Spine

One type of weight-bearing joint in the human spine is the intervertebral disc. They are located between the vertebrae and consist of soft cartilage surrounded by a fibrous sheath called the annulus. In the center of all discs is a semi-gelatinous cartilage, oblong in shape, called the nucleus. The nucleus functions similarly to a ball bearing, acting as an axis for movement in all directions.

What Is It?

Although many patients are familiar with the concept of degenerative disc disease, meaning the loss of fluid and height of a disc as an age-related change, discs can also undergo a derangement of their internal architecture in the form of migration of the nucleus out of its normal position, usually backwards. If the nucleus migrates only to the point of mild pressure against the back of the disc annulus, the clinical result can manifest itself as back pain only. This is because the discs have pain nerve endings that allow us to feel them and experience pain, just as one can experience pain from any other joint in the body. If, however, the nucleus extends far enough backwards to come into contact with one of the lumbar nerve roots (that continue into the lower extremities), the additional symptom of nerve pain (e.g., “sciatica”) into the lower extremity occurs. The medical term for this is “radiculopathy”, and it can be associated with impairment of nerve function, such as numbness, tingling, and loss of strength. Disc herniations are further classified by location in the spinal canal (central, left or right), or foraminal (extending into the opening hole where a nerve exits), or far lateral (outside the opening hole). Herniations are further described by size, and whether the annulus remains intact (a disc protrusion), ruptured (extruded), or can consist of a free fragment of cartilage (sequestrated).

Treatment Options

The natural history (what happens even if untreated) of an acute lumbar disc herniation is generally favorable in that the majority will spontaneously shrink in size through healing. A disc protrusion (intact annulus) is amenable to physical therapy involving extension exercises (arching the back) to apply a force that can in essence push it back in;. If such exercises are effective, the disc protrusion is termed “reducible”, and the patient experiences relief of leg pain with extension movement. While waiting to see if a herniation will heal, the patient has to avoid or minimize aggravating activities that typically include bending, twisting and lifting, limit sitting, and sit with good lumbar support. Prescription medications may be necessary, and the symptoms can be lessened by spinal injections of a mixture of steroid and local anesthetic generally called “epidural steroid injections”, although injections will not make the herniation smaller.

If leg pain persists to a significant degree, despite appropriate time and treatment, then the patient can choose to undergo surgery in the form of a “microdiscectomy”. The exception would be the patient with intolerable pain or with neurologic deficits, especially weakness, which might prove irreversible. In such instances, surgery may be indicated more urgently. This term refers to surgery through a small incision performed with a microscope and involves removing the portion of the disc that is herniated. A new suture technology is now available that often allows a repair of the wall or annulus of the disc to minimize the risk of another herniation at that level. The surgery typically takes 60-90 minutes, has a success rate of over 90%, and is often done as an outpatient procedure. Postoperatively, the patient is to observe the “BLT’s”, i.e. bending/lifting/twisting, restrictions along with a sitting restriction for four weeks to allow disc healing, but is otherwise up and about.

Over the years, many attempts have been made to perform a discectomy in other, less invasive ways, but with lesser success than the gold standard of microdiscectomy. Patients may encounter information about percutaneous mechanized and laser discectomy, arthroscopic and endoscopic discectomy that sound attractive, but those procedures are indicated only for patients with contained protrusions (intact annulus), and published success rates are only about 80% or less. Please note that a laser is not FDA-approved for use within the spinal canal because of the risk of thermal injury to nerve structures. A laser can only be placed into the disc itself to vaporize disc material in hopes of reducing pressure within the disc and thereby the size of a contained herniation, similar to letting the air out of a tire.

What is it?

Spinal Stenosis is a condition caused by narrowing of the spinal canal which causes pressure on the spinal cord, or narrowing of the holes (called neural foramina) where spinal nerves leave the spinal column. It becomes more common as we age (generally over 50 years old) due to "wear-and-tear" and is usually seen in the lower back (lumbar), but can also occur in the neck (cervical). Symptoms include pain, numbness or cramping in the back, buttocks, thighs or calfs (lumbar), or in the neck, shoulders, or arms (cervical). The condition generally worsens gradually over time and can eventually lead to difficulty or imbalance while walking or difficulty with bowel or bladder control.

