The spine in the lower (lumbar) back consists of the bony vertebrae, discs, nerves and other structures. The vertebrae, which stack up to create the spinal column, surround and protect the spinal cord and nerve roots. The end of the spinal cord (conus) is near the top of the lumbar spine. Below this, the nerve roots hang down in individual strands. These nerve roots, when viewed together, are somewhat similar in appearance to a horse’s tail, so the term used to describe them is cauda equina. The nerve roots travel out small bony windows (foramenae). The discs are located between each vertebra. Discs consist of a fibrous outer layer (annulus) surrounding a gelatinous center (nucleus). They allow motion between vertebrae, act as shock absorbers, and distribute the stress and strain placed on the spine
Degenerative Disc Disease: As we age, the water and protein content of the body’s cartilage and discs change. This change results in weaker, more fragile and thin cartilage. Because both the discs and the facet joints that connect the vertebrae are partly composed of cartilage, these areas are subject to wear and tear over time. The gradual deterioration of the discs is referred to as degenerative disc disease. This can be noted on x-ray tests or MRI scanning of the spine as a narrowing of the normal disc space between the adjacent vertebrae. Degeneration of the disc can cause narrowing of the spinal canal (stenosis) and apply pressure on the nerve roots. This can be experienced as pain which radiates down the thigh and/or leg with walking or standing (neurogenic claudication). If the pressure on the spinal nerve roots continues, numbness or muscle weakness in the leg or foot may develop..
Conservative Management: Backache associated with spinal arthritis is common and usually comes and goes without formal treatment. The best prevention and treatment is staying fit and active. For severe episodes of back or leg pain, with the passage of time and treatment with ice, heat, and short periods of rest, inflammation around the nerve roots can resolve on its own. Steroid injections may help relieve the pain by reducing some of the inflammation around the nerves, allowing the irritated nerve time and space to heal. If this conservative care does not relieve symptoms or if there is progressive neurological damage, surgery may be necessary.
Anterior Lumbar Artificial Disc Replacement (LADR) is an operation to restore motion, relieve pressure on irritated nerves, and ensure this pressure does not return. This surgery typically involves an incision in the left lower quadrant of your abdomen, but depending on the number of levels, other incisions may be employed. The spinal surgeon will safely remove the degenerated disc between the two vertebrae. Next, the surgeon will use a template to determine the appropriate size artificial disc for the patient. Then, the artificial disc is placed between the two vertebrae where the disc had been, allowing for motion to occur and act as a replacement to the natural disc. After the operation, patients should have natural restored motion in their spine.
Surgery and anaesthesia involve stresses to many organs and tissues in the body. Incisions and handling tissues during surgery can result in many problems. The benefits of surgery must be carefully weighed against these risks. Some more common or serious problems are listed here.
Spinal Cord or Nerve Root Injury: Permanent injury to the spinal cord or nerve roots is extremely rare. It is not unusual, however to experience minor temporary tingling, numbness, weakness or pain which resolves over several weeks. All precautions will be taken but rarely, more serious nerve injuries may occur, effecting walking, balance, bowel or bladder functions.
Dural Tear: Leakage of spinal fluid can occur due to a tear in the tissue (called the “dura”) holding the spinal fluid and containing the nerves. On rare occasions additional surgery may be needed.
Infection: Infection is always a post-operative risk and occurs in approximately 1–2% of surgical patients, varying by surgery type. Infections may be superficial or deep into the bone. You are given antibiotics before and after the surgery to help prevent this complication. Please follow the instructions for wound care to help prevent infection.
Airway Compromise: Extremely rarely swelling within the neck can cause difficulty with breathing. If this occurs in the hospital, a breathing tube may need to be kept in place. If this occurs at home, it is an emergency and requires transportation to an emergency room.
Other complications: Other possible complications include blood clots, pneumonia and complications related to the general anesthesia. Persistent hoarseness and/or swallowing problems may last for several weeks. Please call us if this persists
Adequate rehabilitation is crucial for a successful result. Many patients with spinal injuries have suffered from spinal pain for some time. This may result in considerable weakening of the spinal muscles due to lack of exercise, so you should return to your normal activities slowly.
The primary form of rehabilitation after surgery is an aggressive walking program. You should start immediately after discharge, walking more and more each day. In general, we recommend two to three episodes of exercise per day. The average patient can be walking 15 minutes twice a day by their first postoperative visit and 30–40 minutes twice a day by six weeks after surgery. Walk more if you are so inclined!
Patients routinely experience a dramatic, remarkable reduction in their arm pain. If the nerve has been irritated for a long time, then a more gradual reduction of the arm pain is to be expected. As the nerve heals, expect tingling or a warm feeling. Depending on how long the symptoms have been present, strength is usually the second symptom to improve. Numbness in your arm / hand is the last to resolve and, if present for long enough prior to surgery, may be permanent.
Neck pain associated with the incision is largely improved within two to three weeks. Increased pain with prolonged sitting and driving is also expected and, for safety reasons, we recommend refraining from driving for approximately three weeks.
At your first post-operative visit we will inspect your wound and remove any stitches as necessary.
Prescribed narcotic pain medication may cause some constipation. To help with this:
If you need a refill on your pain medication, please have your pharmacy fax the refill request to our office @(949) 988-7800 and please allow up to 48 hours for the request to be processed. Refills on pain medication will not be filled after hours or on weekends or holidays. Be aware of how much pain medication you have, & obtain refills before you run out.
Avoid twisting your neck to the extremes, and avoid forced bending of your neck either forward or backward. Gentle range of motion of the neck is OK. Do not drive until you have received permission from your physician.
Dr. Gottlieb, or simply Jamie as most of his patients come to know him, is not your typical doctor. His daily attire of scrubs and cowboy boots is the first indication of his demeanor to most people. You will not find suits and ties in this office. You won’t hear doctor Gottlieb talk in medical jargon when going over your concerns or diagnosis. He speaks in simple straightforward language and will develop an easy to understand plan of care to address your individual needs.
Nonoperative conservative care is the first step and often all that is required to improve your quality of life.
If surgery is needed, Jamie is well versed in traditional, minimally invasive and motion preservation techniques.