Indications for surgical intervention in spinal disorders and when not to operate

1

What are some critical factors that determine the outcome of a spinal procedure?

Critical factors that determine whether a spinal procedure is a success or failure include:

• Surgical indications

• Surgical procedure (type and invasiveness)

• Surgical technique

• Timing of surgery

• Patient psychosocial factors

• Medical comorbidities

• Biologic factors

It is critical to perform the appropriate surgical procedure for the correct indications with technical proficiency at the appropriate time. However, patient psychosocial factors, medical comorbidities, and biologic factors that adversely impact spinal arthrodesis or neural recovery can all negatively influence the outcome of appropriate and well-executed surgery in powerful ways. The relationship among these factors may be summarized in a formula:

2

What are the major indications for spinal procedures?

• Decompression of symptomatic neural compression

• Stabilization of unstable spinal segments

• Realignment of spinal deformities

• Maintenance of intersegmental spinal motion following disc removal

3

Describe some common indications for spinal decompression procedures.

Spinal decompression procedures are indicated for symptomatic spinal cord or nerve root impingement. Common indications for decompression procedures include disc herniation, spinal stenosis, and spinal cord and/or nerve root impingement secondary to fracture, tumors, or infection.

4

Describe some common indications for spinal stabilization procedures.

Spinal stabilization procedures are indicated when the structural integrity of the spinal column is compromised to prevent initial or additional neurologic deficit, spinal deformity, or intractable pain. Common indications for spinal stabilization procedures include fractures, tumors, spondylolisthesis, and spinal instability after laminectomy.

5

Describe some common indications for spinal realignment procedures.

Spinal realignment procedures are performed to correct spinal deformities. Spinal deformities may result from single-level spinal pathology (e.g., spondylolisthesis, fracture, tumors) or pathology involving multiple spinal levels (e.g., kyphosis, scoliosis, complex multiplanar deformity).

6

How do the indications for lumbar and cervical total disc arthroplasty differ?

Lumbar total disc arthroplasty is most commonly indicated for reconstruction of the disc at one spinal level (L4–L5 or L5–S1) following single-level discectomy for treatment of patients with symptomatic degenerative disc disease. Cervical total disc arthroplasty is indicated for reconstruction of the disc (C3–C7) following discectomy at one or two contiguous levels for treatment of radiculopathy with or without neck pain, or myelopathy due to degenerative spinal pathology localized to the level of the disc space.

7

How is the timing of spinal procedures prioritized?

Indications for spinal surgery are prioritized based on the physician’s responsibility to prevent irreversible harm to the patient as a result of spinal pathology, and must take into account the window of time within which surgical intervention likely remains effective. Although there is no universally accepted classification or time frames, surgical indications may be broadly prioritized as:

• 1.

  Emergent indications . Patients in this category are at risk of permanent loss of function if surgery is not performed immediately. Delayed intervention for spinal emergencies may lead to irreversible harms including death, paralysis, or permanent sphincter dysfunction. Emergent surgical intervention is indicated for treatment of progressive neurologic deficits due to spinal cord or nerve root compression caused by conditions such as fractures, dislocations, tumors, abscesses, or massive disc herniations.

• 2.

  Urgent indications . Patients in this category have a serious spinal condition and require surgical intervention soon to prevent development of a significant permanent neurologic deficit or spinal deformity. Absence of a progressive or severe initial neurologic deficit or acute high-grade spinal instability permits limited time for additional spinal imaging studies, preoperative medical optimization, and formulation of a comprehensive surgical plan that enables the spinal procedure to be performed under more ideal conditions. Examples include patients with unstable spinal fractures without significant neurologic deficits and certain spinal tumors and infections.

• 3.

  Elective indications . Patients in this category have the opportunity to explore nonsurgical treatment alternatives and carefully evaluate the benefit-risk ratio of surgical versus nonsurgical treatment. Examples include patients with degenerative spinal disorders and spinal deformities.

8

In what situations is it unrealistic to perform surgery for a patient with a spinal disorder?

Decisions can only be made on a case-by-case basis after a complete medical history and physical examination, imaging workup, and medical risk assessment have been completed. Input from the surgeon, consulting physicians, patient, and family members play a role in decision-making. Some situations in which spinal surgery would not be advised include:

• When the general medical condition of the patient is a contraindication to an appropriate surgical procedure (i.e., the amount of surgery required to address the patient’s spinal problem exceeds the patient’s likely ability to tolerate the indicated surgical procedure).

• In the presence of global spinal pathology not amenable to focal surgical treatment (e.g., axial pain secondary to diffuse degenerative disc changes involving the cervical, thoracic, and lumbar spine may be beyond surgical remedy).

• Poor soft tissue coverage over the posterior aspect of the spine, which is not reconstructible with plastic surgery techniques.

• Severe infection that cannot be eradicated.

• Lack of correlation between imaging studies and the patient’s symptoms.

• Patients with unrealistic expectations and goals with respect to surgical outcome.

• Patients with profound psychological disorders.

9

Is severe back pain ever an indication for spinal surgery?

Only in limited specific circumstances. Back pain is a symptom, not a diagnosis. The lifetime prevalence of back pain exceeds 70%. Surgery is not indicated for treatment of nonspecific low back pain. In specific clinical situations, spinal fusion is a reasonable option for treatment of axial spine pain following adequate nonsurgical treatment if a definite nociceptive focus is identified in a patient without negative psychosocial factors. However, caution is advised when the indication for surgery is spinal pain, as this complaint is subjective and personal, and surgical outcomes may be negatively influenced by a myriad of factors, including concomitant depression, tobacco use, and litigation. Back pain may be a prominent symptom in patients with neural impingement, spinal instability, or certain spinal deformities. In such situations, appropriate spinal decompression, stabilization, and/or realignment may improve back pain symptoms associated with these other spinal pathologies.