ANATOMY OF THE LUMBAR SPINE, THE SPINAL COLUMN AND VERTABRAE
Your spinal column consists of 24 separate bones, called vertebrae, plus the five fused bones of the sacrum and the four fused bones of the coccyx (often referred to as the "tail bone"). The vertebrae are stacked one on top of another and can be divided into:
1. The cervical (neck) spine: the top seven vertebrae;
2. The thoracic (chest) spine: the middle 12 vertebrae; and
3. The lumbar (lower back) spine: the bottom five vertebrae.
Support for the Vertebral (Spinal) Column
Attached to the vertebrae are muscles, tendons and a group of strong bands, called ligaments. Together, they support the spinal column and help to protect its delicate nerves.
THE ROLE OF THE VERTEBRAL (SPINAL) COLUMN
Your spinal column enables you to walk upright. It is the central support for your upper body and carries the weight of your head, chest and arms. The vertebrae in the lumbar (or lower back) portion of your spine carry the majority of this weight. The constant pressure from this weight, even when you are simply sitting in a chair, is what usually leads to problems associated with the lower back.
THE ROLE OF THE INVERTEBRAL DISCS
The bony vertebrae of your spinal column are separated from one another by pads of tough cartilage, called intervertebral discs. These discs act like shock absorbers during activity, preventing the individual vertebra from rubbing against one another. Healthy discs, with their gelatin-like inner core, allow the spine to move freely and provide much of the flexibility found in a young person's spine.
THE INVERTEBRAL DISC NUCLEUS
The gelatin-like center of each intervertebral disc (called the nucleus) is surrounded by a tougher, fiber-like outer lining (called the annulus). As your body ages, the disc's nucleus begins to "dry up" and stiffen, increasing the chances that the central bundle of nerves and/or a spinal nerve may eventually become pinched.
THE SPINAL CANAL
The spinal cord, which begins at the base of the brain and runs within the spinal canal, ends in the lumbar spine area in a bundle of nerves known as the cauda equina. The spinal canal runs through the center of the spinal column and protects the spinal cord and other delicate spinal nerves.
THE SPINAL NERVE ROOTS AND THE FORAMEN
At each vertebral level, a pair of spinal nerve roots branch off from the spinal cord or the cauda equina and pass through an opening in the vertebra called the foramen. "Plump" and healthy discs help to cushion the vertebra and keep the opening of the foramen wide enough for the spinal nerve roots to pass through without being pinched.
THE BODY'S "ELECTRICAL" SYSTEM
The spinal nerve roots are part of the body's "electrical" system, carrying "current" (for sensation and movement) to specific parts of the body. These nerves are protected by an "insulated" covering in the same way a "live" electrical line is coated to prevent contact with the bare wire. When a nerve root is damaged, all or part of its protective coating may be rubbed off at the point of injury. Prior to surgery there is no way of telling how much of this "insulation" has been rubbed off or how much damage has been done to the nerve itself (the body's "live electrical wire").
THE "AGING" SPINE
THE BODY'S AGING PROCESS
Your body goes through many changes as you get older. You may not see or hear as well as you did when you were younger. We recognize that this is a natural process, and we learn to accept it or make adjustments for it, such as getting glasses or a hearing aid. As your spine ages, it also goes through some natural changes. In a condition often referred to as the Degenerative (or "Aging") Spine, the gelatin-like centers of your discs begin to dry out, causing them to become compressed or "flattened". This, in turn, causes the vertebrae to"settle." It's one of the reasons most people actually become shorter as they grow older.
THE SLOWLY CLOSING WINDOW
As your discs begin to "compress" and your vertebrae begin to "settle", the window-like openings of the foramen become smaller and smaller. Eventually, the opening can become so small that the nerve is "pinched" against a vertebra. It's similar to laying your hand on a window sill. As long as the window is open, there is no problem. However, if someone slowly closes the window, there will be a point at which your hand begins to feel the pressure. The more the window is closed, the greater the pressure and the greater the pain you will feel.
THE LOSS OF YOUR SPINE'S "SHOCK ABSORBERS"
At the same time, your aging discs are drying out and losing their ability to act as effective "shock absorbers." Your vertebrae begin to bounce against one another and this jarring action actually causes the bone matter of the vertebrae to grow. This results in the formation of bone spurs. The jagged edges of this new growth can cause both the spinal canal and the foramen to become even smaller. When this happens, the result is often the pinching of the cauda equina and/or a spinal nerve root.