Treatment Options

Nonsurgical treatment includes medications, physical therapy, exercises, and lifestyle changes. Corticosteroid injections (epidural steroids) may relieve pain for a period of time. More severe cases which do not respond to the above measures may require surgery The most common surgical procedure for stenosis is decompressive laminectomy, sometimes accompanied by a fusion. this takes pressure off of the spinal cord and exiting nerves by increasing the area of the spinal canal and enlarging the neural foramina if indicated. There is also a newer procedure which is less invasive called X-STOP device which can offer benefits compared to traditional surgery for lumbar spinal stenosis, including less invasive, shorter hospital stay, and less removal of bone or soft tissue to allow for potentially quicker recovery.

The building blocks of the spinal column are cylindrically-shaped bones called vertebrae. Each vertebra has an arch attached behind it, and taken together, these arches form the spinal canal. According to the National Osteoporosis Foundation, one-in-two women and one-in-four men over age 50 will have an osteoporosis-related fracture in their lifetime; over 700,000 new spinal fractures occur in the spine each year.

What Is It?

When either the top, bottom, or both top and bottom of the vertebra collapses, similar to stepping on an aluminum can, a vertebral compression fracture (VCF) occurs. Most VCF’s occur in the context of osteoporosis, a slowly progressive loss of bone volume that occurs typically beyond age 50, and more likely in women than men, due to the loss of the protective effect of estrogen in women after menopause. Osteoporosis gives no warning signs until fracture occurs. VCF’s also are very common in cancer patients, whether due to malignancies arising in the bone marrow (e.g. multiple myeloma, lymphoma, and leukemia), or due to spread of a malignancy to bone, called metastatic cancer. In either case, the tumor cells replace normal bone, resulting in loss of bone volume. Demineralization of bone can occur in patients with metabolic bone disease, due to a large array of abnormalities ranging from calcium and vitamin D deficiency; testosterone deficiency; thyroid, kidney or liver disease; hyperparathyroidism; and malabsorption syndromes. When metabolic bone disease is the underlying cause, it is termed osteomalacia. Lastly, compression fractures can occur in patients with normal bone density due to trauma or injury. In the case of VCF’s in patients with less than normal bone density, fractures can occur as a result of normal activities of daily living and even spontaneously. Patients can thus develop a compression fracture while simply bending over to pick up something, reaching for an object, or carrying a bag of groceries.

The onset of a VCF is heralded by the experience of sudden pain, often severe, but sometimes mild and persistent. The fact that symptoms of a VCF can be easily confused with other causes of back pain underscores the importance of paying attention to back pain and seeing a physician for diagnosis. Both x-rays and an MRI are required to accurately diagnose VCF’s. This is because x-ray cannot distinguish reliably between an old, healed fracture and a new one; with MRI the hemorrhage and edema that occurs within the vertebra of a new fracture can be seen.

Because VCF’s involve a greater degree of collapse of the front of the vertebral body than the at the back of the vertebra, each fracture causes roundness or a stooped posture termed kyphosis. This kyphosis can make it difficult to walk, reach for things, and conduct normal activities of daily living. Associated problems include height loss, a decrease in abdominal volume resulting in loss of appetite, difficulty sleeping, and a decrease in lung volume with increased risk of cardiopulmonary complications.

Treatment Options

Most VCF’s will heal within a period of 6-12 weeks, even without specific treatment, although VCF’s can further collapse during the healing phase, potentially giving rise to even more serious problems. Traditional treatment of VCF’s in the past was limited to rest, bracing and management of pain. For patients under 50 with traumatically-induced fractures, this treatment still pertains.

For VCF’s due to osteoporosis, osteomalacia, and secondary to malignancy, an FDA-approved, minimally-invasive option is available. Called “balloon kyphoplasty”, the procedure is performed percutaneously (i.e. through small incisions) under fluoroscopic-guidance. The procedure involves placing a pair of small tubes into the back of the vertebra through which two small thick-walled balloons are inserted side-by-side into the vertebral body. The balloons are then inflated, often allowing for some restoration of lost vertebral height and correction of kyphosis, and also creating two cavities within the vertebra. After the balloons are removed, a bone cement is injected into the vertebra which hardens quickly, forming an internal splint that prevents further collapse and reduces/relieves spinal pain. The procedure can be done under either general anesthesia or local anesthesia with IV sedation, and typically takes less than one hour for the treatment of up to four fractures. Most patients are discharged from the hospital within 24 hours. Patients are requested to limit bending, twisting and lifting for four weeks, but encouraged to walk and otherwise be normally active. Most patients are very satisfied with the procedure, and after four weeks are able to resume activity with appropriate precautions

One type of weight-bearing joint in the human spine is the intervertebral disc. They are located between the vertebrae and consist of soft cartilage surrounded by a fibrous sheath called the annulus. In the center of all discs is a semi-gelatinous cartilage, oblong in shape, called the nucleus. The nucleus functions similarly to a ball bearing, acting as an axis for movement in all directions.

