Stabilization of the lumbar spine (instability, spondylolisthesis)
Situations where ability to provide lumbar support is impaired
We deal with findings requiring surgical treatment (excluding traumas)
A team of experienced professionals – including trainers at an international level.
Lumbar spine stabilization operations are performed in cases when the spine loses its ability to provide support. This occurs due to excessive wear, genetic predisposition, or a combination of these factors. Instability is manifested as a disproportionate increase in the extent of movement between vertebrae, or their relative shift (spondylolisthesis). Less frequently the cause is infection or tumour involvement. Such conditions usually lead to the development of lower back pain and cause severe forms of compression of nerve structures and thus problems with the lower limbs (pain, impaired sensitivity, uncertainty or even loss of strength). In severe cases walking, urination and bowel movement may be impaired.
The primary means of treating instability of a non-tumorous and non-infectious origin is exercising and strengthening groups of muscles and ligaments that hold the spine in the correct position (the deep stabilization system). In the case of obesity, weight reduction is essential. Long-term improvement of the condition is achievable with the right rehabilitation leadership, and a good proportion of patients achieve the complete disappearance of their problem.
Surgery, which involves screwing the vertebrae (providing immediate stability) and preparing the ground for their fusion (to guarantee stability in the long term), is only proposed as a last resort. Indications for surgery must always be the result of careful consideration of the risks and benefits. The support function of the spine is renewed by this procedure and the problematic vertebrae stop their increased movement or shifting, or their relative positioning is adjusted (repositioning). If nerve structures are compressed, it is very important to release them sufficiently.
However, any procedure of similar magnitude involves certain risks can be the source of certain long-term pain itself (like any large intervention in the body, whatever the operation or trauma). Some problems in the context of postoperative scarring may occur during changes in the weather or greater exertion. The aim of the operation is to remove the greatest problem and prevent the deterioration of the patient’s condition.
Lumbar spine stabilization operations are medium to large operations. Historically, their methodology was primarily designed and later developed by selected orthopedic facilities. The need to properly release nerve structures often requires a sensitive and careful approach, which also brought neurosurgeons to these operations. In the Czech Republic (in line with the global trend) we are contributing to the development of the field of spondylosurgery, which incorporates complex spinal operations, during which the separate roles of orthopaedic and neuro surgeon are wiped away and replaced by the comprehensive and specialized position of spinal surgeon (spondylosurgeon).
Our team has extensive experience with instability issues of various origins. Stabilization operations are one of our core programmes, where we train many Czech and foreign colleagues and organize international meetings on this topic. Proof of our interest in this field and the high level of care for our patients is the monograph on this subject we published in 2007 in collaboration with our colleagues from the Masaryk University Orthopaedic Clinic in Brno.
We consider proper indication and preoperative consideration to be the cornerstone treatment. Many biomechanical influences enter the play here, which is why we assess the situation as a whole not just from simple images and MRI scans but supplemented by dynamic images (bending forwards and backwards) and in particular whole-body imaging, which helps enable us to correct the patient’s centre of gravity. Individual assessment of local and global parameters is essential for achieving the long-term success of treatment.
In the Czech Republic we can choose from a relatively wide array of implants and materials for the actual implementation of the operational procedure, which can be performed in a variety of ways. Care at our facility is sought by patients who have signs of nerve structure compression in particular. Decompression of nerve structures is necessary for the vast majority of them, which limits operating techniques, which require a more extensive “open”procedure.
As part of the preoperative examination, we need to assess the physical reserves of the patient and prepare them so that they can manage a lengthy operation with the possibility of losing a lot of blood. As screws and intervertebral implants are being inserted, all inflammatory processes in the body must be eliminated – in particular urinary tract infection or inflammation of the tooth, when we delay the operation until 14 days after the discontinuation of antibiotic therapy.
The procedure itself is performed under general anaesthesia. Prior to the operation the patient cannot eat, drink or smoke. This ban is generally valid from midnight to morning. Before surgery patients carry out their bodily needs, wash themselves with special antibacterial soap and have stockings put on their lower extremities to prevent blood clots in the veins.
Patients are taken to the operating theatre, transferred to a wheelchair and after administration of their preoperative medication transported to the operating theatre. The anaesthetist puts the patient to sleep, then the patient is placed in the operating position on their stomach with soft rollers laid beneath the lumbar and thoracic areas. The face lies on a gel mat. X-ray targeting of the segments to undergo operation is performed, cutting lines are marked and the entire area is thoroughly disinfected. Then the whole patient is covered in sterile drapes.
A standard operation with neural decompression begins with an incision down the middle and the revealing of the lumbar spine osseous structures to the extent required to perform the operation. For the vast majority of operations today we use navigation using mobile mainframe CT apparatus, so for this phase of the operation CT scans are performed directly in the operating position, which we immediately take advantage of for the precise targeting and implanting of all screws. This is followed by the ablation of the vertebral arch, which reveals neural structures (dural sac and nerve roots). Further resections of varying extent achieves their full release, and the operation continues with the resection of the intervertebral disc. As much of the cartilaginous matter of the intervertebral disc is removed as possible, and an implant stabilizing the anterior spinal segment (PLIF, TLIF etc.) is inserted. We now connect the implanted screws with rods, adjust the final angular position of the vertebrae and fix the whole structure in the final position. Finally we carefully deal with all sources of bleeding, insert drainage (tubing) which will carry residual blood and tissue fluid from the wound for the next 24-48 hours and close the wound in anatomical layers. We are increasingly using absorbable sutures. We treat the skin surface with tissue adhesive, which greatly facilitates nursing care and the hygiene of the patient (the wound is washable). This approach brings better cosmetic results, but cannot always be used.
After stabilization operations, patients are observed overnight in the neuro-ICU and transferred back to a standard ward the next day, with X-ray scans performed on the way. Rehabilitation and assisted walking follow, and then independent movement. Instructions on home exercises and daily routine are given at the rehabilitation department. Patients are typically discharged to home care 4-7 days after the operation, when the patient is able to walk short distances and take care of themselves. If absorbable suture and adhesive have been administered there is no need for bandages and visits to remove stitching. The adhesive layer spontaneously separates around 2-3 weeks after the operation, when the wound has healed. In the case of classic sutures, their extraction is planned 12-14 days.
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