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At Spine NI, we perform hundreds of procedures every year with consistently high patient satisfaction. With a proven record of effective treatment and recovery management, you can be sure you are in the best of care at Spine NI.
You can be sure you are in the best of care with Ortho NI’s leading spinal specialists.
The extensive experience of our award-winning consultants, Mr Niall Eames covers a comprehensive range of orthopaedic procedures.
Herniated Disk
When people say they have a “slipped” or “ruptured” disk in their neck or lower back, what they are actually describing is a herniated disk-a common source of pain in the neck, lower back, arms, or legs.
Anatomy
Disks are soft, rubbery pads found between the hard bones (vertebrae) that make up the spinal column. The spinal canal is a hollow space in the middle of the spinal column that contains the spinal cord and other nerve roots. The disks between the vertebrae allow the back to flex or bend. Disks also act as shock absorbers.
Disks in the lumbar spine (low back) are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine (neck), the disks are similar but smaller in size.
Cause
A disk herniates or ruptures when part of the center nucleus pushes through the outer edge of the disk and back toward the spinal canal. This puts pressure on the nerves. Spinal nerves are very sensitive to even slight amounts of pressure, which can result in pain, numbness, or weakness in one or both legs.
Animation courtesy Visual Health Solutions, Inc.
Risk Factors/Prevention In children and young adults, disks have high water content. As people age, the water content in the disks decreases and the disks become less flexible. The disks begin to shrink and the spaces between the vertebrae get narrower. Conditions that can weaken the disk include:
- Improper lifting
- Smoking
- Excessive body weight that places added stress on the disks (in the lower back)
- Sudden pressure (which may be slight)
- Repetitive strenuous activities
Symptoms
Lower Back
Low back pain affects four out of five people. Pain alone is not enough to recognize a herniated disk. See your doctor if back pain results from a fall or a blow to your back. The most common symptom of a herniated disk is sciatica—a sharp, often shooting pain that extends from the buttocks down the back of one leg. It is caused by pressure on the spinal nerve. Other symptoms include:
- Weakness in one leg
- Tingling (a “pins-and-needles” sensation) or numbness in one leg or buttock
- Loss of bladder or bowel control (If you also have significant weakness in both legs, you could have a serious problem and should seek immediate attention.)
- A burning pain centered in the neck
Neck
As with pain in the lower back, neck pain is also common. When pressure is placed on a nerve in the neck, it causes pain in the muscles between your neck and shoulder (trapezius muscles). The pain may shoot down the arm. The pain may also cause headaches in the back of the head. Other symptoms include:
- Weakness in one arm
- Tingling (a “pins-and-needles” sensation) or numbness in one arm
- Loss of bladder or bowel control (If you also have significant weakness in both arms or legs, you could have a serious problem and should seek immediate attention.)
- Burning pain in the shoulders, neck, or arm
Diagnosis
To diagnose a herniated disk, your doctor will ask for your complete medical history. Tell him or her if you have neck/back pain with gradually increasing arm/leg pain. Tell the doctor if you were injured.
A physical examination will help determine which nerve roots are affected (and how seriously).
A simple X-ray may show evidence of disk or degenerative spine changes.
MRI (magnetic resonance imaging) or CT (computed tomography) (imaging tests to confirm which disk is injured) or electromyography (a test that measures nerve impulses to the muscles) may be recommended if the pain continues.
Treatment
Nonsurgical Treatment
Nonsurgical treatment is effective in treating the symptoms of herniated disks in more than 90% of patients. Most neck or back pain will resolve gradually with simple measures.
- Rest and over-the-counter pain relievers may be all that is needed.
- Muscle relaxers, analgesics, and anti-inflammatory medications are also helpful.
- Cold compresses or ice can also be applied several times a day for no more than 20 minutes at a time.
- After any spasms settle, gentle heat applications may be used.
Any physical activity should be slow and controlled, especially bending forward and lifting. This can help ensure that symptoms do not return-as can taking short walks and avoiding sitting for long periods. For the lower back, exercises may also be helpful in strengthening the back and abdominal muscles. For the neck, exercises or traction may also be helpful. To help avoid future episodes of pain, it is essential that you learn how to properly stand, sit, and lift.
If these nonsurgical treatment measures fail, epidural injections of a cortisone-like drug may lessen nerve irritation and allow more effective participation in physical therapy. These injections are given on an outpatient basis over a period of weeks.
SurgicalTreatment
Surgery may be required if a disk fragment lodges in the spinal canal and presses on a nerve, causing significant loss of function. Surgical options in the lower back include microdiskectomy or laminectomy, depending on the size and position of the disk herniation.
In the neck, an anterior cervical diskectomy and fusion are usually recommended. This involves removing the entire disk to take the pressure off the spinal cord and nerve roots. Bone is placed in the disk space and a metal plate may be used to stabilize the spine.
For some patients, a smaller surgery may be performed on the back of the neck that does not require fusing the bones together.Each of these surgical procedures is performed with the patient under general anesthesia. They may be performed on an outpatient basis or require an overnight hospital stay. You should be able to return to work in 2 to 6 weeks after surgery.
Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.
Anatomy
Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.
Understanding your spine and how it works can help you better understand low back pain.
Description
Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.
Cause
There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!
Over-activity
One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this “stiffness” and soreness in the low back — and other areas of the body — that usually goes away within a few days.
Disk Injury
Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.
Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation. Another common type of disk injury is a “slipped” or herniated disc.
A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
Disk Degeneration
With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.
This “wear and tear” on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.
Degenerative Spondylolisthesis
Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.
Spinal Stenosis
Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.
When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth (called spurs) can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.
Animation courtesy Visual Health Solutions, Inc.
Scoliosis
This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.
Additional Causes
There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.
Symptoms
Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a “charley horse” type cramp. The type of pain you have will depend on the underlying cause of your back pain.
Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.
People with low back pain may experience some of the following:
- Back pain may be worse with bending and lifting.
- Sitting may worsen pain.
- Standing and walking may worsen pain
- Back pain comes and goes, and often follows an up and down course with good days and bad days.
- Pain may extend from the back into the buttock or outer hip area, but not down the leg.
- Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.
Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.
Tests and Diagnosis
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.
Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
Treatment
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.
Nonsurgical Treatment
Medications. Several medications may be used to help relieve your pain.
- Aspirin or acetaminophen can relieve pain with few side effects.
- Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
- Narcotic pain medications, such as codeine or morphine, may help.
- Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
- Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
- Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
- Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
- Traction is often used, but without scientific evidence for effectiveness.
- Other exercise-based programs, such as Pilates or yoga are helpful for some patients.
Surgical Treatment
Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option “when all else fails.” Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply cannot be treated with surgery.
Spinal Fusion. Spinal fusion is essentially a “welding” process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is that if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a “cage” are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disk Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.
Although no longer considered a new technology, the results of artificial disk replacement compared to fusion are controversial.
Prevention
It may not be possible to prevent low back pain. We cannot avoid the normal wear and tear on our spines that goes along with aging. But there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start.
Exercise
Combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible.
Proper Lifting
Be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.
Weight
Maintain a healthy weight. Being overweight puts added stress on your lower back.
Avoid Smoking
Both the smoke and the nicotine cause your spine to age faster than normal.
Proper Posture
Good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift.
Spondylolysis and spondylolisthesis are common causes of low back pain in young athletes.
Spondylolysis is a crack or stress fracture in one of the vertebrae, the small bones that make up the spinal column. The injury most often occurs in children and adolescents who participate in sports that involve repeated stress on the lower back, such as gymnastics, football, and weight lifting.
In some cases, the stress fracture weakens the bone so much that it is unable to maintain its proper position in the spine—and the vertebra starts to shift or slip out of place. This condition is called spondylolisthesis.
For most patients with spondylolysis and spondylolisthesis, back pain and other symptoms will improve with conservative treatment. This always begins with a period of rest from sports and other strenuous activities.
Patients who have persistent back pain or severe slippage of a vertebra, however, may need surgery to relieve their symptoms and allow a return to sports and activities.
Anatomy
Your spine is made up of 24 small rectangular-shaped bones, called vertebrae, which are stacked on top of one another. These bones connect to create a canal that protects the spinal cord.
The five vertebrae in the lower back comprise the lumbar spine.
Other parts of your spine include:
Spinal cord and nerves. These “electrical cables” travel through the spinal canal carrying messages between your brain and muscles. Nerve roots branch out from the spinal cord through openings in the vertebrae.
Facet joints. Between the back of the vertebrae are small joints that provide stability and help to control the movement of the spine. The facet joints work like hinges and run in pairs down the length of the spine on each side.
Intervertebral disks. In between the vertebrae are flexible intervertebral disks. These disks are flat and round and about a half inch thick. Intervertebral disks cushion the vertebrae and act as shock absorbers when you walk or run.
Description
Spondylolysis and spondylolisthesis are different spinal conditions—but they are often related to each other.
Spondylolysis
In spondylolysis, a crack or stress fracture develops through the pars interarticularis, which is a small, thin portion of the vertebra that connects the upper and lower facet joints.
Most commonly, this fracture occurs in the fifth vertebra of the lumbar (lower) spine, although it sometimes occurs in the fourth lumbar vertebra. Fracture can occur on one side or both sides of the bone.
The pars interarticularis is the weakest portion of the vertebra. For this reason, it is the area most vulnerable to injury from the repetitive stress and overuse that characterize many sports.
Spondylolysis can occur in people of all ages but, because their spines are still developing, children and adolescents are most susceptible.
Many times, patients with spondylolysis will also have some degree of spondylolisthesis.
Spondylolisthesis
If left untreated, spondylolysis can weaken the vertebra so much that it is unable to maintain its proper position in the spine. This condition is called spondylolisthesis.
In spondylolisthesis, the fractured pars interarticularis separates, allowing the injured vertebra to shift or slip forward on the vertebra directly below it. In children and adolescents, this slippage most often occurs during periods of rapid growth—such as an adolescent growth spurt.
Doctors commonly describe spondylolisthesis as either low grade or high grade, depending upon the amount of slippage. A high-grade slip occurs when more than 50 percent of the width of the fractured vertebra slips forward on the vertebra below it. Patients with high-grade slips are more likely to experience significant pain and nerve injury and to need surgery to relieve their symptoms.
Cause
Overuse
Both spondylolysis and spondylolisthesis are more likely to occur in young people who participate in sports that require frequent overstretching (hyperextension) of the lumbar spine—such as gymnastics, football, and weight lifting. Over time, this type of overuse can weaken the pars interarticularis, leading to fracture and/or slippage of a vertebra.
Genetics
Doctors believe that some people may be born with vertebral bone that is thinner than normal—and this may make them more vulnerable to fractures.
Symptoms
In many cases, patients with spondylolysis and spondylolisthesis do not have any obvious symptoms. The conditions may not even be discovered until an x-ray is taken for an unrelated injury or condition.
When symptoms do occur, the most common symptom is lower back pain. This pain may:
- Feel similar to a muscle strain
- Radiate to the buttocks and back of the thighs
- Worsen with activity and improve with rest
In patients with spondylolisthesis, muscle spasms may lead to additional signs and symptoms, including:
- Back stiffness
- Tight hamstrings (the muscles in the back of the thigh)
- Difficulty standing and walking
Spondylolisthesis patients who have severe or high-grade slips may have tingling, numbness, or weakness in one or both legs. These symptoms result from pressure on the spinal nerve root as it exits the spinal canal near the fracture.