What Is It?

Although many patients are familiar with the concept of degenerative disc disease, meaning the loss of fluid and height of a disc as an age-related change, discs can also undergo a derangement of their internal architecture in the form of migration of the nucleus out of its normal position, usually backwards. If the nucleus migrates only to the point of mild pressure against the back of the disc annulus, the clinical result can manifest itself as neck pain only. This is because the discs have pain nerve endings that allow us to feel them and experience pain, just as one can experience pain from any other joint in the body. If, however, the nucleus extends far enough backwards to come into contact with one of the cervical nerve roots (that continue into the upper extremities), the additional symptom of nerve pain into the upper extremity occurs. The medical term for this is “radiculopathy”, and it can be associated with impairment of nerve function, such as numbness, tingling, and loss of strength. Disc herniations are further classified by location in the spinal canal (central, left or right). Herniations are further described by size, and whether the annulus remains intact (a disc protrusion), ruptured (extruded), or can consist of a free fragment of cartilage no longer in continuity with the disc space from which it arose (sequestrated). In the cervical spine, unlike the lumbar spine, within the canal is the spinal cord itself In the lumbar spine, the spinal cord typically ends at about the level of the first lumbar vertebra, meaning that most lumbar herniations affect the lumbar nerve roots emanating from it. With a cervical central disc herniation of sufficient size, therefore, pressure against the spinal cord can occur, as opposed to individual exiting nerve roots. This, in turn, can result in any combination of pain, numbness/tingling, and weakness affecting all four extremities, as well as symptoms of unsteadiness of gait and loss of dexterity in the hands, termed “myelopathy”.

Treatment Options

The natural history (what happens even if untreated) of an acute cervical disc herniation is generally favorable in the majority will spontaneously shrink in size through healing. This process of healing, however, usually takes 2-3 months. A disc protrusion (intact annulus) is amenable to physical therapy, including neck traction and extension exercises (arching the neck) to apply a force that can in essence “push it back in”. If such exercises are effective, the disc protrusion is termed “reducible”, and the patient experiences relief of arm pain with extension movement While waiting to see if a herniation will heal, the patient has to avoid or minimize aggravating activities that typically include bending, twisting and lifting, limit sitting, and sit/lie with good cervical support and posture. Prescription medications may be necessary, and the symptoms can be lessened by spinal injections of a mixture of steroid and local anesthetic generally called “epidural steroid injections”, although injections will not make the herniation smaller.

If arm pain persists to a significant degree, despite appropriate time and treatment, then the patient can choose to undergo surgery. The exception would be the patient with intolerable pain or with neurologic deficits, especially weakness, which might prove irreversible. Patients with spinal cord compression who have significant neurologic symptoms, especially when progressive in nature, are very likely to require surgery. In such instances, surgery may be indicated more urgently.The standard of care, then, is to remove the disc from the front of the neck. Once removed in its entirety, the absence of a disc between the vertebrae necessitates its replacement with a structural bone graft, or alternatively, an artificial disc. We do not yet have sufficient long-term data to prove the superiority of artificial discs over fusion, and for this reason, few insurance companies will authorize them. The default choice, as a result, is fusion, termed “anterior cervical discectomy and fusion” or “ACDF”. Most surgeons accompany an ACDF with anterior plating to increase fusion rates and minimize the risk of graft fracture, dislodgement, subsidence and loss of normal cervical alignment. Most surgeons also use cadaver bone, called an allograft, over the patient’s own bone, termed autograft, given that fusion rates are essentially the same, and to avoid donor site problems. A one-level ACDF can be done in a couple hours as an outpatient procedure or as an overnight stay. Postoperatively, a neck collar is used to limit motion and facilitate fusion until the graft is healed. One level ACDF’s usually heal in 6 weeks, and two or more levels in about eight. Restrictions include limited neck motion, no lifting more than 10 lbs., and avoidance of car travel for 4 weeks. The success rate for relief of arm pain is 90% or greater.