Spinal Conditions
Your spine has three parts – the neck (cervical spine), the mid-back (thoracic spine) and the lower back (lumbar spine). At the bottom is your tailbone (sacrum and coccyx). The whole of your backbone has 33 vertebrae, supports most of your body weight and protects your spinal cord.
The vertebrae in your neck are usually labeled C1 - C7, meaning there are seven cervical vertebrae in that region. The thoracic spine extends from your shoulders to your waist - there 12 vertebrae in that section, T1 – T12. There are five vertebrae in your low back, L1 - L5, and below that is the sacrum which lies between the hipbones. The coccyx is made of small fused bones at the very tail of your spine.
Between each vertebrae are discs, shock absorbers for the vertebrae. Each disc has a tire-like outer band called the annulus fibrosis, a housing for the gel-like inner substance called the nucleus pulposus.
Together, your vertebrae, pedicle bones and discs provide a protective tunnel (the spinal canal) to house the spinal cord and spinal nerves. Spinal nerves run down the center of the vertebrae and exit to various parts of your body through the foraminal canal.
Your spine also has facet joints - two on the back side of each vertebrae. Like all joints in the body, they help you move and are very important to your flexibility. If these joints become enlarged, they put pressure on your sensitive spinal nerves. Further, these joints are very prone to arthritis as you age.
Bulging Disc and Herniated Disc
Arthritis and Degenerative Disc Disease
Pain after Conventional Surgery
Facet Joint Disease In the Lumbar Spine
Cross section of Spinal Cord and relevance to disease
A bulging disc, literally, bulges out into the spinal canal. A herniated disc is a bulging disc that has split or ruptured. They can occur at any level of your spine and may happen suddenly, or gradually progress. When the disc ruptures, or herniates, the inner gel-like substance (nucleus pulposus) leaks out.
People between the ages of 30 and 50 are most at risk because the elasticity and water content of the disc center decrease with age. Not all herniated discs cause pain, but most cause disabling pain and weakness, numbness or tingling in the back, leg or arm. Depending on where the disc has ruptured, you can also lose control of your bladder of bowels due to pressure on the spinal nerves.
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Spinal stenosis is a tightening of the spinal canal that leads to nerve compression as the nerve exits the spinal column - and results in pain, weakness or numbness.
There are also specific varieties of stenosis, for instance foraminal stenosis - a narrowing of the foramen, which compresses the roots of the nerve. Cervical stenosis causes pain in your neck and shoulders, often radiating down your arm or hand. Cervical stenosis can also cause headaches, numbness or muscle weakness, affecting the nerves that control your balance.
When sitting down or leaning forward, the ligament surrounding your spinal column is stretched out and gives your spinal canal more room for the spinal nerves. When you stand up, lean back or walk uphill, the ligament becomes shorter and thicker and the pain is more intense.
The risk of spinal stenosis increases in those over the age of 50. Symptoms develop gradually and gradually get worse. Generally, spinal stenosis pain is in your low back and is due to aging and arthritis.
Our techniques involve decompression of the specific area of narrowing. Minimal tissue is damaged and the spinal structure is mostly intact.
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About the diameter of your finger, the sciatic nerve is the longest and largest nerve in your body. It is five sets of paired nerve roots, starting in your low back, running through the pelvic region and down your thigh. Behind your knee, smaller nerves branch out from the sciatic nerve and travel to your feet.
The sciatic nerve is part of the complex structure of your body’s nervous system. When something presses against it, it hurts and it hurts bad. Many things can go wrong that put pressure on your sciatic nerve, including herniated or bulging discs, degenerative disc disease, spondylolisthesis, spinal stenosis and trauma.
You may feel sciatica in different ways:
- Pain that travels from the low back, through the buttocks and hips, often downward into your leg, and sometimes into your foot.
- Shooting pain down your leg, sometimes described as being like electricity, or burning and tingling sensations.
- Partial leg numbness or weakness.
- Pain, burning, tingling, numbness or weakness on only one side of your entire lower body.