Physical Examination
Your doctor will begin by taking a medical history and asking about your child’s general health and symptoms. He or she will want to know if your child participates in sports. Children who participate in sports that place excessive stress on the lower back are more likely to have a diagnosis of spondylolysis or spondylolisthesis.
Your doctor will carefully examine your child’s back and spine, looking for:
- Areas of tenderness
- Limited range of motion
- Muscle spasms
- Muscle weakness
Your doctor will also observe your child’s posture and gait (the way he or she walks). In some cases, tight hamstrings may cause a patient to stand awkwardly or walk with a stiff-legged gait.
Imaging tests will help confirm the diagnosis of spondylolysis or spondylolisthesis.
Imaging Tests
X-rays. These studies provide images of dense structures, such as bone. Your doctor may order x-rays of your child’s lower back from a number of different angles to look for a stress fracture and to view the alignment of the vertebrae.
If x-rays show a “crack” or stress fracture in the pars interarticularis portion of the fourth or fifth lumbar vertebra, it is an indication of spondylolysis.
If the fracture gap at the pars interarticularis has widened and the vertebra has shifted forward, it is an indication of spondylolisthesis. An x-ray taken from the side will help your doctor determine the amount of forward slippage.
Computerized tomography (CT) scans. More detailed than plain x-rays, CT scans can help your doctor learn more about the fracture or slippage and can be helpful in planning treatment.
Magnetic resonance imaging (MRI) scans. These studies provide better images of the body’s soft tissues. An MRI can help your doctor determine if there is damage to the intervertebral disks between the vertebrae or if a slipped vertebra is pressing on spinal nerve roots. It can also help your doctor determine if there is injury to the pars before it can be seen on x-ray.
Treatment
The goals of treatment for spondylolysis and spondylolisthesis are to:
- Reduce pain
- Allow a recent pars fracture to heal
- Return the patient to sports and other daily activities
Nonsurgical Treatment
Initial treatment is almost always nonsurgical in nature. Most patients with spondylolysis and low-grade spondylolisthesis will improve with nonsurgical treatment.
Nonsurgical treatment may include:
Rest. Avoiding sports and other activities that place excessive stress on the lower back for a period of time can often help improve back pain and other symptoms.
Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as ibuprofen and naproxen can help reduce swelling and relieve back pain.
Physical therapy. Specific exercises can help improve flexibility, stretch tight hamstring muscles, and strengthen muscles in the back and abdomen.
Bracing. Some patients may need to wear a back brace for a period of time to limit movement in the spine and provide an opportunity for a recent pars fracture to heal.
Over the course of treatment, your doctor will take periodic x-rays to determine whether the vertebra is changing position.
Surgical Treatment
Surgery may be recommended for spondylolisthesis patients who have:
- Severe or high-grade slippage
- Slippage that is progressively worsening
- Back pain that has not improved after a period of nonsurgical treatment
Spinal fusion between the fifth lumbar vertebra and the sacrum is the surgical procedure most often used to treat patients with spondylolisthesis.
The goals of spinal fusion are to:
- Prevent further progression of the slip
- Stabilize the spine
- Alleviate significant back pain
Surgical Procedure
Spinal fusion is essentially a “welding” process. The basic idea is to fuse together the affected vertebrae so that they heal into a single, solid bone. Fusion eliminates motion between the damaged vertebrae and takes away some spinal flexibility. The theory is that, if the painful spine segment does not move, it should not hurt.
During the procedure, the doctor will first realign the vertebrae in the lumbar spine. Small pieces of bone—called bone graft—are then placed into the spaces between the vertebrae to be fused. Over time, the bones grow together—similar to how a broken bone heals.
Prior to placing the bone graft, your doctor may use metal screws and rods to further stabilize the spine and improve the chances of successful fusion.
In some cases, patients with high-grade slippage will also have compression of the spinal nerve roots. If this is the case, your doctor may first perform a procedure to open up the spinal canal and relieve pressure on the nerves before performing the spinal fusion.
Outcomes
The majority of patients with spondylolysis and spondylolisthesis are free from pain and other symptoms after treatment. In most cases, sports and other activities can be resumed gradually with few complications or recurrences.
To help prevent future injury, your doctor may recommend that your child do specific exercises to stretch and strengthen the back and abdominal muscles. In addition, regular check-ups are needed to ensure that problems do not develop.
Cervical radiculopathy, commonly called a “pinched nerve” occurs when a nerve in the neck is compressed or irritated where it branches away from the spinal cord. This may cause pain that radiates into the shoulder, as well as muscle weakness and numbness that travels down the arm and into the hand.
Cervical radiculopathy is often caused by “wear and tear” changes that occur in the spine as we age, such as arthritis. In younger people, it is most often caused by a sudden injury that results in a herniated disk.
In most cases, cervical radiculopathy responds well to conservative treatment that includes medication and physical therapy.
Anatomy
Your spine is made up of 24 bones, called vertebrae, that are stacked on top of one another. These bones connect to create a canal that protects the spinal cord.
Animation courtesy Visual Health Solutions, Inc.
The seven small vertebrae that begin at the base of the skull and form the neck comprise the cervical spine.
Other parts of your spine include:
Spinal cord and nerves. These “electrical cables” travel through the spinal canal carrying messages between your brain and muscles. Nerve roots branch out from the spinal cord through openings in the vertebrae (foramen).
Intervertrebral disks. In between your vertebrae are flexible intervertebral disks. They act as shock absorbers when you walk or run.
Intervertebral disks are flat and round and about a half inch thick. They are made up of two components:
- Annulus fibrosus. This is the tough, flexible outer ring of the disk.
- Nucleus pulposus. This is the soft, jelly-like center of the disk.
