Common spinal operations: definitions and terms explained
Spinal Fusion - surgically preparing two or more surfaces or vertebrae to become artificially joined over time, typically with bone graft joining the bony surfaces. The goal is to stabilise a painful, poorly aligned or dysfunctional (e.g. pinching nerves) motion segment. Common reasons (indications) that spine fusion is performed is due to spinal malalignment (e.g. spondylolisthesis, kyphosis or scoliosis), instability (e.g. trauma or spondylolysis - stress fractures), neuroforaminal spinal stenosis (where the fusion aims to increase the disc height by distracting the segment, thereby opening up the tight and collapsed tunnels impinging the nerves), persistent disc related or segmental pain after multiple operations that hasn't responded to conservative measures (to stop the painful segment moving.) Spinal fusions without an adequate indication (e.g. for back pain without a precision diagnosis) are generally discouraged as they are not as successful as surgery that is indicated and well planned for.
Posterior spinal fusion - fusion achieved by preparation of joint surfaces and facet joint, transverse process and lamina and packing with bone graft. Often held with screws either through the pedicles or local bony anatomy (e.g. cortical screws)
Lumbar interbody fusion (LIF) - spinal fusion achieved by insertion of a spacer implant (cage) and bone graft into the intervertebral space (between the discs) with or without screws/plates to stabilise.
Anterior LIF or ALIF - LIF performed through an incision at the front of the abdomen with an approach to the front of the spine around the internal abdominal organs with a front on trajectory to the disc.
Direct Lateral or Extreme Lateral LIF - DLIF/XLIF - LIF performed through an incision at the side of the abdomen with a perpendicular trajectory to the disc through the psoas muscle.
Oblique LIF or OLIF - ~45 degree trajectory to the disc through the abdomen in front of the psoas muscle.
Posterior LIF or PLIF - LIF performed by removing facet joints and shifting the nerve sac to access the back of the disc with disc clearance being back to front around the nerve sac.
Transforaminal LIF or TLIF - performed by accessing the corner of the disc under the exiting nerve root off to the side of the back of the spine.
360 degree fusion - combinations of LIF and posterior fusion.
Total disc replacement - an artificial protheses inserted into the intervertebral disc space intended to maintain spinal motion as opposed to fusion, after clearance of an intervertebral disc. They are commonly made of metal on plastic bearings (although newer combinations are emerging) and bond to the patient's vertebral endplate. On the left is an example of a lumbar total disc while the right is a cervical total disc replacement.
'Hybrid' - Combination of fusion and disc replacement
Decompression - removing pressure off spinal nerves, generally by removing one or more of a protruding disc, enlarged ligament, bony spurs or overgrown joints. Laminectomy (removing the lamina), discectomy (removing part of a disc) and foraminotomy (enlarging the tunnel for the nerve, or foramen) are all forms of decompression. Dr Zotti has been an early adopter of ultrasonic technology to facilitate bone removal and make surgery safer - see the link to the right courtesy of Cantor Spine Clinic, USA, explaining the technology:
Discectomy - surgically paring back or shaving a prolapsed disc touching a nerve. A sequestrectomy is typically performed, only shaving the external disc sitting behind the posterior longitudinal ligament. An aggressive discectomy aims to remove any loose or devitalised pieces in the disc space. Both have pros and cons.
Foraminotomy / Facetectomy - refers to enlarging the space around an exiting nerve root by removal of bony and joint around the foramen and /or facet joint. Usually done on one side but can be bilateral.
Laminoplasty - where a decompression (above) is performed but the lamina and bone parts are held splinted apart with bone or metal plates in an opened and expanded position, maintaining motion and stability.
'Micro' - refers to procedure done under magnification such as a microscope or loupe glasses.
Endoscopic refers to keyhole surgeon done with assistance of a viewing telescope linked to a screen.
Tubular - refers to a modified keyhole where the surgery is down down a tube with instruments
'Minimally invasive' / 'keyhole' - refers to procedure done with smaller incisions and less muscle damage than conventionally available operations. While appealing, there are also potential downsides to such approaches.
Navigated & Robotic - Refers to the computer assisted and guided implantation of spinal hardware often calculated and referenced off the patient's bone anatomy from imaging such as CT scans or paired-calibrated Xrays in theatre. Robotic navigation uses a proprietary 'arm' or robotic aiming device to assist in precise hardware planning that generally requires less tissue dissection - below is Dr Zotti performing robotic spinal surgery, for which he was the first in Queensland to perform robotic spine surgery and the first surgeon in Australia to perform a case with the MazorX system
Prone - Patient face down, abdomen down
Supine - Patient face up, abdomen up
Lateral - Patient placed on side
Radiofrequency ablation / neurotomy / denervation / pulsing - all refer to targeted procedures using needles through the skin to alter pain fibres in nerves using radiofrequency energy delivered around the tip of a needle. Ablation aims for permanent destruction of a nerve (e.g. to an arthritic joint) whereas pulsing is less permanent and aims to just desensitise a sensitive nerve (see Back pain - non surgical procedures section).
Spinal instrumentation or stabilisation - refers to insertion of spinal metalwork for the purpose of stabilising a segment. This may be to promote bony fusion (by holding the segment still and supported) or in the context of trauma such as unstable fractures.
Coccygectomy - removal of part of the coccyx bone.
Spinal cord stimulation or 'neuromodulation' - the use of implantable battery powered electrodes to deliver signals to the spinal cord or affected nerves and alter the ascending pain signals travelling to the brain, thereby altering the pain experience for the patient from the pain stimulus below.
NERVE SURGERY - Carpal tunnel, cubital tunnel and peroneal nerve decompression (left, middle and right, respectively) - following the nerve through common sites of compression and ensuring that it is free of tethering or impingement. Transposition is where a new pathway for the nerve is fashioned, often under skin or muscle flaps.
Closed reduction - fracture brought back together without directly opening the fracture site
Open Reduction - fracture brought back together by directly opening / manipulating the fracture site
Internal Fixation - position held with internal metalwork - screws, pins, rods or plates (or combination)
External Fixation - position held via external frame or plaster
Open fracture - fracture exposed to external environment with broken soft tissue overlying
Closed fracture - skin/soft tissue overlying fracture is intact
Neurovascularly intact - there is no compromise to circulation or sensation/nerve function as a result of the fracture
Skeletally mature - fracture has occurred in someone with closed/no growth plates
Arthroplasty - replacement of joint - Hip hemi(half) arthroplasty common for neck of femur fractures
Above: Open reduction internal fixation radius (wrist) fracture, closed reduction internal fixation (hip nail), closed reduction and external immobilisation (plaster after manipulation under anaesthesia for wrist fracture in skeletally immature patient), hip hemiarthroplasty for fractured neck of femur, open reduction internal fixation of fibula (ankle fracture, Open reduction and internal fixation with tension band wires of patella (kneecap) fracture
Brief procedural descriptions courtesy of Spine-Health.com