerve pain (e.g., diabetic neuropathy, sciatica), a stimulator around the spinal cord can be surgically implanted.

• Disc replacement. An artificial intervertebral disc may be inserted to restore the separation of two adjacent vertebrae. Made of materials such as metals and plastics, these prostheses can replace an entire disc or just the core (nucleus pulposus). Artificial discs sometimes provide an alternative to spinal fusion and still allow vertebral range of motion. The U.S. Food and Drug Administration (FDA) has approved an artificial disc for treatment of degenerative disc disease, but this newer treatment is not yet commonly performed.

Five years after performing the first transplants of intervertebral discs from humans, Chinese surgeons in 2007 reported long-term success in relieving chronic back pain due to disc degeneration. However, it may take many more years of research before such transplants are approved in the United States.

• Intradiscal electrothermal therapy (IDET). Thermal (heat) energy to treat pain from a bulging or cracked spinal disc or sciatica. An IDET procedure involves inserting a special needle through a catheter into the affected disc and heating it for several minutes, causing the disc wall to seal. This may be effective at reducing disc inflammation and spinal nerve pain. A recent review of 51 clinical studies found that IDET may in many cases offer enough relief to spare patients from more-invasive spinal fusion.
  

• Nucleoplasty. Procedure similar to IDET, but uses radiofrequency to produce heat and treat pain associated with contained or mildly herniated discs. A needle is inserted into the disc to remove painful disc material. The area is then heated to shrink the tissue and seal the disc wall. Multiple insertions may be made depending on how much material needs to be removed. Radiofrequency ablation is also used to remove benign and cancerous spinal tumors.

Researchers are developing additional methods. These include an interspinous implant for spinal stenosis that is still used only experimentally in the United States. In a method called posterior dynamic stabilization surgery, several devices are being studied to bolster the spine and provide a possible alternative to spinal fusion. Balloon cyphoplasty is similar to kyphoplasty but is being used to treat traumatic spinal fractures in younger people rather than osteoporotic fractures.

Diagnostic tests such as  x-ray, arthrography, CAT scan or MRI are performed before deciding on surgery. Sometimes injections are used as diagnostic tests before deciding on surgery (e.g., discography, selective nerve root injection).

Because surgery carries certain risks, a physician may perform a surgical risk assessment before operating on the spine. Facts about the patient’s health (e.g., pre-existing conditions, allergies) that may increase surgical risk are considered. Findings from diagnostic tests and a patient’s medical history may be reviewed. A physical and/or neurological examination may be given, and a patient may be referred for consultation with additional specialists prior to surgery.

In addition, a physician may give instructions to patients who require spine surgery before the procedure begins. These may include references to:

• Medications. Anticoagulants (medications that reduce the ability of blood to clot) may complicate surgery in some instances. Patients may be required to stop taking anticoagulants several days prior to surgery. Intake of certain other daily medications may need to be temporarily discontinued as well in some instances. 
  
  
• Food and drink intake. Food and liquid are typically restricted prior to surgery. Guidelines will be given prior to surgery.
  
  
• Smoking. Patients who smoke will be advised to quit several days or weeks prior to spine surgery.
  
  
• Transportation. Arrangements to and from the hospital should be made well in advance. Patients are not usually allowed to drive immediately after surgery, even if it is an outpatient procedure.
  
  
• Assistance. Some spine surgeries may require home assistance. Arrangements may be necessary if assistance is required for an extended period of time (e.g., home health aide).

The patient’s experience during spine surgery will vary according to the type of procedure. Some arthroscopic or other minimally invasive surgeries can be performed at a physician's office under a local anesthetic, but more serious procedures may require a general anesthetic during surgery and an extended hospital stay.

During the surgery, one or several incisions may be made in the back or neck. Incisions may be made on the front or back of the body, depending on the portion of the spine involved. Special instruments are used to remove growths or sections of vertebrae. Other procedures may reposition or realign portions of the spine or the nerves that run through the spinal column. Bone grafts, cements or devices such as bone screws may be inserted to strengthen the spine.

Following spine surgery, a physician may give a patient may instructions designed to aid healing and reduce pain. These may include:

• Use of postoperative devices. Some postoperative devices (e.g., brace, collar) may be necessary after some surgeries (e.g., spinal fusion) to limit pain and prevent re–injury.
  
  
• Instructions for bandages, staples or sutures. Some activities, such as showering, may be restricted until these have been removed. Bulky bandages may be removed before discharge from the hospital in many cases. Staples or sutures may not be removed for several weeks after surgery in some cases.  
  