Cause
Cervical radiculopathy most often arises from degenerative changes that occur in the spine as we age or from an injury that causes a herniated, or bulging, intervertebral disk.
Degenerative changes. As the disks in the spine age, they lose height and begin to bulge. They also lose water content, begin to dry out, and become stiffer. This problem causes settling, or collapse, of the disk spaces and loss of disk space height.
As the disks lose height, the vertebrae move closer together. The body responds to the collapsed disk by forming more bone —called bone spurs—around the disk to strengthen it. These bone spurs contribute to the stiffening of the spine. They may also narrow the foramen—the small openings on each side of the spinal column where the nerve roots exit—and pinch the nerve root.
Degenerative changes in the disks are often called arthritis or spondylosis. These changes are normal and they occur in everyone. In fact, nearly half of all people middle-aged and older have worn disks and pinched nerves that do not cause painful symptoms. It is not known why some patients develop symptoms and others do not.
Herniated disk. A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive nerve root, causing pain and weakness in the area the nerve supplies.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
Symptoms
In most cases, the pain of cervical radiculopathy starts at the neck and travels down the arm in the area served by the damaged nerve. This pain is usually described as burning or sharp. Certain neck movements—like extending or straining the neck or turning the head—may increase the pain. Other symptoms include:
- Tingling or the feeling of “pins and needles” in the fingers or hand
- Weakness in the muscles of the arm, shoulder, or hand
- Loss of sensation
Some patients report that pain decreases when they place their hands on top of their head. This movement may temporarily relieve pressure on the nerve root.
Doctor Examination
Physical Examination
After discussing your medical history and general health, your doctor will ask you about your symptoms. He or she will then examine your neck, shoulder, arms and hands—looking for muscle weakness, loss of sensation, or any change in your reflexes.
Your doctor may also ask you to perform certain neck and arm movements to try to recreate and/or relieve your symptoms.
Tests
X-rays. These provide images of dense structures, such as bone. An x-ray will show the alignment of bones along your neck. It can also reveal whether there is any narrowing of the foramen and damage to the disks.
Computed tomography (CT) scans. More detailed than a plain x-ray, a CT scan can help your doctor determine whether you have developed bone spurs near the foramen in your cervical spine.
Magnetic resonance imaging (MRI) scans. These studies create better images of the body’s soft tissues. An MRI of the neck can show if your nerve compression is caused by damage to soft tissues—such as a bulging or herniated disk. It can also help your doctor determine whether there is any damage to your spinal cord or nerve roots.
Electromyography (EMG). Electromyography measures the electrical impulses of the muscles at rest and during contractions. Nerve conduction studies are often done along with EMG to determine if a nerve is functioning normally. Together, these tests can help your doctor determine whether your symptoms are caused by pressure on spinal nerve roots and nerve damage or by another condition that causes damage to nerves, such as diabetes.
Treatment
It is important to note that the majority of patients with cervical radiculopathy get better over time and do not need treatment. For some patients, the pain goes away relatively quickly—in days or weeks. For others, it may take longer.
It is also common for cervical radiculopathy that has improved to return at some point in the future. Even when this occurs, it usually gets better without any specific treatment.
In some cases, cervical radiculopathy does not improve, however. These patients require evaluation and treatment.
Nonsurgical Treatment
Initial treatment for cervical radiculopathy is nonsurgical. Nonsurgical treatment options include:
Soft cervical collar. This is a padded ring that wraps around the neck and is held in place with Velcro. Your doctor may advise you to wear a soft cervical collar to allow the muscles in your neck to rest and to limit neck motion. This can help decrease the pinching of the nerve roots that accompany movement of the neck. A soft collar should only be worn for a short period of time since long-term wear may decrease the strength of the muscles in your neck.
Physical therapy. Specific exercises can help relieve pain, strengthen neck muscles, and improve range of motion. In some cases, traction can be used to gently stretch the joints and muscles of the neck.
Medications. In some cases, medications can help improve your symptoms.
-
- Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, including aspirin, ibuprofen, and naproxen, may provide relief if your pain is caused by nerve irritation or inflammation.
- Oral corticosteroids. A short course of oral corticosteroids may help relieve pain by reducing swelling and inflammation around the nerve.
- Steroid injection. In this procedure, steroids are injected near the affected nerve to reduce local inflammation. The injection may be placed between the laminae (epidural injection), in the foramen (selective nerve injection), or into the facet joint. Although steroid injections do not relieve the pressure on the nerve caused by a narrow foramen or by a bulging or herniated disk, they may lessen the swelling and relieve the pain long enough to allow the nerve to recover.
- Narcotics. These medications are reserved for patients with severe pain that is not relieved by other options. Narcotics are usually prescribed for a limited time only.
Surgical Treatment
If after a period of time nonsurgical treatment does not relieve your symptoms, your doctor may recommend surgery. There are several surgical procedures to treat cervical radiculopathy. The procedure your doctor recommends will depend on many factors, including what symptoms you are experiencing and the location of the involved nerve root.
If you suddenly start feeling pain in your lower back or hip that radiates to the back of your thigh and into your leg, you may have a protruding (herniated) disk in your spinal column that is pressing on the nerve roots in the lumbar spine. This condition is known as sciatica.
Symptoms
Sciatica may feel like a bad leg cramp, with pain that is sharp (“knife-like”), or electrical. The cramp can last for weeks before it goes away. You may have pain, especially when you move, sneeze, or cough. You may also have weakness, “pins and needles” numbness, or a burning or tingling sensation down your leg.
Causes
You are most likely to get sciatica between the ages of 30 and 50 years. It may happen as a result of the general wear and tear of aging, plus any sudden pressure on the disks that cushion the bones (vertebrae) of your lower spine.
Animation courtesy Visual Health Solutions, Inc.
