Spine Health & Spinal Hygiene

For individuals who have exhausted all other treatment options for low back pain and nerve root compression, can laser spine surgery help alleviate nerve compression and provide long-lasting pain relief?

Laser Spine Surgery

Laser spine surgery is a minimally invasive surgical procedure that uses a laser to cut through and remove spinal structures that are compressing nerves and causing intense pain. The minimally invasive procedure often results in less pain, tissue damage, and faster recovery than more extensive surgeries.

How It Works

Minimally invasive procedures result in less scarring and damage to surrounding structures, often reducing pain symptoms and a shorter recovery time. (Stern, J. 2009) Small incisions are made to access spinal column structures. With open-back surgery, a large incision is made down the back to access the spine. The surgery differs from other surgeries in that a laser beam, rather than other surgical instruments, is used to cut structures in the spine. However, the initial incision through the skin is made with a surgical scalpel. Laser is an acronym for Light Amplification Stimulated by Emission of Radiation. A laser can generate intense heat to cut through soft tissues, especially those with a high water content, like spinal column discs. (Stern, J. 2009) For many spine surgeries, the laser cannot be used to cut through bone as it generates instant sparks that can damage surrounding structures. Rather, laser spine surgery is primarily used to perform a discectomy, which is a surgical technique that removes a portion of a bulging or herniated disc that is pushing against the surrounding nerve roots, causing nerve compression and sciatic pain. (Stern, J. 2009)

Surgical Risks

Laser spine surgery may help resolve the cause of nerve root compression, but there is an increased risk of damage to nearby structures. Associated risks include: (Brouwer, P. A. et al., 2015)

• Infection
• Bleeding
• Blood clots
• Remaining symptoms
• Returning symptoms
• Further nerve damage
• Damage to the membrane around the spinal cord.
• Need for additional surgery

A laser beam is not precise like other surgical tools and requires practiced mastery and control to avoid damage to the spinal cord and nerve roots. (Stern, J. 2009) Because lasers cannot cut through bone, other surgical instruments are often used around corners and at different angles because they are more efficient and allow greater accuracy. (Atlantic Brain and Spine, 2022)

Purpose

Laser spine surgery is performed to remove structures that are causing nerve root compression. Nerve root compression is associated with the following conditions (Cleveland Clinic. 2018)

• Bulging discs
• Herniated discs
• Sciatica
• Spinal stenosis
• Spinal cord tumors

Nerve roots that are injured or damaged and constantly send chronic pain signals can be ablated with laser surgery, known as nerve ablation. The laser burns and destroys the nerve fibers. (Stern, J. 2009) Because laser spine surgery is limited in treating certain spinal disorders, most minimally invasive spine procedures do not use a laser. (Atlantic Brain and Spine. 2022)

Preparation

The surgical team will provide more detailed instructions on what to do in the days and hours before surgery. To promote optimal healing and a smooth recovery, it is recommended that the patient stay active, eat a healthy diet, and stop smoking prior to the operation. Individuals may need to stop taking certain medications to prevent excess bleeding or interaction with anesthesia during the operation. Inform the healthcare provider about all prescriptions, over-the-counter drugs, and supplements being taken.

Laser spine surgery is an outpatient procedure at a hospital or outpatient surgical center. The patient will likely go home on the same day of the operation. (Cleveland Clinic. 2018) Patients cannot drive to or from the hospital before or after their surgery, so arrange for family or friends to provide transportation. Minimizing stress and prioritizing healthy mental and emotional well-being is important to lowering inflammation and aiding recovery. The healthier the patient goes into surgery, the easier the recovery and rehabilitation will be.

Expectations

The surgery will be decided by the patient and healthcare provider and scheduled at a hospital or outpatient surgical center. Arrange for a friend or family member to drive to the surgery and home.

Before Surgery

• The patient will be taken to a pre-operative room and asked to change into a gown.
• The patient will undergo a brief physical examination and answer questions about medical history.
• The patient lies on a hospital bed, and a nurse inserts an IV to deliver medication and fluids.
• The surgical team will use the hospital bed to transport the patient in and out of the operating room.
• The surgical team will assist the patient in getting onto the operating table, and the patient will be administered anesthesia.
• The patient may receive general anesthesia, which will cause the patient to sleep for the surgery, or regional anesthesia, injected into the spine to numb the affected area. (Cleveland Clinic. 2018)
• The surgical team will sterilize the skin where the incision will be made.
• An antiseptic solution will be used to kill bacteria and prevent the risk of infection.
• Once sanitized, the body will be covered with sterilized linens to keep the surgical site clean.

