Guide for Patients Spinal Dynamic Stabilisation or Spinal Fusion?

A Guide for Patients

Spinal Fusion

The goal of spinal fusion surgery is to provide relief from the pain you have been having and make your spine more stable. After surgery, your ability to move should improve, and you can get back to doing the daily activities you may have been missing.

Dynesys® Dynamic Stabilisation System:  

The Dynesys Dynamic Stabilisation System is a newer concept in the surgical treatment of lower back and leg pain -- one that uses flexible materials to stabilise the spine and offers a potential alternative to traditional fusion.

This web page will help you understand:

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This information is provided as support, if you have any questions, please ask your surgeon as he or she is the only one qualified to comment on your specific condition.

A glossary is also provided to help you become familiar with medical terms your doctor may use to describe your condition and treatment.

Healthy spine The Healthy Spine

The spine is one of the most important structures in the human body, supporting much of your weight and protecting the spinal cord, which carries communication from the brain to the rest of the body. The spine is strong but flexible, allowing wide range of movement.

The spine extends from the base of the skull to the tailbone and is made up of thirty-three bones known as the vertebrae. The first seven vertebrae (the cervical vertebrae) are in the neck and are numbered C1 through C7. Nerve compression in this area can cause neck pain, which may radiate down the arms to the hands and fingers.

The next twelve vertebrae make up the thoracic region (T1 through T12); the ribs attach to these vertebrae and protect the heart and lungs. Few spinal problems occur in this region; it’s usually very stable. The lumbar region is the lower back, which contains five vertebrae (L1 through L5).

Vertebrae The lumbar spine plays a significant role in motion and flexibility. It is the source of most motion and supports most of the body weight. Overload or taxing movements may strain the structure, compress the nerves and cause back pain, which may radiate down the legs to the feet.

The regions beneath the lumbar spine are the sacrum (S1 through S5) and coccyx (a series of small bones often called the tailbone). These are fused; they do not have discs between them.

Each vertebra is composed of a body and a spinous process which protect the spinal cord and nerve roots. The vertebrae in the cervical, thoracic and lumbar regions are separated by discs. Discs serve as a cushion between the vertebrae, helping also to protect them and the nerves that run from the spinal cord to the rest of the body.

Problems of the Back

It is estimated that 38% of the adult UK population have low back pain in any year 1,2. Most back pain is acute, meaning that it occurs for a short time and then heals. In some cases, however, the pain and symptoms can last for months or keep coming back; this is considered a chronic, or long-term, problem and requires a doctor's care.
Since the spine is so important for support and movement, damage to the spine can disrupt even the simplest daily activities.

Conditions of the Spine
There are a number of factors that can cause back disorders and affect movement. As our body ages, time, old injuries and habitual positions and movements can be costly to spine health and can influence disc degeneration. This web page addresses phenomena linked with the degeneration of the spine; it does not address spinal fractures or deformities.

A spinal disc shrinks when it degenerates, narrowing the space between the vertebrae and sometimes pinching nerves. This can cause pain at the site, and it can also cause symptoms in the parts of the body served by these nerves. People with spine degeneration may have low back pain or numbness that travels down one or both legs to the feet, possibly with a weak feeling in the leg muscles.

Your doctor may recommend physical therapy to strengthen the muscles that support the spine and to ease pain. Your doctor may also prescribe medication. This may resolve the issue; some problems and pain may continue.

Sometimes the pain will not go away. There are a number of possible reasons for this:

Disc Degeneration

Over time, discs between the vertebrae can dry out and can no longer cushion and absorb shock in the spine. Degeneration triggers stenosis, the narrowing in the canal that protects the spinal cord and nerve roots. This may cause pain in the lower back or legs when walking or standing and be relieved by sitting or bending forward.

Stenosis

Fig. 1 Stenosis

 

Disc Herniation

The disc between the vertebrae may rupture and protrude, which creates pressure on the spinal cord or nerves.

Herniated Disc

Fig. 2 Herniated Disc

Sciatica

A herniated disc of the lumbar spine may cause pain along the sciatic nerve and radiate to the buttocks and to the back of the thigh.

Spondylolisthesis

The vertebrae may become out of line, with one or more vertebra becoming displaced, causing pressure on the nerves.