Sciatica is most commonly caused by a herniated disk. The gel-like center (nucleus) of a disk may protrude into or through the disk’s outer lining. This herniated disk may press directly on the nerve roots that become the sciatic nerve. Nerve roots may also get inflamed and irritated by chemicals from the disk’s nucleus.
Approximately 1 in every 50 people will experience a herniated disk at some point in their life. Of these, 10% to 25% have symptoms that last more than 6 weeks.
In rare cases, a herniated disk may press on nerves that cause you to lose control of your bladder or bowel, referred to as cauda equina syndrome. If this happens, you may also have numbness or tingling in your groin or genital area. This is an emergency situation that requires surgery. Phone your doctor immediately.
Doctor Examination
Diagnosis begins with a complete patient history. Your doctor will ask you to explain how your pain started, where it travels, and exactly what it feels like.
A physical examination may help pinpoint the irritated nerve root. Your doctor may ask you to squat and rise, walk on your heels and toes, or perform a straight-leg raising test or other tests.
X-rays and other specialized imaging tools, such as a magnetic resonance imaging (MRI) scan, may confirm your doctor’s diagnosis of which nerve roots are affected.
Treatment
Nonsurgical Treatment
The condition usually heals itself, given sufficient time and rest. Approximately 80% to 90% of patients with sciatica get better over time without surgery, typically within several weeks.
Nonsurgical treatment is aimed at helping you manage your pain without long-term use of medications. Nonsteroidal anti-inflammatory drugs such as ibuprofen, aspirin, or muscle relaxants may also help. In addition, you may find it soothing to put gentle heat or cold on your painful muscles. It is important that you continue to move. Do not remain in bed, as too much rest may cause other parts of the body to feel discomfort.
Find positions that are comfortable, but be as active as possible. Motion helps to reduce inflammation. Most of the time, your condition will get better within a few weeks.
Sometimes, your doctor may inject your spinal area with a cortisone-like drug.
As soon as possible, start stretching exercises so you can resume your physical activities without sciatica pain. Your doctor may want you to take short walks and may prescribe physical therapy.
Surgical Treatment
You might need surgery if you still have disabling leg pain after 3 months or more of nonsurgical treatment. A part of your surgery, your herniated disk may be removed to stop it from pressing on your nerve.
The surgery (laminotomy with discectomy) may be done under local, spinal, or general anesthesia. This surgery is usually very successful at relieving pain, particularly if most of the pain is in your leg.
Rehabilitation
Your doctor may give you exercises to strengthen your back. It is important to walk and move while limiting too much bending or twisting. It is acceptable to perform routine activities around the house, such as cooking and cleaning.
Following treatment for sciatica, you will probably be able to resume your normal lifestyle and keep your pain under control. However, it is always possible for your disk to rupture again.
Scoliosis is a condition that causes the spine to curve sideways. There are several different types of scoliosis that affect children and adolescents. By far, the most common type is “idiopathic,” which means the exact cause is not known.
Most cases of idiopathic scoliosis occur between age 10 and the time a child is fully grown. Scoliosis is rarely painful—small curves often go unnoticed by children and their parents, and are first detected during a school screening or at a regular check-up with the pediatrician.
In many cases, scoliosis curves are small and do not require treatment. Children with larger curves may need to wear a brace or have surgery to restore normal posture.
Description
Scoliosis causes the bones of the spine to twist or rotate so that instead of a straight line down the middle of the back, the spine looks more like the letter “C” or “S.” Scoliosis curves most commonly occur in the upper and middle back (thoracic spine). They can also develop in the lower back, and occasionally, will occur in both the upper and lower parts of the spine.
Idiopathic scoliosis curves vary in size, and mild curves are more common than larger curves. If a child is still growing, a scoliosis curve can worsen rapidly during a growth spurt.
Although it can develop in toddlers and young children, idiopathic scoliosis most often begins during puberty. Both boys and girls can be affected, however, girls are more likely to develop larger curves that require medical care.
Other less common types of scoliosis include:
- Congenital scoliosis. Problems in the spine sometimes develop before a baby is born. Babies with congenital scoliosis may have spinal bones that are not fully formed or are fused together.
- Neuromuscular scoliosis. Medical conditions that affect the nerves and muscles, such as muscular dystrophy or cerebral palsy, can lead to scoliosis. These types of neuromuscular conditions can cause imbalance and weakness in the muscles that support the spine.
Cause
Although doctors do not know the exact cause of idiopathic scoliosis, they do know that it is not related to specific behaviors or activities — like carrying a heavy backpack or having poor posture.
Research shows that in some cases genetics plays a role in the development of scoliosis. Approximately 30% of patients with adolescent idiopathic scoliosis have a family history of the condition.
Symptoms
Small curves often go unnoticed until a child hits a growth spurt during puberty and there are more obvious signs, such as:
- Tilted, uneven shoulders, with one shoulder blade protruding more than the other
- Prominence of the ribs on one side
- Uneven waistline
- One hip higher than the other
Because adolescents are often self-conscious and avoid wearing form-fitting clothes, many cases of scoliosis are first detected during a school screening or regular pediatric checkup.
If your pediatrician suspects scoliosis, he or she may refer you to a pediatric orthopaedic surgeon or a spinal deformity surgeon for a full evaluation and treatment plan.
Physical Examination
The standard screening test for scoliosis is the “Adam’s forward bend test.” During the test, your child will bend forward with feet together, knees straight and arms hanging free. Your doctor will observe your child from the back, looking for a difference in the shape of the ribs on each side. A spinal deformity is most noticeable in this position.
With your child standing upright, your doctor will also check to see if the hips and shoulders are level, and if the position of the head is centered over the hips. He or she will check the movement of the spine in all directions.
To rule out other causes of spinal deformity, your doctor will check for limb-length discrepancies, abnormal neurological findings, and other physical problems.