During Surgery

• For a discectomy, the surgeon will make a small incision less than one inch in length with a scalpel along the spine to access the nerve roots.
• A surgical tool called an endoscope is a camera inserted into the incision to view the spine. (Brouwer, P. A. et al., 2015)
• Once the problematic disc portion causing the compression is located, the laser is inserted to cut through it.
• The cut disc portion is removed, and the incision site is sutured.

After Surgery

• After surgery, the patient is brought to a recovery room, where vital signs are monitored as the effects of the anesthesia wear off.
• Once stabilized, the patient can usually go home one or two hours after the operation.
• The surgeon will determine when the individual is clear to resume driving.

Recovery

Following a discectomy, the individual can return to work within a few days to a few weeks, depending on the severity, but it can take up to three months to return to normal activities. Length of recovery can range from two to four weeks or less to resume a sedentary job or eight to 12 weeks for a more physically demanding job that requires heavy lifting. (University of Wisconsin School of Medicine and Public Health, 2021) During the first two weeks, the patient will be given restrictions to facilitate the spine's healing until it becomes more stable. Restrictions can  include: (University of Wisconsin School of Medicine and Public Health, 2021)

• No bending, twisting, or lifting.
• No strenuous physical activity, including exercise, housework, yard work, and sex.
• No alcohol in the initial stage of recovery or while taking narcotic pain medications.
• No driving or operating a motor vehicle until discussed with the surgeon.

The healthcare provider may recommend physical therapy to relax, strengthen, and maintain musculoskeletal health. Physical therapy may be two to three times weekly for four to six weeks.

Process

Optimal recovery recommendations include:

• Getting enough sleep, at least seven to eight hours.
• Maintaining a positive attitude and learning how to cope and manage stress.
• Maintaining body hydration.
• Following the exercise program as prescribed by the physical therapist.
• Practicing healthy posture with sitting, standing, walking, and sleeping.
• Staying active and limiting the amount of time spent sitting. Try to get up and walk every one to two hours during the day to stay active and prevent blood clots. Gradually increase the amount of time or distance as recovery progresses.
• Do not push to do too much too soon. Overexertion can increase pain and delay recovery.
• Learning correct lifting techniques to utilize the core and leg muscles to prevent increased pressure on the spine.

Discuss treatment options for managing symptoms with a healthcare provider or specialist to determine if laser spine surgery is appropriate. Injury Medical Chiropractic and Functional Medicine Clinic care plans and clinical services are specialized and focused on injuries and the complete recovery process. Dr. Jimenez has teamed with the top surgeons, clinical specialists, medical researchers, therapists, trainers, and premiere rehabilitation providers. We focus on restoring normal body functions after trauma and soft tissue injuries using Specialized Chiropractic Protocols, Wellness Programs, Functional and integrative Nutrition, Agility and mobility Fitness Training, and Rehabilitation Systems for all ages. Our areas of practice include Wellness & Nutrition, Chronic Pain, Personal Injury, Auto Accident Care, Work Injuries, Back Injury, Low Back Pain, Neck Pain, Migraine Headaches, Sports Injuries, Severe Sciatica, Scoliosis, Complex Herniated Discs, Fibromyalgia, Chronic Pain, Complex Injuries, Stress Management, Functional Medicine Treatments, and in-scope care protocols.

The Non-Surgical Approach

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research studies or studies supporting our posts. We provide copies of supporting research studies that are available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how they may assist in a particular care plan or treatment protocol; therefore, to discuss the subject matter above further, don't hesitate to contact Dr. Alex Jimenez or us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Stern, J. SpineLine. (2009). Lasers in Spine Surgery: A Review. Current Concepts, 17-23. https://www.spine.org/Portals/0/assets/downloads/KnowYourBack/LaserSurgery.pdf

Brouwer, P. A., Brand, R., van den Akker-van Marle, M. E., Jacobs, W. C., Schenk, B., van den Berg-Huijsmans, A. A., Koes, B. W., van Buchem, M. A., Arts, M. P., & Peul, W. C. (2015). Percutaneous laser disc decompression versus conventional microdiscectomy in sciatica: a randomized controlled trial. The spine journal: official journal of the North American Spine Society, 15(5), 857–865. https://doi.org/10.1016/j.spinee.2015.01.020

Atlantic Brain and Spine. (2022). The Truth About Laser Spine Surgery [2022 Update]. Atlantic Brain and Spine Blog. https://www.brainspinesurgery.com/blog/the-truth-about-laser-spine-surgery-2022-update?rq=Laser%20Spine%20Surgery