Spondylolisthesis

Fig. 3 Spondylolisthesis

 

Treatments

Treatments If physical therapy and medication do not solve the problem, a spine specialist will order further diagnostic tests to help find the root cause of the pain and determine the severity of the problem. You will fill out a questionnaire about your symptoms, pain and mobility, and the specialist will complete a series of tests, including dynamic radiography for imaging and/or an MRI (Magnetic Resonance Imaging).  

Taking into consideration your history, condition and situation, your specialist will use the test results to determine an appropriate treatment for you.

Non-Surgical Treatment

Non-Surgical Treatments Non-surgical or conservative treatment consists of a combination of rest, weight control, exercise, physical therapy, application of heat and cold, injections and/or antiinflammatory medications. The persistence of pain is evaluated after this treatment. A spine specialist will decide whether surgical treatment is necessary.

Surgical Treatment

Surgical Treatments Your doctor may recommend surgical treatment under anesthesia to realign the spine, restore the space between vertebrae and relieve pressure on the nerves that are causing pain. An anesthesia test will be completed before surgery to evaluate possible risks. Your history, condition, diagnosis and the goals of the surgery are all considered when determining the best surgical procedure for you. Depending on the level of disc degeneration, the surgeon will choose between rigid fixation (which fuses vertebrae) and non-rigid fixation (also called dynamic stabilisation).

Spinal fusion, in which the affected discs are removed and the associated vertebrae gradually fuse together through new bone growth, has historically been the standard treatment and is still in use depending on the patient’s conditions. An implant of screws and inflexible rods holds the vertebrae in place during the fusion process.

A non-rigid, dynamic implant system is an alternative to fusion. Flexible materials between screws help to preserve anatomical structures, restore the healthy alignment of the vertebrae and relieve the weight overload on the vertebrae adjacent to the implant.

Spinal Fusion Surgery Spinal Fusion Surgery

Depending on the condition of the spine, the doctor may use an anterior approach, which means the incision will be in the abdomen, or a posterior approach, which means the incision will be in the back.

Sometimes the doctor may choose to use a combination of the two. If the doctor uses a posterior approach, then a pedicle screw system is used to stabilise the spine while it fuses. The pedicle screw system may be used alone or it can be combined with another stabilising device.

During surgery, the doctor may relieve the nerve compression by removing the disc (the procedure is called a discectomy). The doctor may also relieve pressure on the nerve by trimming or removing the roof, or lamina, of the vertebra to create more space for the nerve (called laminectomy ). The doctor then restores the space around the nerves and prepares to stabilise the spine with the pedicle screw system. There are a number of components in a pedicle screw system, and the doctor will choose the ones that will work best for your spine.

The screws are placed through each side of the vertebrae in the part of the part of the bone called the pedicle. Rods are then attached to connect the screws and hold the spine in its restored position. The pedicle screw system is now secure. In the last step of the surgery, the doctor places bone graft (small chips of bone) alongside of the vertebrae to be fused or puts the graft in and around a device that's placed between the vertebrae. Bone graft can come from the patient's hip bone, from a bone bank, or from a combination of both.

The pedicle screw system will hold the spine stable until the bone graft fuses with the vertebrae. Although bone fusion is a natural biological process, complete fusion can take up to one year. In some cases, people may have trouble fusing their spine. Many things, such as smoking or various medications, can interfere with successful fusion. Your doctor will discuss with you the risks associated with your specific surgery.

Spinal Non Fusion Surgery with the Dynesys Dynamic Stabilisation System

This non-rigid, dynamic implant system is an alternative to fusion. Flexible materials between screws help to preserve anatomical structures, restore the healthy alignment of the vertebrae and relieve the weight overload on the vertebrae adjacent to the implant.

How can the Dynesys System help?

The Dynesys System is a pedicle-screw fixation system, an implant device consisting of a spacer, cord and pedicle screw. It offers a unique approach to stabilisation and mobilisation of the spine and pain relief -- a "dynamic" approach -- that relies on flexible materials and preserves much of the spinal anatomy.

Normal at rest

Flexion

Extension

At rest: The Dynesys System supports an intervertebral joint

Flexion: The Dynesys System supports the affected joint as the spine bends forward

Extension: It also supports the joints as the spine bends backwards

Which patients are candidates for the Dynesys System?