X-rays
X-rays will provide clear images of the bones in your child’s spine. They allow your doctor to see the exact location of the curve and to measure how severe it is. In general, curves greater than 25° are considered serious enough to require treatment.
Treatment
Your doctor will consider several things when planning your child’s treatment:
- The location of the curve
- The severity of the curve
- Your child’s age
- The number of remaining growing years — once an adolescent is fully grown, it is not common for a curve to rapidly worsen.
By evaluating these factors, your doctor will determine how likely it is that your child’s curve will worsen and be able to suggest the best treatment option.
Nonsurgical Treatment
Observation. If your child’s spinal curve is less than 25° or if he or she is almost full-grown, your doctor may recommend simply monitoring the curve to make sure it does not get worse. Your doctor will recheck your child about every 6 to 12 months and schedule follow-up x-rays until your child is fully grown.
Bracing. If the spinal curve is between 25° and 45° and your child is still growing, your doctor may recommend bracing. Although bracing will not straighten an existing curve, it often prevents it from getting worse to the point of requiring surgery.
In a recent research study of scoliosis patients with curves at a high risk for worsening, bracing significantly decreased the incidence of curves that progressed to the point of needing surgery.
There are several types of braces for scoliosis. Most of them are underarm braces that are custom-made to fit your child’s body comfortably. Your doctor will recommend the type that best meets your child’s needs and will determine how long the brace should be worn each day.
Clothes in loose-fitting styles easily cover the brace. Your child can take off the brace for sports activities.
Surgical Treatment
Your doctor may recommend surgery if your child’s curve is greater than 45°-50° or if bracing did not stop the curve from reaching this point. Severe curves that are not treated could eventually worsen to the point where they affect lung function.
A surgical procedure called “spinal fusion” will significantly straighten the curve and then fuse the vertebrae together so that they heal into a single, solid bone. This will stop growth completely in the part of the spine affected by scoliosis.
During the procedure, the spinal bones that make up the curve are realigned. Small pieces of bone — called bone graft — are placed into the spaces between the vertebrae to be fused. Over time, the bones grows together — similar to when a broken bone heals.
Metal rods are typically used to hold the bones in place until the fusion happens. The rods are attached to the spine by hooks, screws, and/or wires.
Exactly how much of the spine is fused depends upon your child’s curve(s). Only the curved vertebrae are fused together. The other bones of the spine remain able to move and assist in motion.
Recovery
By the second day after surgery, most patients are able to walk without wearing a brace. Discharge from the hospital is usually less than 1 week following surgery. Most children can return to school and resume their daily activities within 4 weeks.
Long-Term Outcome
Spinal fusion is very successful in stopping the curve from growing. Surgery is also able to straighten the curve significantly, which improves the patient’s appearance.
Most children can return to sporting activities within 6 to 9 months after surgery. Because surgery causes permanent limitation of some spine movements, however, participation in contact sports such as football is discouraged.
Spinal fusion does not increase the risk of complications during girls’ future pregnancies or deliveries.
Listed below are a sample procedures available at Spine NI.
When preparing for your spinal procedure it is important you listen to instruction by your surgeon.
Your surgeon may ask you to stop taking certain medicine or to stop smoking to prepare for surgery. Depending on your age and general medical fitness, your surgeon may ask you to have a general medical checkup by your family doctor.
Medication
Some medicines may interfere with or affect the results of your surgery. They may cause bleeding or may interfere with the effects of your anesthesia. These medications include aspirin and non-steroidal anti-inflammatory drugs. Your surgeon may ask you to stop taking the medication before your surgery.
Advance Planning
You will be able to walk after surgery, but you may need to arrange for some help for a few days after your return home with activites like washing, dressing, cleaning, laundry, and shopping.
Your surgeon will probably recommend that you do not drive a car for a period of time after surgery. You will need to arrange for transportation to and from your hospital appointments and to other places that you need to go during this time. You should consult your doctor before taking car trips.
Your Surgery
Before Your Operation
Patients usually are admitted to the hospital on the day of surgery. After admission, you will be taken to the preoperative preparation area where you will be interviewed by your anaesthetist who will review your medical history and physical examination reports.
You and the anaesthetist will discuss the type of anesthesia to be used. (Sometimes this is done during an outpatient visit up to 7 days before your surgery.) The most common types of anesthesia used for low back surgery are general (you are asleep for the entire operation) or spinal (you may be awake but have no feeling from your waist down).
Surgical Procedure
The surgical procedure usually takes from 1 to 3 hours, depending on your problem.
When your surgery is completed, you will be moved to the recovery room, where you will be observed and monitored by a nurse until you awake from the anesthesia. You will have an intravenous (IV) line inserted into a vein in your arm. You also may have a catheter inserted into your bladder to make urination easier.
When you are fully awake and alert, you will be taken to your hospital room.
Rehabilitation
There is usually pain for the first few days after surgery. Pain medication will be given regularly, perhaps by a patient-controlled analgesia. Your IV line and catheter will be removed within a few days after surgery.
Your spine must be kept in proper alignment. You will be taught how to move properly, reposition, sit, stand, and walk.
While in bed, you will be instructed to turn frequently using a “log rolling” technique. This maneuver allows your entire body to move as a unit, avoiding twisting of the spine.
You may be discharged from the hospital with a back brace or cast. Your family will be taught how to provide care at home.
Complications
The incidence of complications after low back surgery is low. Risks for any surgery include bleeding and infection. For spine surgery, complications include difficulties with urination (retention) and temporary decreased or absent intestinal function.
Major complications that can occur include, but are not limited to:
- Infection
- Heart attack
- Stroke
- Blood clots
- Recurrent disk herniations
Although rare, new nerve damage can occur as a result of this surgery. These complications may result in pain and prolonged recovery time.
