Spinal surgery

The spine is a complex system of bones, intervertebral discs, joints and ligaments. Its task is to ensure stability and at the same time enable mobility. Over the years, there is a natural process of wear and tear that affects several structures:

• Intervertebral discs lose fluid: the intervertebral discs act like shock absorbers. With age, they dry out and become flatter. This causes them to lose elasticity.
• Increased load on the vertebral joints: When the intervertebral discs become thinner, the load is distributed less evenly. The small joints between the vertebrae are subjected to greater strain.
• Bone reacts with remodelling processes: The body tries to improve stability. This results in small bony protrusions, so-called osteophytes ("bone spurs").

Here is an important distinction: spondylosis is initially a natural ageing process - not a disease in the classic sense. Many people have radiologically visible changes without ever developing symptoms. Problems only arise when:

• Nerves become irritated or constricted
• inflammatory processes cause pain
• mobility is significantly restricted

Spondylolisthesis can often be detected in the case of spinal wear and tear. In this case, neighbouring vertebrae shift forwards (or backwards = retrolisthesis) against each other. Depending on the strength and duration of the spondylolisthesis, individual or several nerves can become trapped in the spinal canal, which can lead to nerve damage and loss of function. At the same time, spondylolisthesis leads to severe wear and tear of the intervertebral discs and vertebral joints in the affected segment, which causes severe pain.

Spondylolisthesis is either congenital and leads to malformations during growth or is the result of age-related severe wear and tear (degeneration) of the spine. Overstressing the spine in competitive sport can also cause spondylolisthesis. Serious injuries to the spine can also severely impair stability and cause the vertebrae to slip.

Patients initially complain of back pain, which can range from slight pulling to deep-seated, stabbing pain. It occurs not only when the spine is strained, but also after standing up when the back muscles are relaxed. Recurrent acute back pain (lumbago, lumbago) can be the first sign of wear and tear on the spine. As the disease progresses, leg pain (sciatica) increases when walking, so that walking distances become shorter and shorter (caudicatio spinalis = intermittent claudication). Leg pain in older patients is also often due to spondylolisthesis with narrowing of the spinal canal (spinal canal stenosis).

In very severe cases, paralysis can even occur, which also impairs the function of the bladder and rectum (cauda equina syndrome).

Whether an operation is really necessary and which procedure is used depends on the symptoms. In the case of mild slippage with little discomfort, movement exercises, chiropractic or targeted infiltrations (injections) with a cortisone depot into the spinal canal (sacral block, epidural infiltration) often help. In principle, however, all movements with a strong backward curvature (extension) should be avoided.

If there is a pronounced displacement of the vertebrae, the vertebral bodies must be stiffened (spondylodesis). A distinction is made between two surgical procedures: In a so-called open spondylodesis, the spinal column is exposed and the spinal canal is opened, the constricted nerves are freed from thickened joint capsules and bony growths and the affected vertebrae are joined together with screws and longitudinal rods. At the same time, the intervertebral discs are replaced with titanium spacers to increase the stability of the fusion and improve the bony fusion of the vertebral bodies. With closed spondylodesis, the spine does not have to be exposed as the screws and longitudinal rods are inserted through small incisions through the skin above the affected vertebral bodies (percutaneous spondylodesis). The spinal canal is then opened through a further incision, the nerves are relieved and the intervertebral disc is replaced with placeholders. Compared to open spondylodesis, the blood loss, muscle damage caused by the open approach and post-operative pain are significantly lower. Patients recover more quickly with this procedure.

Patients undergoing spondylodesis remain hospitalised for approximately one week. They can get up and start light exercise as early as the first day after the operation.

In the majority of cases, a good to very good result is achieved with spondylodesis. Patients experience significantly less pain and can therefore move better again, which significantly improves their quality of life. The fusion of vertebral bodies does not necessarily mean restricted mobility of the spine. In rare cases, post-operative haemorrhage, wound healing disorders or loosening of a screw may necessitate a repeat operation. Complications such as paralyses or infections are also very rare. However, a progressive degenerative change in the spine can lead to stiffening of other vertebrae.

Many patients are concerned with the question before an operation: "Will I still be mobile afterwards?"

The spine does not become "rigid as a board", but merely less flexible in certain directions. The more segments are stiffened, the greater the restriction. At the same time, a considerable amount of movement is retained, as other sections of the spine compensate and the hips and pelvis play an important role.

There is good news here: most everyday activities remain possible - and often even better than before because the pain is reduced. Driving and sports such as swimming, cycling and walking are generally possible. Depending on the extent of the operation and the physical strain, most professional activities, hobbies and sports are usually possible again.