When a spinal nerve is pinched by a narrowing of the foramen, the condition is referred to as lateral recess stenosis. Symptoms include intense pain, numbness and/or weakness in one leg. When the cauda equina becomes compressed by a narrowing of the spinal canal, the condition is referred to as lumbar canal stenosis and the pain, numbness and/or weakness appears in both legs.
If the aging of the spine is a natural process and happens to everyone, why does one person end up with lateral recess stenosis or lumbar canal stenosis while his/her neighbor is seemingly unaffected? The answer is that everyone's spine is unique. Some people are born with discs which are naturally more"plump" than others. Some have wide foraminal or spinal canal openings, while others have narrow ones. These factors as well as your weight, posture and level of physical activity help to determine who will be adversely affected by the aging process.
CERVICAL NECK PAIN
Thousands of Americans suffer from episodes of acute or chronic neck pain each year as a result of injury, strain, overuse or aging. However, a pain in the neck should not be ignored and left undiagnosed and untreated. Problems in the cervical spine, the first seven bones (vertebrae) in the neck running from the base of the brain to just past the shoulder blades, require assessment and treatment to prevent further, more permanent, damage. The cervical spine is where the spinal cord lives. The spinal cord is the most delicate tissue in the entire body. Even minor damage to the spinal cord cannot be repaired. Unlike low back pain, in which waiting to seek treatment may prolong the pain but usually doesn't cause any further damage, untreated spinal cord compression can lead to irreversible damage.
Two Types of Neck Pain: There are two distinct types of cervical neck pain. The first type often involves a dull pain in the neck that radiates down the shoulders and arms. Patients may also notice weakness in specific muscles in the arms. A herniated (bulging) disc in the spine pinching a nerve root in the neck often causes this type of neck pain. Discs are found between each vertebra, or bone, in the spinal column. They serve as "shock absorbers" within the spine and have a gel-like center that makes them flexible, allowing the spine to bend and move. However, because the discs are soft they can also bulge and become misshapen. When this occurs, they can place pressure on the spinal cord or irritate one of the nerves leading from the spinal cord out to the arms and upper torso. If the bulge becomes severe, the disc may herniate and push into the spinal canal. The result can be weakness, tingling, clumsiness and numbness in the arm and hands. Bulging discs can be caused by injuries like whiplash, stress on the spine by overuse, or by arthritis/degeneration in the spine. The second type of neck pain often isn't experienced as 'pain' by patients at all. It usually involves numbness or weakness in the arms or legs, difficulty walking, loss of pain or temperature sensation in the hands and arms, poor balance and stiffness in the neck. In this case, there is pressure directly on the spinal cord. Because this type of "pain" is not felt in the neck itself, it is easily misdiagnosed. We usually see patients with neck pain in one of three different scenarios. One, they've been in some sort of accident and have suffered a whiplash-type injury. Two, they have a chronic injury caused by overuse, most likely caused by working at a computer for endless hours. Or they've experienced one of the first two scenarios in the past and now have arthritis or a tissue degeneration problem.
Neck Injuries: A more common neck injury is whiplash. Symptoms include neck stiffness, shoulder or arm pain, headache, facial pain and dizziness. Aggressive physical therapy, time and medication are often the most effective treatment for whiplash injuries, unless there is a herniation of a disc in the cervical spine. If the symptoms still persist after four to six weeks, or if there is severe weakness in the arms, hands or legs, a consult should be considered.
Degenerative Conditions: The neck is also susceptible to osteoarthritis and degenerative disc disease, which can be caused by general wear and tear on the spine. The discs begin to lose their flexibility and ability to absorb stresses in the spine. Or, bone spurs develop on the vertebrae. In either case, the nerves in the cervical spine can become irritated or pinched, causing pain in the neck or the arms. If there is a great deal of degeneration in the cervical spine, the spinal cord and nerve roots may become compressed, causing irreversible damage. Cervical stenosis is another condition that may result from degeneration in the spine. It occurs when the spinal canal narrows and compresses the spinal cord. If the pain from stenosis is restricted to the neck, conservative treatment is prescribed.