Cleveland Clinic. (2018). Can Laser Spine Surgery Fix Your Back Pain? https://health.clevelandclinic.org/can-laser-spine-surgery-fix-your-back-pain/

University of Wisconsin School of Medicine and Public Health. (2021). Home Care Instructions after Lumbar Laminectomy, Decompression or Discectomy Surgery. https://patient.uwhealth.org/healthfacts/4466

El Paso, TX. Chiropractor, Dr. Alexander Jimenez discusses the anatomy of nerve fibers, receptors, spinal tracts and brain pathways. Regions of the Central Nervous System (CNS) coordinate various somatic processes using sensory inputs and motor outputs of peripheral nerves. Important areas of the CNS that play a role in somatic processes are separated in the spinal cord brain stem. Sensory pathways that carry peripheral sensations to the brain are referred to an ascending pathway, or tract. Various sensory modalities follow specific pathways through the CNS. Somatosensory stimuli activate receptors in the skin, muscles, tendons, and joints throughout the entire body. The somatosensory pathways are divided into two separate systems based on the location of the receptor neurons. Somatosensory stimuli from below the neck run along the sensory pathways of the spinal cord, and the somatosensory stimuli from the head and neck travel through cranial nerves.

ANATOMY OF RECEPTORS, NERVE FIBERS, SPINAL CORD TRACTS AND BRAINSTEM PATHWAYS

RECEPTORS AND RECEPTOR BASED THERAPY

NEURONS NEED THREE THINGS TO SURVIVE!

FUNCTIONAL NEUROLOGY KEY CONCEPTS

The cell needs three things to survive.

• Oxygen, glucose and stimulation.
• Stimulation = Chiropractic, exercise, etc.
• Stimulation leads to neuronal growth
• Neuronal growth leads to plasticity
• Subluxations alter the frequency of firing of neurons
• Activation of one side will stimulate ipsilateral cerebellum and contralateral cortex (usually)
• Proper stimulation CAN reduce pain.

CHIROPRACTIC IS RECEPTOR-BASED THERAPY

INTRODUCTION

• The ongoing activity and output of the CNS are greatly influenced, and sometimes more or less determined, by incoming sensory information.
• The basis of this incoming sensory information is an array of sensory receptors, cells that detect various stimuli and produce receptor potentials in response, often with astonishing effectiveness.
• The health of the neuron, however, plays a huge role in how neurons can produce receptor potentials, the endurance of the neuron and the ability to create plasticity.
• ”Neurons that fire together, wire together.” Hebbian Theory

TYPES OF RECEPTORS

• Chemoreceptors
• Smell, taste, interoceptors
• Thermoreceptors
• Temperature
• Mechanoreceptors
• Cutaneous receptors for touch, auditory, vestibular, proprioceptors
• Nociceptors
• Pain

PARTS OF RECEPTORS

Although their morphologies vary widely, all receptors have three general parts:

1. Receptive Area
2. Area Rich In Mitochondria

• Health of the neurons within the receptors will determine its response to stimulation

3. Synaptic Area To Pass Messages To The CNS

RECEPTIVE FIELDS

• These are particular areas in the periphery where application of an adequate stimulus causes the receptors to respond.
• Neurons in successive levels of sensory pathways (second- order neurons, thalamic and cortical neurons-also have receptive fields, although they may be considerably more elaborate than those of the receptors.

TRANSDUCTION

Sensory receptors use ionotropic and metabotropic mechanisms to produce receptor potentials

• Sensory receptors transduce some physical stimulus into an electrical signal – a receptor potential – that the nervous system can understand.
• Sensory receptors are similar to postsynaptic membranes as their adequate stimuli are analogous to neurotransmitters. 

THE DIAMETER OF A NERVE FIBER IS CORRELATED WITH ITS FUNCTION

BIGGER = FASTER

Larger fibers conduct action potentials faster than do smaller fibers.

• Aα fibers are the largest and most rapidly conducting myelinated fibers.
• The slowest conducting fibers of the body are the C fibers

RECEPTORS IN MUSCLES AND JOINTS DETECT MUSCLE STATUS AND LIMB POSITION

MUSCLE SPINDLES

Muscle spindles (Fig. 9-14) are long, thin stretch receptors scattered throughout virtually every striated muscle in the body.