Pain and other symptoms may be constant and vary from mild to severe. Sitting, walking and the act of standing up may be painful and difficult. Coughing, sneezing and other sudden movements may intensify the pain. It affects your everyday life, and can sometimes cause loss of bowel or bladder control.
Depending on where your sciatic nerve is pinched, you can experience sciatica in different ways and in different parts of your hip and leg.
- If your pain is especially intense above your knee, you may have trouble bringing your foot up. With these symptoms, it's likely that the sciatic nerve is being pinched by the piriformis muscle, which moves your thigh side to side.
- If your pain is below your knee and into your foot, you will not react as quickly when the doctor tests your knee-jerk reflex. Most likely, the nerve is being pinched at the L3-L4 level of your low back.
- If the pain is on the side of your foot, it's difficult to lift your heel off the ground or walk on your tiptoes. With these symptoms, your sciatic nerve is probably being pinched at the L5-S1 level.
- If your big toe and ankle are painful, this is known as foot drop. You may have numbness and pain on the top of your foot as well, but it is most intense in your big toe. If so, it's likely that your sciatic nerve is being pinched at the L4-L5 level.
The most common cause of sciatica is a bulging or herniated disc. With the disc bulges, the disc presses on nerve roots. Further, if the disc is herniated, the acid that leaks into the spinal column causes nerve inflammation.
Spinal stenosis also contributes to sciatica. Nerves travel through the passageways of your spine and when that space narrows, with stenosis, it can put pressure on the nerves in your low back.
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Arthritis and Degenerative Disc Disease
As you age, your discs break down - like all other joints in the body. DDD involves the intervertebral discs, the pillow-like cushions between your vertebrae. They help your back carry weight and allow complex motions while maintaining stability. Discs can lose flexibility and elasticity, and become thinner as they dehydrate . When this happens, movement of any kind causes pain.
DDD is a gradual process, usually occurring in your low back or neck. There are many stages of the disease, and as your disc continue to shrink, they are much more prone to herniation. Also, bone spurs can form as your spine tries to adjust to the intervertebral disc changes.
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Your spinal joints are covered by cartilage, which protects your bones as you move. Without cartilage, your bones would rub together. But cartilage can be affected by general wear and tear on your spine, and it can wear away. That's when bone spurs (osteophytes) can form as your body attempts to repair itself.
Bone spurs press on the nerves, causing great pain - in the neck, lower back, or most any part of your body that feed off of the nerves in your back.
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If a vertebrae slips forward over the vertebrae below it, this slip can pinch the nerve and cause sciatica. Spondylolisthesis is a common cause of back pain in teenagers and often develops during a growth spurt. An MRI is needed to view the involvement of spinal nerves.
Many people with spondylolisthesis are symptom-free, only discovered when a patient has an X-ray for an unrelated problem. More chronic patients can have:
Low back pain and tenderness
Buttock pain
Thigh and leg pain and/or weakness in one or both legs
Difficulty controlling bowel and bladder functions
Tight hamstring muscles
Swayback
Protruding abdomen
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Whiplash
A sudden forced movement of the head or neck in any direction, and the resulting “rebound” of the head or neck in the opposite direction is known as whiplash. The sudden whipping motion causes injury to the surrounding and supporting tissues of your neck and head. Muscles react by tightening and contracting, creating muscle fatigue - resulting in chronic pain and stiffness.
Severe whiplash can also involve injury to the intervertebral discs, joints, ligaments, muscles and nerve roots. Car accidents are the most common cause. Also, if you've had a head injury, your neck is most likely involved, even if you don't feel it right away.
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Cervical Anatomy and Disease
The cervical spine is designed for motion. The structure is similar to lower mammals and is made for ultimate sensory input. The head can move in multiple planes to allow our senses to function, but this motion can lead to problems, thus pain. Pain in the neck can lead to other problems because the neck is controlled by many muscles. These muscles can spasm and lead to pain in the neck and other associated areas, such as the head. In fact, most headaches that people call migraines are actually called cervicogenic headaches or headaches caused by neck problems. True migraines are usually not usually caused by neck problems and require medications to keep them at bay. Headaches caused by cervical related issues may be correctable.