Warning Signs
It is important that you carefully follow any instructions from your doctor relating to warning signs of blood clots and infection. These complications are most likely to occur during the first few weeks after surgery.
Warning signs of possible blood clots include the following:
- Swelling in the calf, ankle or foot
- Tenderness or redness, which may extend above or below the knee
- Pain in the calf
Occasionally, a blood clot will travel through the blood stream and may settle in your lungs. If this happens, you may experience a sudden chest pain and shortness of breath or cough. If you experience any of these symptoms, you should notify your doctor immediately. If you cannot reach your doctor, someone should take you to the hospital emergency room or call 911.
Infection following spine surgery occurs very rarely. Warning signs of infection include:
- Redness, tenderness, and swelling around the wound edges
- Drainage from the wound
- Pain or tenderness
- Shaking chills
- Elevated temperature, usually above 100°F if taken with an oral thermometer
If any of these symptoms occur, you should contact your doctor or go to the nearest emergency room immediately.
Your Recovery at Home
After your discharge from the hospital, you will need to follow your doctor’s orders exactly to ensure a successful recovery.
You should arrange for transportation home that will allow you to ride in a leaning back or lying down position. You may do as much for yourself as you can, as long as you maintain a balanced position of your spine. You should not stay in bed during the day. Do not hesitate to ask for help from your family members or friends if it is needed. If necessary, arrangements can be made for a home health aide.
Wound Care
Your wound may be closed with stitches (sutures) or staples, which will be removed approximately 2 weeks after surgery. If the wound is clean and dry, no bandage is needed. If drainage continues after you are home, cover the wound with a bandage and call your surgeon.
Diet
Some loss of appetite is common. Eating well-balanced meals and drinking plenty of fluids are important. Your doctor may recommend an iron supplement or vitamins before and after your surgery.
Activity
Many people experience a loss of energy after major surgery, but this improves over time. Your doctor may prescribe an exercise program designed to gradually increase your strength and stamina.
Initially, your doctor will recommend that you should only participate in walking. Later, your doctor will encourage you to swim or use an exercise bike or treadmill to improve your general physical condition.
Spinal Fusion
Spinal fusion is a surgical procedure used to correct problems with the small bones of the spine (vertebrae). It is essentially a “welding” process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spine surgery is usually recommended only when your doctor can pinpoint the source of your pain. To do this, your doctor may use imaging tests, such as x-rays, computed tomography (CT), and magnetic resonance imaging (MRI) scans.
Spinal fusion may relieve symptoms of many back conditions, including:
- Degenerative disk disease
- Spondylolisthesis
- Spinal stenosis
- Scoliosis
- Fracture
- Infection
- Tumor
Understanding how your spine works will help you better understand spinal fusion.
Description
Spinal fusion eliminates motion between vertebrae. It also prevents the stretching of nerves and surrounding ligaments and muscles. It is an option when motion is the source of pain, such as movement that occurs in a part of the spine that is arthritic. The theory is if the painful vertebrae do not move, they should not hurt.
If you have leg pain in addition to back pain, your surgeon may also perform a decompression (laminectomy). This procedure involves removing bone and diseased tissues that can put pressure on spinal nerves.
Fusion will take away some spinal flexibility, but most spinal fusions involve only small segments of the spine and do not limit motion very much.
Procedure
Lumbar spinal fusion has been performed for decades. There are several different techniques that may be used to fuse the spine. There are also different “approaches” your surgeon can take for your procedure.
Your surgeon may approach your spine from the front. This is an anterior approach and requires an incision in the lower abdomen.
A posterior approach is done from your back. Or your surgeon may approach your spine from the side, called a lateral approach.
Animation courtesy Visual Health Solutions, Inc.
Minimally invasive techniques have also been developed. These allow fusions to be performed with smaller incisions.
The right procedure for you will depend on the nature and location of your disease.
Bone Grafting
All spinal fusions use some type of bone material, called a bone graft, to help promote the fusion. Generally, small pieces of bone are placed into the space between the vertebrae to be fused.
A bone graft is primarily used to stimulate bone healing. It increases bone production and helps the vertebrae heal together into a solid bone. Sometimes larger, solid pieces are used to provide immediate structural support to the vertebrae.
In the past, a bone graft harvested from the patient’s hip was the only option for fusing the vertebrae. This type of graft is called an autograft. Harvesting a bone graft requires an additional incision during the operation. It lengthens surgery and can cause increased pain after the operation.
Immobilization
After bone grafting, the vertebrae need to be held together to help the fusion progress. Your surgeon may suggest that you wear a brace.
In many cases, surgeons will use plates, screws, and rods to help hold the spine still. This is called internal fixation, and may increase the rate of successful healing. With the added stability from internal fixation, most patients are able to move earlier after surgery.
Complications
As with any operation, there are potential risks associated with spinal fusions. It is important to discuss all of these risks with your surgeon before your procedure.
- Infection. Antibiotics are regularly given to the patient before, during, and often after surgery to lessen the risk of infections.
- Bleeding. A certain amount of bleeding is expected, but this is not typically significant.
- Pain at graft site. A small percentage of patients will experience persistent pain at the bone graft site.
- Recurring symptoms. Some patients may experience a recurrence of their original symptoms.
- Pseudarthrosis. Patients who smoke are more likely to develop a pseudarthrosis. This is a condition where there is not enough bone formation. If this occurs, a second surgery may needed in order to obtain a solid fusion.
- Nerve damage. It is possible that the nerves or blood vessels may be injured during these operations. These complications are very rare.
- Blood clots. Another uncommon complication is the formation of blood clots in the legs. These pose significant danger if they break off and travel to the lungs.
Warning Signs
It is important that you carefully follow any instructions from your doctor relating to warning signs of blood clots and infection. These complications are most likely to occur during the first few weeks after surgery.