• These muscle spindles sense muscle length and proprioception (“one’s own” perception).
• They are quite simple in principle, consisting of a few small muscle fibers with a capsule surrounding the middle third of the fibers.
• These fibers are called intrafusal muscle fibers (fusus is Latin for “spindle,” so intrafusal means “inside the spindle”), incontrast to the ordinary extrafusal muscle fibers (“outside the spindle”).
• The ends of the intrafusal fibers are attached to extrafusal fibers, so whenever the muscle is stretched, the intrafusal fibers are also stretched.
• The central region of each intrafusal fiber has few myofilaments and is noncontractile, but it does have one or more sensory endings applied to it.
• When the muscle is stretched, the central part of the intrafusal fiber is stretched, mechanically sensitive channels are distorted, the resulting receptor potential spreads to a nearby trigger zone, and a train of impulses ensues at each sensory ending.

GOLGI TENDON ORGANS

• Golgi tendon organs are spindle-shaped receptors found at the 
• junctions between muscles and tendons. They are similar to Ruffini endings in their basic organization, consisting of interwoven collagen bundles surrounded by a thin capsule (Fig. 9-16).
• Large sensory fibers enter the capsule and branch into fine processes that are inserted among the collagen bundles. Tension on the capsule along its long axis squeezes these fine processes, and the resulting distortion stimulates them.
• If tension is generated in a tendon by making its attached muscle contract, tendon organs are found to be much more sensitive and can actually respond to the contraction of just a few muscle fibers.
• Thus Golgi tendon organs very specifically monitor the tension generated by muscle contraction and come into play whe
• n fine adjustments in muscle tension need to be made (e.g., when handling a raw egg).
• Thus the mode of action of Golgi tendon organs is quite different from that of muscle spindles (Fig. 9-17). If a muscle contracts isometrically, tension is generated across its tendons, and the tendon organs signal this; however, the muscle spindles signal nothing because muscle length has not changed (assuming that the activity of the gamma motor neurons remains unchanged).
• In contrast, a relaxed muscle can be stretched easily, and the muscle spindles fire; the tendon organs, however, experience little tension and remain silent. A muscle, by virtue of these two types of receptors, can have its length and tension monitored simultaneously.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668288/

https://www.ncbi.nlm.nih.gov/pubmed/23709641

By RYAN CEDERMARK, DC DACNB RN BSN MSN

El Paso, TX. Chiropractor, Dr. Alexander Jimenez continues the discussion on the anatomy of nerve fibers, receptors, spinal tracts and brain pathway/s. As the spinal nerve nears the spinal cord, it splits into the dorsal and ventral roots. The dorsal root only contains the axons of sensory neurons. While the ventral roots contain only the axons of motor neurons. Some of the branches synapse with local neurons in the dorsal root ganglion, posterior (dorsal) horn, and even the anterior (ventral) horn, at the spine where they enter.

Other branches travel short distances up or down the spine to interact with neurons at other levels of the spinal cord. A branch can also turn into the posterior (dorsal) column white matter to connect with the brain. Spinal nerve systems that connect to the brain are contralateral, in that the right side of the body is connected to the left side of the brain and the left side of the body is connected to the right side of the brain.

Cranial nerves convey specific sense information from the head and neck directly to the brain. Whereas spinal information is contralateral, cranial nerve systems are for the most part ipsilateral, meaning that a cranial nerve on the right side of the head is connected to the right side of the brain. Some cranial nerves contain only sensory axons. Other cranial nerves have both sensory and motor axons, including the trigeminal, facial and glossopharyngeal. General senses of somatosensation for the face travel through the trigeminal system.

PATHWAYS

THE POSTERIOR COLUMN– MEDIAL LEMNISCUS SYSTEM CONVEYS INFORMATION ABOUT TOUCH AND LIMB POSITION

POSTERIOR COLUMN MEDIAL LEMNISCAL PATHWAY

• The term posterior column refers to the entire contents of a posterior funiculus, exclusive of its share of the propriospinal tract. The posterior columns consist mainly of ascending collaterals of large myelinated primary afferents carrying impulses from various kinds of mechanoreceptors (although substantial numbers of second-order fibers and unmyelinated fibers are also included). This has traditionally been considered the major pathway by which information from low-threshold cutaneous, joint, and muscle receptors reaches the cerebral cortex.

2-Minute Neuroscience: Touch & The Dorsal Columns-Medial Lemniscus

DAMAGE TO THE POSTERIOR COLUMN–MEDIAL LEMNISCUS SYSTEM CAUSES IMPAIRMENT OF PROPRIOCEPTION AND DISCRIMINATIVE TACTILE FUNCTIONS

“As might be expected from the types of afferents contained in the posterior columns, this pathway carries information important for the conscious appreciation of touch, pressure, and vibration and of joint position and movement. However, because input from cutaneous receptors also reaches the cortex by other routes, damage to the posterior columns causes impairment, but not abolition, of tactile perception. Complex discrimination tasks are more severely affected than is the simple detection of stimuli. Other functions, such as proprioception and kinesthesia, are classically considered to be totally lost after posterior column destruction. The result is a distinctive type of ataxia (incoordination of movement); the brain is unable to direct motor activity properly without sensory feedback about the current position of parts of the body. This ataxia is particularly pronounced when the patient’s eyes are closed, preventing visual compensation.”