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Pain after Conventional Surgery
The spinal cord is very sensitive to any compressive forces. If there is any pressure on the nerves it will generally result in pain, weakness, or numbness. Residual pain after surgery is usually due to residual nerve compression. This is due to many sources but the most common are: reherniation of the disc, Incomplete decompression of the spinal cord or the foraminal canals. Numbness or weakness that results after a surgery may signify nerve damage that may be non-repairable. Pain is usually due to continued forces acting on the spinal cord or the nerves themselves. These forces may be stretching or compressive, although compressive is more common. Many people get pain a few months after their surgery and they are told that it is due to scar tissue or arachnoiditis. This is usually only partly true. The scar tissue in and of itself isn't the problem. The problem is that the scar tissue is acting as a space occupying lesion and thus it is compressing the nerves against a solid object such as bone or disc. Another important reason for residual pain after surgery is that the surgery was performed at the wrong spot. As stated before the spinal cord is very sensitive to any compression and if the surgery was done in the wrong area then residual pain may be present. This is not to say that the surgery performed a incorrect surgery, nerves can be compressed at various areas and most surgeons partially guess at where the nerve is being compressed. This is one reason why if we have any question as to what your source of pain is we will perform diagnostic blocks to confirm our diagnosis. The correct diagnosis will usually lead to the correct surgery and thus resolution of the pain. Finally, another reason for residual pain is that the original pain was resolved but a "new" pain has developed. People often focus on their "worst" pain and once that "worst" pain is resolved, then "new" pains may come to the surface. The best way to describe this is if someone hit your thumb with a hammer, until the thumb pain resolved, you wouldn't be focusing on your back pain. Our mind focuses on the most important insulting injury so that we can deal with it and survive.
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Lumbar Anatomy and Disease
The human spine is made for motion and protection. It houses the spinal cord and thus protects the major nerves of the body. It is very flexible but this mobility also leads to possible injury and especially in humans who walk upright there is a tendency for disc herniation which are much less common in other mammals. Also, humans live longer than most other mammals and thus succumb to the problems associated with the degeneration of aging.
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S1 Joint Dysfunction
It is sometimes difficult for patients to understand that the pain is from the ligaments of the SI joint and not the joint itself. Most patients are told that the joint is slipping or overly mobile and this is why they need to have the joint fused. We believe that the problem is the highly innervated tissues that surround the joint and not actually the joint itself. We determined this by performing our procedures on the patients while they are awake with mild sedation. The patients tell us exactly what is causing their pain and they tell us when it is gone. After performing hundreds of these procedures, we determined that the soft tissues are the pain generator. This conclusion is contrary to the opinion held by most doctors, who believe that the pain is from abnormal joint mobility. Unfortunately, 50% of patients still have pain even after the joint is fused! If the pain were from a mobile joint, then the problem should have been solved once the joint cannot move. The problem, however, often remains and patients are told that the joint is probably still mobile.
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Degenerative Disc Disease
Discs are located between the bones of the spine. They act as shock absorbers and add height to the spine. The disc consists of two parts. The inner nucleus pulposus is an area of stringy fibrous material of high water content. it is solid, but weak in structure. The outer fibrous annulus is a strong ligamentous structure that helps contain the disc.
Degenerative disc disease to some extent is hereditary. Often one will have family members with similar back pain problems. Discs gradually decay with aging and the fibrous annular tissue can fracture and lead to herniations of the inner nuclear material. These herniations can cause pain locally in the neck or back, or they can cause pain down the extremity due to nerve compression.
Many people have chronic back pain due to DDD. This pain is due to the fact that the annular region of the disc is highly innervated. The nuclear material contains chemicals which irritate these nerves that innervate the disc's annular region. The pain associated with DDD is commonly referred to as deep achy pain, with occasional sharp jolts.
A normal spine has a disc that maintains a normal space between the vertebra and has no herniations.
Some individuals claim to be able to deinnervate the disc via a annuloraphy procedure. Unfortunately, this is nearly impossible due to the vast innervation of the disc. The nerves that supply sensation to the disc come from multiple nerves and regions. The only way to deinnervate the disc is to actually remove the disc itself. Procedures such as IDET and annuloraphy do not deinnervate the disc to any significant degree and this is why the results with such procedures are extremely poor.
