What Happens When Tiny Fractures in Your Spine Cause Life-Altering Pain?
What happens when tiny fractures in your spine cause life-altering pain and the solution requires GPSG guided lasers, abdominal surgery, and a surgical team in perfect harmony? I’m Dr. Kelly Bridges, board certified neurosurgeon, and I want to walk you through a case that highlights the complexity and the precision of modern spine surgery.
The Patient’s History
I recently met a woman in her mid to late 50s with a long-standing history of low back pain. Over the past year, she developed pain going down the back of her leg into her foot. She had numbness in the bottom of her foot and an occasional weakness with picking up her foot. She had spine imaging which demonstrated bilateral L5 pars fractures and an ismic spondylloisthesis with severe framinal stenosis.
Now I know that’s a mouthful. So let’s break that down into more simple terms.
Breaking Down the Anatomy
The spine is made up of rings of bones called vertebrae which are stacked on top of each other, separated by discs and connected by joints. At each level, there is an opening between the two vertebrae that allows a nerve root on either side to leave the spine and go out to its target elsewhere in the body such as the back of the leg and foot. This tunnel is called a fammen.
At the back of each vertebrae, there’s a thin segment called the pars inner articularis. This part of the bone can fracture often from repetitive stress of the spine. This fracture is called a pars fracture and this can cause the top vertebrae to slip forward over the bottom vertebrae. When this slip happens, it’s called spondyllyis or ismic spondyololisthesis.
As this slip occurs, those tunnels where the nerves exit become narrow. That narrowing is called stenosis. And when it affects those tunnels, it’s called framinal stenosis. So this narrowing can become severe enough that it can pinch the nerves causing pain, numbness, tingling or weakness.
So let’s get back to our patient and her specific imaging.
She has bilateral pars fractures at L5, the lowest vertebrae in the lumbar spine. This has caused her L5 vertebrae to slip forward on S1, which is the top of the sacrum. The L5S1 framina have become narrowed and her L5 nerve roots are being pinched. This is in stark contrast to the nerves at the other levels which exit their foramina or tunnels freely. My patient’s MRI shows her L5 nerve to be severely compressed. This caused her to have leg pain and weakness of her foot.
Why Surgery Became the Definitive Treatment
When structural instability like this occurs, surgery becomes the definitive treatment. And there are multiple surgical approaches to correcting this problem, each with their own risks and benefits tailored to the patients specific anatomy, symptoms, and overall health.
For this particular patient, I chose to begin the correction with an anterior approach, entering through the abdomen to access the disc directly, remove the disc, then implant a large cage between the L5 and S1 vertebrae. This is called an anterior lumbar innerbody fusion or AIF for short.
I team up with a vascular or general surgeon to access the spine and move the major blood vessels. Once we reach the disc space, I remove the disc and insert a cage filled with bone graft. This restores the disc height, reopens that framinal space and lifts the pressure off the nerves.
As you can see from the X-rays taken during surgery and the CAT scan thereafter, this anterior approach provided a significant improvement in the height of the disc now more closely matching her normal disc heights at the levels above. And her alignment of L5 relative to S1 improved as well. An MRI proved complete decompression of the L5 nerve roots, which now had plenty of space around them.
Because this anterior step was so effective, I was then able to perform a minimally invasive posterior fusion using a special navigation system to place screws and rods through small incisions in the back without having to disrupt the muscles around her spine.
This technique uses the patient’s CAT scan loaded into a navigation software, which works like a GPS. We then use infrared lasers in the operating room to essentially help guide our instruments directly to our pre-planned targets in the spine. This helps us insert screws with pinpoint precision, even in small or narrow bones, which she had, measuring nearly 5 mm in height. That is about the thickness of a chocolate bar or your USB connector.
The Team Behind Modern Spine Surgery
Modern-day spine surgery is not a solo act. It is a coordinated effort involving a team of people dedicated to ensuring the surgery goes smoothly. Let’s review them together.
The circulating nurse manages the room, ensures sterility, and coordinates getting supplies. A scrub tech hands instruments to the surgeon, maintains the sterile field, and anticipates a surgeon’s needs step by step. An X-ray technician operates special machinery to provide interoperative X-rays or CAT scans during surgery.
A neurom monitoring tech tracks nerve signals in real time to identify if there are any problems with the nerves during surgery. An instrument rep ensures we have the correct implants and tools and helps troubleshoot if there are any problems with those instruments. A navigation system rep supports our neuron navigation system while navigating the software and maneuvering the equipment as needed during surgery so the surgeon can stay sterile and focused on the procedure itself.
The anesthesia team keeps the patient safely asleep and comfortable, monitoring vital signs and administering additional medications as needed throughout the surgery. A physician assistant assists the surgeon with exposure, instrumentation, and closure. And then there’s the surgeon or two who perform the procedure, make interoperative decisions, and ensure precision.
Sometimes there is a large team of people in an operating room during surgery with each person playing a vital role in the patients safety and surgical success.
The Role of Neuromonitoring During Surgery
While this particular surgery was being performed, I opted to have a specialized person called a neurom monitoring technologist in the operating room with me. They help monitor nerve signals and pathways during the surgery.
These technologists track how signals travel through the spinal cord and the nerves in real time. If those signals change, like if they slow down or weaken or show abnormal muscle activity, it could mean a nerve is being irritated or injured. The technician alerts the surgeon immediately so those adjustments can be made before any lasting damage occurs.
Surgical Outcome
Overall, the surgery was a success. The combination of an anterior lumbar inner body fusion with minimally invasive neuronavigated posterior screw fixation gave this patient dramatic symptom relief without needing a large posterior decompression.
With precision tools and a multidisciplinary approach, we were able to relieve nerve compression, restore anatomy, and avoid excessive tissue disruption. Spine surgery today is a blend of art, science, and technology. With the right team, tools, and strategy, we can transform lives even in complex cases.
So, if you found this helpful, please like, subscribe, and share with others who might benefit. From medical students to patients navigating their own spine journey, let’s empower through education. More stories and surgical insights are coming soon.