The Dynesys System can be used in skeletally mature patients to provide immobilisation and stabilisation of spinal segments. It is used to treat degenerative disc disease in the lumbar and / or sacral regions when there is evidence of resulting neurologic impairment.

Your doctor will decide the best way to perform surgery for your unique conditions. Keep in mind that other factors will also have an impact on your recovery after surgery. Obesity, smoking and psychological problems may decrease your chance for a successful outcome.

When should the Dynesys System not be used?

The Dynesys System should not be used in the cervical spine or for patients that are obese, pregnant, abuse alcohol or other drugs, or who have:

  • an active or systemic infection
  • mental illness
  • severe osteoporosis or osteopenia
  • sensitivities or allergies to metals, polymers, polyethylene, polycarbonate urethane and polyethylene terephthalate
  • soft tissue deficit
  • congenital abnormalities
  • tumors
  • inadequate pedicles of the thoracic, lumbar and sacral vertebrae

The Dynesys System is also not appropriate for individuals with any medical or mental condition that puts them at high risk from surgery of this severity, those with a condition that will not allow them to benefit from the surgery or decrease the useful life of the device, and those who are unwilling or unable to follow post-operative instructions.

What does surgery with the Dynesys System involve?

The Dynesys System is compatible with conventional posterior surgical techniques, and in some cases can be implanted using a minimally invasive approach. On average, the procedure to implant the Dynesys System takes two to three hours which is similar to the time required for traditional fusion procedures, depending on patient conditions.

The Dynesys System is attached to the bony extrusion (pedicle) on each side of the affected segment. Once in place, the components create a dynamic push-pull relationship that stabilises the affected joints and keeps your vertebrae in a natural position.

What to Expect Before and After Surgery

Before Surgery

Before surgery You are an active participant in the surgery’s success. Proper preparation for surgery is mandatory. It is important to be as fit as possible when you go into the clinic; this will help your recovery and enable you to be mobile and active more quickly after surgery.

Improve your general health and follow healthy dietary recommendations. Both obesity and smoking increase the risks during the surgery and may complicate recovery.

Strengthen your muscles; some exercises may prepare your back muscles for surgery. Therefore your doctor may recommend exercises for you.

Inform you doctor of allergies, medicines and antibiotics. Patients who regurlarly take aspirin must, if recommended by his/ her doctor, stop taking them eight to ten days before surgery.

Surgery

A spinal implantation follows a very accurate protocol and is a standard operation for spine surgeons. The medical team is familiar with the procedure and is fully equipped to take care of you.

The surgery takes place under general anesthetic. The possible risks with anesthesia will be discussed with you before surgery.

Depending on the most suitable surgical posterior approach, either one or two skin incisions will be made on your lower back.

The standard duration of surgery is two hours (1), typically with minimal blood loss. Post-surgical pain is usually controlled by a sedative injection in the spinal canal during surgery.

(1) Depending on the number of levels operated on.

Risks

Any surgery involves risk. Your doctor will inform you about the risks related to the surgery and your case.

Position 1 Knee/Chest

 Position 1 Knee/Chest

Position 2 Prone  

Position 2 Prone

After Surgery

After surgery A trained medical team will accompany you in the recovery room. Depending on your condition, you will likely be asked to move around the day after surgery. Early movement is important to beginning an efficient recovery process after a surgery with a dynamic spinal implant. With each new step forward, you improve your future ability to move and improve your quality of life.

The day after surgery, measures will be taken to relax muscles; you should be able to make controlled movements. Extensive movements that tax the back are not recommended early on. You back should not be required to withstand too high a load at this point, and you should take care not to start driving too early.

Any surgery involves risk. Contact your doctor if you have any of the following symptoms after surgery:

  • Signs of infection, such as fever, chills, redness around the incision or a feeling of pressure in the spine.
  • Sudden pain or a significant increase in pain
  • Loss of feeling in your hands or feet

After the surgery- Spinal Fusion

After surgery 2 Recovery from spinal fusion surgery happens in stages as your body heals. The first stage of recovery involves the healing of the incision and soft tissues. This will happen over the first few weeks. Movement, such as walking, does a lot to help with healing. You can expect to be doing some walking as soon as the day after surgery, and you will be expected to walk every day after that. Your doctor may also have you go to physical or occupational therapy for gentle exercise in the early weeks of recovery.