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Lumbar Artificial Discs
What is the artificial disc? How does it work? Many people have heard wondrous stories of this new device and many have fantastic visions of what it looks like or how it works. The artificial disc was developed in Germany in the 1960's and has been used in Europe for a number of years. It is not an artificial disc at all but is a stainless steel mobile "fusion". The device is inserted through the abdomen into the disc space once the disc is removed. The operation involves a large (approximately 4 inch) abdominal incision, moving the abdominal contents and the major blood vessels to gain access to the anterior spine. This is not minor surgery, but no spinal surgery is minor. Recovery appears to be similar to most abdominal or spinal surgeries.
The concept of the artificial disc is simple. First, remove the real disc since it is causing pain; secondly, allow mobility so that the remaining discs do not eventually fail as with most fusions. The artificial disc does allow this mobility and only has success rates similar to conventional fusions. No long term studies have been done on whether the long term disc herniation rates are lower for fusions or artificial discs. Success rates are similar for fusions versus artificial discs, in that U.S. studies reveal success rates to be around 68% good to excellent.1 European studies reveal higher success rates at 79%.2 The higher success rates associated with European studies are not unusual but the American studies are considered to be more accurate.
Contraindications for the procedure include: infection, spinal stenosis, spondylolisthesis, posterior facet joint disease, significant radiculopathy, osteoporosis and any prior spinal fusion. Thus, artificial discs are probably not amenable to most patients over the age of 50 due to some degree of spinal stenosis.
In this day and age, people want "replacement" parts that will make them "like new". Does the artificial disc give long term success? That is the big unknown. Artificial joints have been around for years and as time progressed, it was found that they were only temporary replacements. They were temporary because they eventually loosened, causing pain and dysfunction. The artificial joints had to then be replaced with new artificial joints. To replace an artificial joint is very difficult and mortality and morbidity rates are high. The surgery is quite lengthy and leads to much greater blood loss and complications. Can one conclude that similar results will occur with the artificial disc? At present, that is an unknown. However, given that it happens with every other replacement "joint" product, one can only conclude that usage of the cervical artificial disc will result in similar outcomes. The concern, therefore, is that it may be 10 years after these steel devices are inserted that they loosen. This could lead to a large group of people with back instability and pain due to bad artificial discs which cannot be easily replaced. It is, therefore, evident that, for the time being, the best solution is to resolve back problems without any artificial material being utilized.
Another option is a gel-filled sack by Raymedica that fits within the disc itself and thus only the inside of the disc is removed. This gel filled prosthesis can be inserted through a conventional discectomy, and possibly endoscopically. This offers a soft spacer that retains disc height without the major surgery involved with an artificial disc.
There are several questions about this device. What prevents the device from moving or even herniating? How long does this gel product or sack actually last before the extreme forces of the spine destroy the device? With this device there are no long term studies to date and it is not yet FDA approved in the United States. Movement of the device is a major concern since any movement may compress the spinal cord and cause paralysis or nerve injury.
What are our alternatives to these therapies? There are several non-hardware treatments for back pain. For disc related pain, the physicians at MicroSpine still believe the best initial treatment for degenerative disc disease is to perform an endoscopic discectomy. This is a relatively benign procedure and offers a 60 to 70% success rate without the insertion of any foreign material. Percutaneous discectomies can also be utilized in some cases. For some cases, we offer intradiscal injections of various substances that can help heal the disc or bio-absorbable fusions which temporarily fuse the spine.
Nonetheless, all spinal surgery has similar results. Success rates of around 70% are considered the norm for most spine related surgery. Keep this in mind when deciding what type of surgery to utilize. That is why we recommend the least invasive approach for any spine related problem.
Footnotes:
1 A 1997 independent study, conducted by the Texas Back Institute and the Institutes for Spine and Biomedical Research, followed 67 patients who underwent intervertebral disc replacement with the SB Charité III device
2 A 1997 study conducted in France by Lemaire et al reviewed 105 cases undergoing SB Charité III prosthetic disc replacement.