Warning signs of possible blood clots include the following:
- Swelling in the calf, ankle or foot
- Tenderness or redness, which may extend above or below the knee
- Pain in the calf
Occasionally, a blood clot will travel through the blood stream and may settle in your lungs. If this happens, you may experience a sudden chest pain and shortness of breath or cough. If you experience any of these symptoms, you should notify your doctor immediately. If you cannot reach your doctor, someone should take you to the hospital emergency room or call 911. Infection following spine surgery occurs very rarely. Warning signs of infection include:
- Redness, tenderness, and swelling around the wound edges
- Drainage from the wound
- Pain or tenderness
- Shaking chills
- Elevated temperature, usually above 100°F if taken with an oral thermometer
If any of these symptoms occur, you should contact your doctor or go to the nearest emergency room immediately.
Recovery
Pain Management
After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
Rehabilitation
The fusion process takes time. It may be several months before the bone is solid, although your comfort level will often improve much faster. During this healing time, the fused spine must be kept in proper alignment. You will be taught how to move properly, reposition, sit, stand, and walk.
Your symptoms will gradually improve. So will your activity level. Right after your operation, your doctor may recommend only light activity, like walking. As you regain strength, you will be able to slowly increase your activity level.
Maintaining a healthy lifestyle and following your doctor’s instructions will greatly increase your chances for a successful outcome.
Artificial Disk Replacement in the Lumbar Spine
In artificial disk replacement, worn or damaged disk material between the small bones in the spine (vertebrae) is removed and replaced with a synthetic or “artificial” disk. The goal of the procedure is to relieve back pain while maintaining more normal motion than is allowed with some other procedures, such as spinal fusion.
Lumbar Fusion and Artificial Disk Replacement
Although it is estimated that 70% to 80% of people will experience low back pain at some point in their lives, most will not need surgery to improve their pain. Surgery is considered when low back pain does not improve with conservative treatment.
For patients who have exhausted nonsurgical options and are still in pain, lumbar fusion surgery remains the most common option for treating low back pain. Fusion is essentially a “welding” process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
While many patients are helped by lumbar fusion, the results of the surgery can vary. In addition, some patients whose fusion surgeries heal perfectly still end up with no improvement of their back pain.
Some doctors believe that the failure to improve after fusion surgery is due to the fact that fusion prevents normal motion in the spine. For this reason, artificial disk replacement—which aims to preserve normal motion—has emerged as an alternative treatment option for low back pain.
Artificial disk replacement initially gained FDA approval for use in the U.S. in 2004. Over the past several years, numerous disk replacement designs have been developed and are currently being tested.
Who Is a Candidate for Disk Replacement?
To determine if you are a good candidate for disk replacement, your surgeon may require a few tests, including:
- Magnetic resonance imaging (MRI) scans
- Discography
- Computed tomography (CT) scans
- X-rays
Information from these tests will also help your surgeon determine the source of your back pain.
Artificial disk replacement is not appropriate for all patients with low back pain. In general, good candidates for disk replacement have the following characteristics:
- Back pain caused by one or two problematic intervertebral disks in the lumbar spine
- No significant facet joint disease or bony compression on spinal nerves
- Body size that is not excessively overweight
- No prior major surgery on the lumbar spine
- No deformity of the spine (scoliosis)
Surgical Procedure
Most artificial disk replacement surgeries take from 2 to 3 hours.
Your surgeon will approach your lower back from the front through an incision in your abdomen. With this approach, the organs and blood vessels must be moved to the side. This allows your surgeon to access your spine without moving the nerves. Usually, a vascular surgeon assists the orthopaedic surgeon with opening and exposing the disk space.
During the procedure, your surgeon will remove your problematic disk and then insert an artificial disk implant into the disk space.
Disk Design
Some disk replacement devices comprise the nucleus (center) of the intervertebral disk while leaving the annulus (outer ring) in place, although this technology is still in an investigative stage.
In most cases, total artificial disk replacements substitute both the annulus and nucleus with a mechanical device that will simulate spinal function.
There are a number of different disk designs. Each is unique in its own way, but all maintain a similar goal: to reproduce the size and function of a normal intervertebral disk.
Some disks are made of metal, while others are a combination of metal and plastic, similar to joint replacements in the knee and hip. Materials used include medical grade plastic (polyethylene) and medical grade cobalt chromium or titanium alloy.
Your surgeon will talk with you about which disk design is best for you.
Recovery
In most cases, you will stay in the hospital for 1 to 3 days following artificial disk replacement. The length of your stay will depend upon how well-controlled your pain is and your return to function.
In most cases, patients are encouraged to stand and walk by the first day after surgery. Because bone healing is not required following artificial disk replacement, the typical patient is encouraged to move through the mid-section. Early motion in the trunk area may lead to quicker rehabilitation and recovery.
You will perform basic exercises, including routine walking and stretching, during the first several weeks after surgery. During this time, it is important to avoid any activities that cause you to hyperextend your back.
Outcomes
Most patients can expect improvement of lower back pain and disability in weeks to months following surgery. Studies show that disk replacement improves, but does not completely eliminate pain. Before your surgery, it is important to talk with your surgeon about realistic expectations for pain relief.
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Very many thanks for your wonderful care and attention given to me in my recent operation. It was really helpful to be kept informed of what was happening, and overall I found the experience an enjoyable one. Thanks and Best wishes.
A.M.
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Thank you so much for bringing me through this operation. Your care, kindness and professionalism shone through. You're so positive and confident that it helps us so much. Long may you continue to serve the people in this way.
S.M.
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Thank you for all the kind and expert care you gave me while I was in hospital. For all your concern, kindness and skills which have enabled me to recover and a chance to enjoy life to the full once again.
D.H.
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