Harvesting bone from the iliac crest can be accomplished through the same spinal or separate surgical incision. There are consequences and complications related to this portion of the surgery. Studies have shown that up to 30% of patients experience residual pain at the bone graft harvest site. This pain tends to be self-limiting and improves with time. Collections of blood may develop at the harvest site. This is called a hematoma. Nerve or muscle injury is possible. Bone (called the "ileum") fracture is rare but can occur. Despite these complications, iliac crest bone is perhaps the best fusion material currently available for spine fusion. For this reason, spine surgeons continue to harvest the iliac crest as a preferred source of bone. Recently, the availability of substitutes such as bone morphogenetic protein (INFUSEÃƒÂ¢Ã¢â‚¬Å¾Ã‚Â¢, Medtronic) is beginning to replace the iliac crest bone graft harvest procedure.
Infection related to any type of surgery can occur. Spine fusion surgery is no different. The literature suggests that the incident of infection is approximately one percent. We provide the patient with prophylactic antibiotic coverage to help prevent infection. If infection does occur, treatment may include washing the wound out and starting aggressive antibiotic therapy. Antibiotic therapy is routinely administered for six weeks to completely eradicate the infection. Only under rare circumstances must the surgeon remove the hardware or bone grafting material from the fusion bed to cure the infection.
Fortunately, neurologic injury is a rare occurrence with spine surgery. The literature suggests that simple discectomy or laminectomy surgery carries a rate of neurologic injury of one in 10,000 surgeries. Spine fusion surgery may carry a higher rate between one in 1,000 to one in 5,000 cases. The surgeons at CCSI use all the latest technologies to help protect your nerves and to monitor your spinal cord throughout surgery. Unfortunately, this does not entirely eliminate the possibility of injury.
Spinal cord and nerve root level monitoring is performed using Somatosensory Evoked Potential Monitoring, EMG nerve root monitoring, and Motor Evoked Potential Monitoring. This monitoring system involves state-of-the-art, real-time computer analysis of ongoing spinal cord and nerve root function. This advanced technique allows your surgeons at CCSI to help minimize the risk of neurologic injury. The monitoring is performed by a certified technologist who is dedicated to this monitoring function during the entire surgery. To monitor these functions, electrodes are attached to your scalp, arms and legs after you are asleep. Spinal cord and nerve root monitoring is just another example of how CCSI continues to employ the latest techniques and technologies to make spine surgery as safe and effective as possible.
Exposure of the spine does result in some disruption of the musculature. The more minimally invasive techniques being developed at the Colorado Comprehensive Spine Institute can help to minimize tissue disruption. Nonetheless, some degree of soft tissue disruption is inevitable. This can result in residual pain or dysfunction after surgery.
Hardware to internally secure the spine in position has been a tremendous advance. Without this, many modern spine procedures would be impossible. Spinal hardware such as rods, hooks, and screws must be very carefully positioned. Malpositioning or displacement of the hardware may occur, thereby causing nerve or muscle irritation. This may necessitate the need for further surgery to correct the situation.
The purpose of spinal hardware is to stabilize the spine and to correct a deformity. Spinal hardware is meant to hold the spine in an immobilized position until the fusion can become solid. Immobility is critical to the fusion process. Solid fusion takes anywhere from six months to one year to occur. Since the surgeons at CCSI use the latest spine fusion techniques available, our patients enjoy a very high fusion rate. This may be in the range of 96 percent or more depending on the specifics of the problem and the nature of the fusion surgery.
It must be understood however, that if the fusion does not become solid, that the hardware will eventually fail. Specifically, the point of anchoring to the bone may loosen or the screws, rods, or hooks may actually break. For optimal results, it is critical that the fusion does indeed become solid. Fusion progress will be monitored using x-rays throughout your recovery. Your surgeons will report your progress to you. Should the fusion not become solid or your hardware fail, you most likely will require further surgery to correct the problem.
Exposure of the anterior spine (i.e. the front),carries with it some unique risks. Specifically, major blood vessels, which run along the front of the spine must be gently mobilized and retracted to expose the spinal column and discs. In less than one percent of cases, injury to these vessels can occur and may require repair. As a result, excessive bleeding or blood clot can occur.
In addition, although rare, injury to the surrounding musculature, bowel, ureter, or nerves can occur. It may be necessary to repair some of these structures during surgery. Failure of the abdominal wall muscles after surgery, which is called a hernia, may require repair later.
Injury to specialized nerves in the area of L5 -S1 in the male can cause fertility problems. This problem is called retrograde ejaculation and it occurs in approximately one percent of anterior surgeries done at the L5-S1 level in male patients. This condition does not affect females. Moreover, this does not affect the sexual function of erection, orgasm, or penile sensation in the male. As a routine, the spine surgeons at CCSI enlist the assistance of a general surgeon or cardiothoracic surgeon to participate in the anterior exposure. This allows the surgical team to be better prepared should an injury occur. Generally, you will not meet this assisting surgeon prior to the operation.
The specialists at CCSI will discuss with you the relative risks and benefits of performing your spine surgery anteriorly or posteriorly.
Laminectomy and or discectomy surgery is often called decompression. Many of the risks and complications as described above are of concern in this type of surgery. In general however, this type of surgery involves a lesser degree of risk than the fusion procedure. The issues of hardware and fusion failure or bone graft harvest of course do not apply here. The risks associated with the anterior surgery also do not apply.
Neurologic injury is also seen less frequently with decompression only surgery. With the overall magnitude of decompression surgery being less than that of a fusion, a shorter surgery, hospital stay, and recovery tends to be the norm.
It is important to understand that decompression surgery alone does not stabilize the spine. In fact, the process of bony removal during a laminectomy or discectomy may result in further instability not present before. The surgeons at CCSI are extremely careful to remove the minimum amount of bone necessary to adequately free the nerves without causing further instability. If instability exists, fusion must be performed. Indeed, performing bony removal with laminectomy can actually weaken or destabilize the spine.
Discectomy may be performed to remove a herniated portion of a disc pressing on a nerve. This procedure, while very effective, does not repair or stabilize the disc in any way. In fact, despite some claims, there is currently no currently accepted method or technology that can actually repair the disc. Consequently, further injury or degeneration of this disc can and does occur. Remember, degeneration occurs in all of our discs as we age and surgery does not alter or avoid this process. Understanding this fact makes the process of postoperative rehabilitation and strengthening that much more important.
In general, cervical surgery seems to involve similar yet somewhat lesser risks than those seen in thoracic or lumbar surgeries. The good news with cervical surgery is that it is usually less painful than most thoracic or lumbar procedures. A member of the CCSI team will review the specific differences with you as needed.
It should be understood that even with an optimal surgical outcome it is rare that a patient will be rendered 100 percent pain-free. Nonetheless, depending on the patients' given condition, it is not unusual to alleviate 80 percent of the patient's preoperative symptoms. Eighty percent appears to be a "good goal to shoot for" for an expected outcome from a spine fusion surgery. Remember that your rehabilitative efforts after surgery will play a major role in your overall recovery process.
Each patient's situation is different and results most certainly vary. This discussion of potential surgical complications is meant to be only a guide and is by no means meant to be an exhaustive list of all possibilities. Other types of complications can and do occur. Your surgeon will discuss some of these with you. Moreover, spine surgery is a serious matter and carries significant risks. Philosophically, at CCSI, surgery is only recommended when these risks are clearly outweighed by the potential benefits.
It must be remembered however that there are no guarantees. Our spine specialists will do everything in their power to minimize these risks and optimize your recovery from your spinal injury. As the central figure in the decision-making process for surgery, you should be fully aware of these matters prior to considering the surgery.