Your doctor will monitor and evaluate the bone fusion throughout your recovery. This will mean visits to the doctor's office, where x-rays will be taken to see how the bone is fusing. Your doctor will tell you what things you can do to help your recovery.

Complete fusion surgery takes months, and recovery is different, for each patient. Depending on how many levels of your spine are fused, you may notice some changes in the flexibility of your back. Your doctor will tell you what you can expect during your recovery.

Spinal fusion surgery using a pedicle screw system is designed to stabilise your spine, giving you the ability to move more easily and with less pain. For most people, spinal fusion surgery offers significant relief and improved ability to move and function in their daily lives.

This page  is meant to help you understand spinal fusion surgery and pedicle screw systems like the Silhouette ™, OPTIMA  ZS or ST360  Systems, so you can work with your doctor to make the treatment decision that is right for you. If you have any questions, please talk to your doctor.

After Surgery - Dynesys Dynamic Stabilisation

It may take several weeks to fully recover from pain resulting from the surgery. However, you may feel almost immediate relief of any leg pain. Back pain should diminish over time now that the vertebrae have been stabilised and nerves are no longer compressed. In most cases, a short hospital stay is required to ensure you adjust to oral pain medication and can move without any problems. Most patients return home within a few days.

Following your surgery, your doctor will prescribe rehabilitation and follow-up visits as needed. It's important to follow your physician's instructions carefully to help ensure a full and quick recovery.

You need to modify your normal lifestyle to adjust to your spinal implant. You will gain more stability as your back muscles heal. Though you may be able to continue living life as normal, some measures need to be taken to preserve your back.

At home At Home

You need to modify your normal lifestyle to adjust to your spinal implant. Further regular exercises will be recommended to care for your back. These will strengthen muscles and your entire back. Though you may be able to continue living life as normal, some measures need to be taken to preserve your back.

To keep from overloading the implant:

  • Do not carry heavy-weight objects
  • Do not make large motions (2).

You may engage in some sports again, but only in a progression after few weeks, depending on your situation, the success of your therapy and the state of your muscles. Ask your doctor first. Your doctor can give you more information on what is right for you.

(2) Your doctor will give substantial details according to your case.

Symptoms To Watch For After Surgery
As your doctor will explain, any surgery involves risk. After surgery, if you have any of these symptoms, you should contact your doctor:

  • Signs of infection (fever, chills, redness around the incision, increased pain, a feeling of pressure in the spine)
  • Bleeding or excessive drainage from the incision
  • Sudden pain, or a significant increase in your pain level
  • Loss of feeling in your hands or feet
  • Increased or ongoing shortness of breath

Are complications possible?

Surgery always involves some risk. General surgical complications may include:

  • reactions to anesthesia
  • heart attack
  • infection
  • blood vessel damage/bleeding
  • bruise (hematoma)
  • pneumonia
  • blood clots
  • wound closure problems
  • death

Potential risks associated with the implantation of the Dynesys System are similar to those associated with any spinal fusion procedure and those risks specific to the implantation of other pedicle-screw systems. They may include:

  • tear in the outer lining of the spinal cord which may result in spinal fluid leakage
  • temporary decreased or absent intestinal function
  • leg pain
  • nerve complications
  • fractured sacrum

Please consult with your doctor for a complete list of all warnings and precautions.

What to Expect from the Surgery

What to expect The primary goal of this surgery is to restore segmental stability in order to relieve your back and leg pain. As with any treatment for pain, relief symptoms will vary from patient to patient.

How can I improve my chances of a good outcome?

It's well known that smokers experience lower surgery success rates than non-smokers. If you smoke, please consider stopping as far in advance of surgery as possible. In addition, poor nutrition impacts your body's ability to heal itself. Eat well-balanced, nutritional meals as far in advance of surgery as possible.

Frequently Asked Questions

Frequently Asked Questions When can I go home from the hospital?

Usually within a few days, once you have adjusted to oral pain medications and have shown that you can get up and move around without problems.

