Spinal stenosis involves a narrowing of the spinal canal and lateral recesses through which the nerve roots and blood vessels pass. This narrowing is produced by a combination of thickening of the ligamentum flavum and facet joint hypertrophy. Patients with spinal stenosis are able to walk only short distances in a stooped position before experiencing leg pain. This pain (neurogenic claudication) typically travels down one or both legs below the knees. Usually the pain travels in a band like fashion down the side or back (or both) of the leg(s). Stooping or sitting allows relief by providing flexion of the lumbar spine, while standing upright increases the lordotic curve and increases symptoms.

Detailed diagnostic work up is required to differentiate these symptoms from lower extremity vascular claudication, or spinal tumor which can present in a similar manner. CT and often MRI or myelography are used to demonstrate the impingement upon the cauda equina and nerve roots. Spinal stenosis is a progressive process and may require surgical intervention if symptoms are disabling. Best results are obtained when surgical intervention is performed prior to the development of permanent neurological deficit.

In performing a decompressive lumbar laminectomy, the neurosurgeon removes the lamina, ligamentum flavum, and facet joints to eliminate the pressure which they exert on the nerve roots. The nerve roots are then "unroofed" at the lateral recess to provide room for free movement. A major study performed by this practice and published in "Journal of Neurosurgery" found that at short term follow-up (8.4 months), 93% of patients have relief of pain and 95% return to full activity. Despite the fact that elderly patients have many other disabling diseases, such as arthritis, to slow them down, at long term follow up (4.7 years), two thirds still had relief of pain, and half were able to perform normal activities. Age did not influence the good outcomes. Therefore, surgery may be considered in all patients with symptoms of spinal stenosis confirmed by diagnostic testing if those symptoms are significantly disabling.

The lumbar intervertebral disk is made up of a fibrous outer ring called the annulus and a gelatinous inner portion called the nucleus. The disk acts as a cushion between the vertebral bodies. When herniation occurs, the nucleus pushes through the annulus of the disk producing pressure on the nerve root and/or cauda equina.

Nearly all patients complain of leg pain (sciatica) in the distribution of one or more nerve roots. Some have back pain as well. Frequently, patients can be treated conservatively with success. However, when their ability to perform normal day to day functions is degraded for a substantial period of time (4-6 weeks), or in the presence of progressing neurological deficit (i.e. foot drop, loss of control of bowel and bladder, cauda equina syndrome), lumbar microdiskectomy is the most effective treatment. During microdiskectomy, the offending disk fragment and much of the loose nucleus are removed through a small, one to two inch incision.

The success rate is very high for this procedure and patients are able to return to work and full activity in an average of about 10 weeks. Our group has the most extensive experience in Western New York performing outpatient microdiskectomy.  Patients prefer this to overnight stay in the hospital.

The painful mechanical instability of the lumbar spine associated with spondylo-listhesis and degenerative disk disease is difficult to manage. Patients experience symptoms associated with compression of the nerve roots and cauda equina. Back pain is usually the primary complaint making it important to differentiate the pain from that caused by musculo-ligamentous strain. It is for this reason that we stress the importance of extensive conservative therapy before considering surgical intervention.

Plain x-ray flexion/extension films may demonstrate movement of one vertebral body over the other as well as reduced disk space height. A positive diskogram, where injection of radiopaque dye into the affected disk reproduces the patients pain and outlines a fissured or ruptured disk, localizes the level of involvement and is helpful in some cases. While compression may be caused in part by herniation of the disk, diskectomy alone is not effective in providing relief since additional impingement is produced by the reduction in disk space height and abnormal amount of additional movement allowed by the joint.

In Lumbar Interbody Fusion with cages the disk is removed and cages filled with bone are inserted between the vertebral bodies in order to maintain disk space height and fuse the joint, thereby eliminating abnormal movement. The cages can be inserted from an anterior approach (through the abdomen) or a posterior one (through the back). Your surgeon will determine the best approach.

Patients are kept in the hospital for 1-2 days after the procedure, and are usually able to return to work in 6-9 months. Your doctor will provide details of the procedure that is right for you as well as the benefits and risks. He will also provide instructions for your care before and after the procedure.

Fusions are performed in patients with degenerative disk disease, spondylolysthesis, recurrent herniated disks, and spinal stenosis. In fusion of the lumbar spine two or more vertebral segments are joined together, eliminating movement in the joints. The procedure is performed with the hope of reducing pain caused by movement and associated compression of the nerve roots.

While there are numerous methods available to fuse the spine, in patients whose pathology allows it, the TLIF procedure can be minimally invasive. This means that there is a reduction in the amount of muscle and skin that is damaged during surgery and there is less blood loss and post operative pain. Potentially recovery time is quicker as well.

As can be seen in the illustrations above, dilators are placed over one another in progressively larger sizes.  A tube is then placed over the dilator and the dilator removed. Instruments are used inside the tube to remove disk material and make a space for the bone implant or fusion cage.  The bone implant (Medtronic Boomerang shown here) or cage is inserted. Often, percutaneous pedicle screws are inserted to stabilize the joint while fusion occurs.

