Lumbar diskectomy without or with spondylodesis? Revival of an old dilemma

Indications for spine fusion in combination with removal of a lumbar intervertebral disc are not as well defined or as widely accepted. Extreme opinions have been expressed on both side of this issue, but it seems unreasonable that every segment should be fused after removal of a disc or that none should be. The indication for fusion or for no fusion is often based on the specialist to whom the patient is referred. Orthopedists perform often fusion, neurosurgeons rarely. The problem is not the superiority of combined operation or simple disc excision, but the right indication for one or other procedure. It is clear that for the patient with acute disc displacement with leg-pain as the predominant symptom, simple laminectomy and disc excision will yield good results in most cases. Basically the are two indications for combined operation: the first of this is a strong history of instability troubles prior to the disc prolapse; second indication is the bilateral hemilaminectomy and discectomy, which can lead the spine quite instable. Indication for secondary spinal fusion are: 1) the presence after disc excision of complain of pain in the back with relatively little sciatic radiation, sometimes as intermittent claudication; 2) the overproduction of scar tissue is seen very often in instable segment after disc excision and partial or complete facetectomy. Decompression of the nerve root and fusion may result in a great benefit. Finally we recall the possibility to perform simple fusion in flexion without excision of the disc and without laminectomy in cases with median protrusion of the disc, seen in CT in patients with chronic low back pain and inconstant radicular pain radiation. We describe our own technic of combined operation.