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Facet Joint Disease In the Lumbar Spine
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Cervical Facet Joint Pain
The cervical facet joints can lead to pain like any other joint in the body. Bone spurs or other arthritic conditions lead to decay of the joint surfaces. This causes the joints to rub against their bony surfaces, thus causing inflammation. The inflammation leads to further joint decay and pain. Arthritis is a natural condition associated with aging but it can be worsened by stresses or trauma. There is no cure for arthritis but there are treatments or cures for the pain associated with arthritis.
The cervical region is unique in that it allows a lot of motion. Thus, arthritis of the cervical spine can lead to several problems. People with cervical facet disease can have everything from neck pain to headaches. The cervical joints are designed to offer motion in two planes which means that problems here are usually much worse than elsewhere in the body. The pain in the joints often leads to muscular spasms that only confound the pain and worsen the motion of the neck. This vicious circle continues until the pain is treated. It may take a significant amount of time for the muscular pain and motion to resolve.
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Leg Innervations and Pain
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Cross section of Spinal Cord and relevance to disease
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Cervical Artificial Discs
There's is nothing natural about artificial discs. Why do doctors like to install prosthetics into patients? Artificial disc replacements are available for the lumbar spine. Similarly, artificial discs have been developed for the cervical spine. The cervical spine, however, is significantly different from the lumbar spine, in that it requires a great deal of motion but generally carries very little load. This mean that maintaining motion in the cervical spine is very important. It also means that discogenic pain from disc loading is not as common. More commonly, the cervical discs degenerate and lead to nerve compression. This nerve compression leads to shoulder and arm pain. True cervical pain from the discs is not as common but is definitely seen. The question remains as to whether an artificial disc is warranted, especially when endoscopic cervical discectomy has a success rate of around 90%.
The device is somewhat similar to the lumbar artificial discs and consists of metal plates with a silicon disc. It is held in place by two screws. Bending and flexion is maintained, but rotation is decreased which is very important in the cervical spine.
There are no long term studies regarding the cervical artificial disc and the possibility that the device will loosen and possibly move. Only one facility is performing the insertion of the device on an experimental basis. The surgery is done through a standard conventional anterior cervical approach with a 2 to 3 inch incision. Because movement will be anteriorly, there isn't any risk of spinal cord impingement. However, there is a risk of esophageal or tracheal compression. This could possibly lead to problems with swallowing or even breathing which may necessitate removal of the device and, subsequently, fusion of the spine.
At MicroSpine, our concern is that there may be no real need for a cervical artificial disc when the long term success rates with endoscopic cervical discectomy or decompressive surgeries are so impressive. This disc replacement system may be a very good resort when endoscopic discectomy fails. Nonetheless, we recommend an endoscopic discectomy prior to any fusion or disc replacement therapy, because of the high success rates and the decreased risks, when compared with these more invasive techniques.
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Links to informational websites
If you wish to further your knowledge or suggest a link to us, (a good forum or informational site), please contact the Webmaster.
Board Certification Information Sites
American Board of Anesthesiology
American Board of Pain Medicine
American Board of Medical Specialties
Online Medical Dictionary
Online Medical Literature Search Site
Spine Universe
Understand Your MRI
The physicians on staff at MicroSpine examine your MRI. They consider it as one of the many tools necessary to formulate an accurate diagnosis. It is important that the patient understand that a abnormal MRI doesn't mean that you must have pain, nor does a normal MRI imply that pain cannot exist. A study once concluded that 50% of people who have NO pain had abnormal MRI's. So even though there is more to resolving your pain then just the review of your MRI, it is an excellent initial procedure.
To view graphics of MRI's that reveal abnormalities, please click on the various conditions listed below. These are copyrighted pictures and not for distribution.
1. Cervical Disc Bulge
2. Normal Cervical MRI
3. Lumbar Disc Herniation
4. Normal Lumbar MRI
5. "Bad" or Blackened Lumbar Discs
6. Spinal Stenosis 1
7. Spinal Stenosis 2
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