How do I rehabilitate after surgery?

Every surgeon follows a slightly different program depending on the patient’s physical condition. Physical therapy is often a part of recovery.

What kind of follow-up can I expect?

Follow-up varies from surgeon to surgeon. Your first follow-up visit will probably be within a few weeks of surgery, then every few months for the first year. You should be checked annually after the first year.

When can I go back to work?

Your doctor will recommend the best way to progressively continue the activities in your life based on the progress of physical therapy.

What if I have more questions?

This web site is provided to give you information about your treatment options, but it is not intended to replace professional medical care or provide medical advice. If you have any further questions or need additional information about the Dynesys System or spinal fusion using Silhouette, Optima ZS or ST360 Pedicle Screw Systems, please call or see your doctor, who is the only one qualified to diagnose and treat your condition.

Glossary

Arthrosis: Degenerative disease of the joint.

Back Disc: The cushion between the vertebrae in the spine.

Bone Bank: a laboratory where allograft bone is stored for use in surgery.

Bone Graft: there are two kinds of bone grafts. Autograft bone is bone that is harvested from one place in a person and then transplanted to another location in the same person. Allograft bone is bone donated from one person and harvested, processed, stored and then transplanted to another person.

Collapsed Disc: Closure of the space between the vertebrae where the disc has degenerated or herniated.

Degenerative disc disease (DDD): loss of elasticity and flexibility of the disc. Although it can happen quickly, most DDD develops over time due to use or misuse.

Degenerative Spondylolisthesis: Slippage of one or more vertebrae in relation to others.

Disc Protrusion: A disc between the vertebrae that has pushed outside its normal space into the spinal canal.

Disc: a fluid-filled, jelly-like cushion between the vertebrae of the spine. Each disc is identified by the vertebrae that surround it. For example, the L4-5 disc is the disc between the L4 and L5 vertebrae.

Discectomy: a surgical procedure that involves removing damaged disc material from between the vertebrae.

Dynamic Stabilisation: Surgical procedure that aims to restore the stability in the spine using pedicle screws and flexible components.


Facet Joint Osteoarthritis: Degenerative arthritis involving breakdown of cartilage between the facet joints (part of the vertebrae).

Fusion:the joining of bones.

Herniated Disc: The squeezing out of the soft center of the intervertebral disc due to deterioration of the outer layer of the disc (the annulus fibrosis), usually into the spinal canal.

Incision: a cut made through the skin and into the body during surgery.

Laminectomy: a surgical procedure that relieves pressure on the spinal nerves by trimming or removing the lamina (roof) of the vertebra to create more space.

Osteoarthritis: Degenerative arthritis involving the breakdown of cartilage between the joints.

Osteoporosis: Disease characterised by low bone mass and the deterioration of the structural integrity of bone tissue, leading to bone fragility and an increased susceptibility to bone fractures.

Pedicle: a stem-like area on the back of the vertebra that connects the main part of the vertebra to the structures (e.g. the lamina) that project from it. Each vertebra has two pedicles.

Pedicle screw system: a system of screws and rods or flexible components that holds the vertebrae stable.

Sciatica: Pain along the sciatic nerve (lower back).

Scoliosis: a condition in which there is a sideways curve to the spine.

Spinal fusion surgery: a procedure to restore and maintain the space between the vertebrae by stabilising the bones until they can grow together.

Spine: the bony column from the base of the skull to the tailbone. The structure is made up of vertebrae and contains five regions: the cervical, thoracic, lumbar, sacrum and coccyx.

Stenosis: a general term used to describe a condition in which the spinal canal narrows and presses on the nerve.

Vertebra(Vertebrae): one of 33 bones that form the spine. Each vertebra is identified by number within its region of the spine. For example, L1 is the first vertebra in the lumbar region.

If you have any questions about Spinal Fusion Surgery or Dynesys® Dynamic Stabilisation System, please talk to your doctor.

  1. Palmer K.T, Walsh K, Bendall H, Cooper C & Coggon D Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years B.M.J. 2000 320 1577-1578
  2. Walsh K, Cruddes M, Coggon D. Low Back Pain in eight areas of Britain J. Epidemiol. Comm. Health 1992 46 277-230