HERNIATED DISC- LUMBAR
A common cause of low back and leg pain is a herniated or ruptured disc. Symptoms may include dull or sharp pain, muscle spasm or cramping, sciatica, and leg weakness or loss of leg function. Sneezing, coughing, or bending usually intensifies the pain. Rarely is bowel or bladder control lost, but if this occurs, seek medical attention at once. Sciatica is a symptom frequently associated with a lumbar herniated disc. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that extends from the buttock into the leg and sometimes into the foot. Usually one side (left or right) is affected.Anatomy - Normal Lumbar Disc In between each of the five lumbar vertebrae (bones) is a disc, a tough fibrous shock-absorbing pad. Endplates line the ends of each vertebra and help hold individual discs in place. Each disc contains a tire-like outer band (called the annulus fibrosus) that encases a gel-like substance (called the nucleus pulposus).Nerve roots exit the spinal canal through small passageways between the vertebrae and discs. Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or nerve roots. Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape. This is called a Herniated Nucleus Pulposus (HNP) or herniated disc.
Progressive Steps Toward Herniation: Many factors increase the risk for disc herniation: (1) Lifestyle choices such as tobacco use, lack of regular exercise, and inadequate nutrition substantially contribute to poor disc health. (2) As the body ages, natural biochemical changes cause discs to gradually dry out affecting disc strength and resiliency. (3) Poor posture combined with the habitual use of incorrect body mechanics stresses the lumbar spine and affects its normal ability to carry the bulk of the body's weight. Combine these factors with the affects from daily wear and tear, injury, incorrect lifting, or twisting and it is easy to understand why a disc may herniate. For example, lifting something incorrectly can cause disc pressure to rise to several hundred pounds per square inch! A herniation may develop suddenly or gradually over weeks or months. The four stages to a herniated disc include:1) Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation. 2) Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion. 3) Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc. 4) Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).
Locating the Cause of Pain: Interestingly, not every herniated disc causes symptoms. Some people discover they have a bulging or herniated disc after an x-ray for an unrelated reason. Most of the time the symptoms prompt the patient to seek medical care. The visit with the doctor usually includes a physical and neurological exam; review of medical history, symptom evaluation and the history of treatments and medication the patient has tried. An x-ray may be needed to rule out other causes of back pain such as osteoarthritis or spondylolisthesis. A CT or MRI scan verifies the extent and location of disc damage. Sometimes a myelogram is necessary.
Treatment · Non-Surgical: Most patients do not need surgery! Initially, the doctor may recommend some bed rest, cold therapy, and medications. Bed rest takes the pressure off nerves in the low back. During the first 24 to 48 hours cold therapy helps to reduce swelling, muscle spasm, and pain by reducing blood flow. Never apply cold or ice directly to skin; instead wrap the ice pack or cold product in a towel and apply for no longer than 15 minutes. Medications may include an anti-inflammatory to reduce swelling, a muscle relaxant to calm spasm, and a pain-killer (narcotic) to alleviate intense but short-lived pain (acute pain). Mild to moderate pain may be treated with non-steroidal anti-inflammatory drugs (NSAIDs). These work by relieving both swelling and pain. Discuss NSAID use with your physician first. Usually, after the first 48 hours, heat therapy can be applied. Heat increases blood flow to warm and relax soft tissues. Increased blood flow helps to flush away irritating toxins that may accumulate in tissues as a result of muscle spasm and disc injury. Never apply heat directly to skin; instead, wrap the heat source in a thick towel for no longer than 20 minutes. If leg pain is severe, or leg weakness is developing, the doctor may prescribe an epidural injection. An epidural is an injection of anti-inflammatory medication into the space near the affected nerves. You should discuss this option with your doctor and ask about potential side effects before beginning this treatment. The doctor may recommend physical therapy. The doctor's orders are transmitted to the physical therapist by prescription. Physical therapy includes a combination of non-surgical treatments to decrease pain and increase flexibility. Ice and heat therapy, gentle massage, stretching, and pelvic traction are some examples. In four to six weeks, the majority of patients find their symptoms are relieved without surgery! Be optimistic about your treatment plan and remember that less than 5% of all back problems require surgery!