Given the role of the posterior column, the patient should be screened for any abnormalities regarding their sense of fine touch, vibration, barognosis, graphesthesia, stereognosis, kinaesthesia, two-point discrimination and conscious proprioception:

• A common way of testing for fine touch is to ask the patient to recognize common objects placed within a cloth using their touch.
• Vibration sense can be tested using a low pitched C128 tuning fork placed along a bony prominence of the desired corresponding spinal level(s) to be tested.
• Barognosis refers to the ability to determine the approximate weight of an object.
• Graphesthesia refers to the ability to recognize writing on the skin by touch. The practitioner can draw out a letter on the patients skin as a way of testing.
• Kinaesthesia refers to ones own sense of body motion (excluding equilibrium which is controlled in part by the inner ear) and is commonly tested using the subject’s ability to detect an externally imposed passive movement, or the ability to reposition a joint to a predetermined position.
• Proprioception is often assessed using the Rombergs test. This examination is based on the notion that a person requires at least two of the three following senses to maintain balance while standing: proprioception; vestibular function and vision. A patient who has a defect within their proprioceptive mechanism can still maintain balance by using vestibular function and vision. In the Romberg test, the patient is stood up and asked to close their eyes. A loss of balance is interpreted as a positive Romberg sign.

THE SPINOTHALAMIC TRACT CONVEYS INFORMATION ABOUT PAIN AND TEMPERATURE

A GOOD BRAIN CAN MODULATE PAIN

SPINOTHALAMIC TRACT

• Pain is a complex sensation, in that a noxious stimulus leads not only to the perception of where it occurred but also to things such as a rapid increase in level of attention, emotional reactions, autonomic responses, and a greater likelihood that the event and its circumstances will be remembered. Corresponding to this complexity, multiple pathways convey nociceptive information rostrally from the spinal cord. One of them (the spinothalamic tract) is analogous to the posterior column–medial lemniscus pathway.

SPINOTHALAMIC TRACTS

Two main parts of the Spinothalamic Tract (STT)

• Lateral Spinothalamic Tract
• Transmission of pain and temperature
• Anterior Spinothalamic Tract
• Transmission of crude touch and firm pressure 

DAMAGE TO THE ANTEROLATERAL SYSTEM CAUSES DIMINUTION OF PAIN AND TEMPERATURE SENSATIONS

Examination:

Given the role of the spinothalamic tract, the patient should be screened for any abnormalities regarding their sense of touch, pain, temperature, and pressure sensation.

Screening for such abnormalities is commonly done using gentle pin pricks and cotton wool, to contrast between sharp and soft, following cutaneous sensory nerve root distributions. Hot and cold discrimination can be ascertained using the cold metal arm of a tuning fork, and a warm palm or heated object.

2 Minute Neuroscience: Pain & The Anterolateral System 

HAUSER ET AL. FIBROMYALGIA, 2015

• “Pain processing and its modulation: Activation of peripheral pain receptors (also called nociceptors) by noxious stimuli generates signals that travel to the dorsal horn of the spinal cord via the dorsal root ganglion. From the dorsal horn, the signals are carried along the ascending pain pathway or the spinothalamic tract to the thalamus and the cortex. Pain can be controlled by nociception- inhibiting and nociception-facilitating neurons. Descending signals originating in the supraspinal centers can modulate activity in the dorsal horn by controlling spinal pain transmission. CNS, central nervous system.”

SPINAL INFORMATION REACHES THE CEREBELLUM BOTH DIRECTLY AND INDIRECTLY

The spinal cord is an important source of information used by the cerebellum in the coordination of movement. This information reaches the cerebellar cortex and nuclei both directly, by way of spinocerebellar tracts, and indirectly, by way of relays in brainstem nuclei. A number of spinocerebellar tracts have been described, some representing the upper extremity and others the lower extremity. Only three have been well characterized.

Ascending Tracts | Spinocerebellar Tract

DESCENDING PATHWAYS INFLUENCE THE ACTIVITY OF LOWER MOTOR NEURONS

By RYAN CEDERMARK, DC DACNB RN BSN MSN