Your doctor will provide details of the procedure that is right for you as well as the benefits and risks. He will also provide instructions for your care before and after the procedure.

As early as 1911 back and leg pain have been reported to arise from articular facet joints. These are the joints in the spine other than the intervertebral disk joint. Facet denervation (rhizotomy) has been successful in relieving chronic pain arising from abnormalities of the facet joint. This is an outpatient, percutaneous procedure for patients whose pain is not related to disk herniation. Other procedures are available for patients with disk herniation.

Percutaneous facet rhizotomy was developed in 1974 by Sheeley. Patients must undergo a selection process consisting of successful nerve blocks using a temporary anesthetic injected around the nerves of the facet joint. Only patients who experience significant pain relief for several hours are considered candidates for facet rhizotomy.

The actual rhizotomy is performed using a radiofrequency generator. The radio frequency probe with a needle with an electrode at the tip is placed alongside the small facet nerves to the facet joint.   At this location the facet nerve (nerve of Luschka) is blocked by the radio frequency generator.

Back and leg pain can come from many different sources. Among these sources are herniated disks or degenerated disks that can irritate nerve roots causing them to become inflamed and producing pain. While in some cases surgery is required for relief of this pain, sometimes an epidural injection is all that is needed.

Epidural injections are performed to reduce inflammation around the nerve roots allowing nature to heal the problem and make the pain go away. Some patients experience relief that is short lived (days to weeks) while in others relief can be longer term (months to years) or permanent. Some patients have no relief at all. Sometimes one injection is all that is needed while in many cases, multiple injections over time are required to attempt to bring relief of pain.

Your doctor will provide details of the procedure that is right for you as well as the benefits and risks. He will also provide instructions for your care before and after the procedure.

Fusions are performed in patients with degenerative disk disease, spondylolysthesis, recurrent herniated disks, and spinal stenosis. Fusion is performed in these patients when conservative forms of treatment have failed. In fusion of the lumbar spine two or more vertebral segments are joined together, eliminating movement in the joints. The procedure is performed with the hope of reducing pain caused by movement and compression of the nerve roots.

Pedicle screws have long been used to provide structural support to the spine allowing the joint space between the vertebral bodies to fuse. Screws are inserted into the pedicle of the vertebrae at the level above and below the disk space to be fused. A rod is then attached to solidly link both pedicle screws.

During the placement of conventional pedicle screws a considerable amount of muscle must be cut and stripped away from the bone in order to insert the screws. This can result in a lengthy healing time and considerable post operative pain for the patient. Minimally invasive percutaneous pedicle screw and rod placement eliminates the need to perform much of this cutting and stripping of muscle.

The percutaneous pedicle screw system (Medtronic’s Sextant is shown here) allows the screws and rods to be placed through small puncture wounds in the skin under x-ray fluoroscopic guidance.

The painful mechanical instability of the lumbar spine associated with spondylolisthesis and degenerative disk disease is difficult to manage. Patients experience symptoms associated with compression of the nerve roots and cauda equina. Back pain is usually the primary complaint making it important to differentiate the pain from that caused by musculo-ligamentous strain. It is for this reason that we stress the importance of extensive conservative therapy before considering surgical intervention.

Plain x-ray flexion/extension films may demonstrate movement of one vertebral body over the other as well as reduced disk space height. A positive diskogram, where injection of radiopaque dye into the affected disk reproduces the patients pain and outlines a fissured or ruptured disk, localizes the level of involvement and is helpful in some cases. While compression may be caused in part by herniation of the disk, diskectomy alone is not effective in providing relief since additional impingement is produced by the reduction in disk space height and abnormal amount of movement allowed by the joint.

When conservative measures have failed, fusion of the joint has been the treatment of choice for relief of pain. Fusion, however, limits flexibility of the spine. Disk replacement maintains flexibility. Disk replacement also eliminates the need to obtain bone from the hip associated with fusion procedures.

The FDA approved the CHARITÉ™ Artificial Disc in October of 2004 after extensive review of the two year U.S. clinical trial results. In addition to these studies, total disc replacement with the CHARITÉ™ Artificial Disc has been performed in Europe for over 17 years and has been used in treating thousands of patients worldwide with successful results. There are additional risks associated with disk replacement and you should discuss these with your doctor.

A vertebral compression fracture (VCF) occurs when the vertebral body fractures and collapses. Most VCFs are caused by osteoporosis, a disease that causes bones to become brittle and break easily. Compression fractures can also occur as a result of certain types of cancer or tumors.

Balloon Kyphoplasty is a minimally invasive treatment in which special balloons are used to gently elevate the bone fragments in an attempt to return them to the correct position. X-rays and magnetic resonance imaging (MRI)are used to determine the exact location of the fracture before the procedure is performed.

Compared to the standard Vertebroplasty procedure, Kyphoplasty adds the introduction and inflation of the balloon. This provides the advantage of allowing the cement to be injected into the space created by the balloon under a lower pressure than would otherwise be required. Kyphoplasty also provides, in some cases, the ability to raise the collapsed vertebra and return it to its normal position.

Your doctor will provide details of the procedure that is right for you as well as the benefits and risks. He will also provide instructions for your care before and after the procedure.