  
• Pain medications. A physician may prescribe pain medication, such as opioids, after spine surgery. Over-the-counter analgesics may also be effective at reducing pain.
  
  
• Antibiotics. These drugs may be prescribed to prevent bacterial infection of the wound.
  
  
• Inspection of incisions. The site of the surgical incision may need to be checked frequently for signs of infection.  
  
  
• Sleeping positions. Depending on the procedure, certain sleep positions may be recommended or prohibited to aid recovery and reduce pain after spine surgery.
  
  
• Heavy lifting. Lifting objects in excess of 10 to 15 pounds is generally forbidden following spine surgery.
  
  
• Driving. Operating an automobile is not allowed immediately after most spine surgeries. Limiting the time spent riding as a passenger may also be advised to prevent pain and stiffness.

Depending on the condition and the type of surgery, patients may benefit from inpatient or outpatient rehabilitation including physical therapy, exercise therapy, instruction in posture and ergonomics and sometimes occupational therapy. 

Spine surgery is often reserved for injuries or conditions that cannot be managed with conservative nonsurgical treatments, such as medication and physical therapy. For instance, only a minority of patients with low back pain will require surgery.

Most surgeries are successful and achieve the following therapeutic goals:

• Restoration of normal spine alignment
  
  
• Removal of overgrown, diseased or damaged areas (e.g., discs, joints, nerves)
  
  
• Protection from potentially serious injury (e.g., fractures)

• Relief of pain, weakness, numbness or tingling from compressed nerves
  
  
• Spinal stabilization

As with any surgical procedure, there are risks. Spinal surgery involves proximity to the spinal cord and most of the nervous system, which transmit messages throughout the body. Surgery in this area may include risks in addition to those normally associated with any surgical procedure. Some of these potential risks include:

• Failure of surgery. In some cases, spine surgery may not be effective at correcting a condition or reducing pain. Some patients experience temporary pain relief, with eventual recurrence of symptoms. Some procedures may not heal properly (e.g., fusions, implants, fracture repair). Rarely, pain may increase after the surgery.
  
  
• Anesthesia. Drug or agent used to eliminate pain and sensation. Problems can arise in reaction to the anesthesia, other drugs being used or other medical conditions the patient may have. Patients are encouraged to consult their physician about possible anesthesia complications prior to spine surgery.
  
  
• Bleeding. Unexpected bleeding may occur during spine surgery. Large blood vessels may be temporarily moved during surgery to help prevent damage.
  
  
• Blood clots. The risk of developing some blood clots may increase after spine surgery. In serious cases, blood clots may travel to the lungs, where they can block oxygen supply, or to the brain and cause a stroke. Physicians may administer anticoagulants (medications that reduce the ability of blood to clot) to reduce this risk. They may prescribe walking or other activity after surgery to help prevent blood clots and deep vein thrombosis.
  
  
• Dural tear. A small sac of tissue (dura mater) covers the spinal cord and surrounding nerves. During spine surgery, a tear of this sac may occur. It is usually repaired during surgery, but an unrecognized tear may not heal properly, increasing the risk for conditions such as meningitis. Additional surgery may be necessary to repair a tear that does not heal naturally.
  
  
• Lung function. Lungs that function improperly following surgery may cause conditions such as pneumonia. Patients may be advised to take preventive measures that keep the lungs working properly, such as taking deep breaths and sitting upright.
  
  
• Infection. Spine surgery carries a risk of infection, though this complication is rare. An infection may be treated methods including antibiotics or additional surgery depending on its severity.
  
  
• Spine or nerve damage. The spinal cord or connecting nerves may be injured during spine surgery, although this rarely occurs. Damage to the spinal cord or surrounding nerves may cause a wide variety of serious problems including sexual dysfunction or paralysis.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients (or parents) may wish to ask their doctor the following questions about spine surgery:

1. Do I have any alternatives to spine surgery?
   
   
2. What type of spine surgery is recommended for me, and what does it involve? Will anything be implanted or removed?
   
   
3. Do I need to do anything to prepare for my surgery?
   
   
4. What kind of anesthesia will I undergo?
   
   
5. What complications am I most at risk for as a result of my surgery?
   
   
6. Will my surgery require a hospital stay?
   
   
7. How long will it take for me to recover from my surgery?
   
   
8. Will I need a brace or other device?
   
   
9. What medications might I need after the operation?
   
   
10. Will I need physical therapy or other treatments afterward?
    
    
11. What are the chances my surgery will be effective?
    
    
12. Will spine surgery affect my child’s development?