Treatment · Surgical Surgery is considered if non-surgical treatment does not relieve symptoms. Constant pain, leg weakness, or loss of function requires further evaluation. Rarely, lumbar HNP causes bowel/bladder incontinence or groin/genital numbness, which requires immediate medical attention. If surgery is recommended, always ask the purpose of the operation and what results you can expect. Never be afraid to obtain a second opinion. To relieve nerve pressure and leg pain, surgery usually involves a partial disc removal or discectomy. In addition, the surgeon may need to access the herniated disc by removing a portion of the bone covering the nerve. This procedure is called a laminotomy. Fortunately, these procedures can often be done utilizing minimally invasive techniques. Minimally invasive surgery does not require large incisions, but instead uses small cuts and tiny specialized instruments and devices such as an endoscope during the procedure. Prevention Aging is inevitable, but lifestyle changes can help prevent lumbar disc disease. Risk factors include poor posture and body mechanics, weak abdominal muscles, smoking, and obesity. Start now to adopt habits that will help preserve your spine for the future.
Degenerative Disc Disease and Low Back Pain
Degenerative Disc Disease (DDD) is a gradual process that may compromise the spine. Although DDD is relatively common, its effects are usually not severe enough to warrant medical attention. In this discussion we address DDD in the lumbar spine.
Degenerative Changes to a Disc
Degenerative changes in the spine are often referred to those that cause the loss of normal structure and/or function. The intervertebral disc is one structure prone to the degenerative changes associated with wear and tear, aging, even misuse (e.g. smoking). Long before DDD can be seen radiographically, biochemical and structural changes occur. Some of these changes are not unlike those associated with osteoarthritis. Over time the collagen (protein) structure of the annulus fibrosus weakens and may become structurally unsound. Additionally, water and proteoglycan (PG) content decreases. PGs are molecules that attract water. These changes are linked and may lead to the disc's inability to handle mechanical stress. Understanding the lumbar spine carries a large portion of the body's weight; the stress from motion may result in a disc problem (e.g. herniation).
Degeneration of the intervertebral discs can result from a variety of conditions, including aging, trauma, and several types of arthritic conditions. As we age, our tissues tend to lose water. That's why skin wrinkles with age, and various body parts begin to sag. When this occurs in the intervertebral disc, the disc tends to shrink, becoming thinner and less cushiony. The condition is fairly common in adults past middle age, and may be asymptomatic - causing no symptoms - other than occasional lower back pain, or stiffness. At other times, however, the associated collapse of the disc space, especially in the lumbar spine (lower back), can be the source of severe mechanical back pain, or radicular leg pain. Under these circumstances, surgical intervention may be appropriate. The inner portion of the disc, the nucleus pulposis, is composed of proteoglycans - chemical combinations of sugar and protein. When the disc degenerates, small cracks or tears form in the outer annulus, allowing these chemical substances to leak out into the epidural space. Proteoglycans have been shown to cause irritation or inflammation of the nerves surrounding and adjacent to the damaged disc. Minimally invasive, endoscopic procedures, designed to remove the diseased or damaged portion of the disc, may be helpful in alleviating such pain. Under other circumstances, collapse of the disc space can lead to a condition more recently termed "vertical instability". In this case, shrinkage of the disc allows abnormal movement across a motion segment (2 vertebrae and the intervening disc), and may result in mechanical back pain - pain which arises from changes in position, or attempts at strenuous activities. In such cases, fusion of the interspace may be the procedure of choice. (Perhaps, at some point in the future, replacement of the disc by an artificial substitute may become an option, when such devices are eventually developed and approved for use, by the FDA - see below).
In some patients, the pain response may limit their flexibility. Prescribed stretching exercises can improve flexibility of the trunk muscles. Flexion exercises may help to widen the intervertebral foramen. The intervertebral (between the vertebrae) foramen are small canals through which the nerve roots exit the spinal cord. The intervertebral foramen are located on the left and right sides of the spinal column.
Extension exercises, such as the McKenzie method, focuses on the muscles and ligaments. These exercises help maintain the spine's natural lordotic curve, important to good posture. Aerobics (no/low impact) offers many benefits including improved muscular endurance, coordination, strength, strong abdominal muscles, and weight loss. Strong abdominal muscles work like a brace (or corset) to reduce the loads to the lumbar spine. It is also known that aerobics help to combat anxiety and depression. The loads on the discs during walking are only slightly greater than when lying down. Walking, bicycling, and swimming are forms of aerobic exercise a physician may suggest.
During the acute phase of low back pain, drugs may be prescribed. Some of these may include narcotics, acetaminophen, anti-inflammatory agents, muscle relaxants, and anti-depressants. Narcotics are used on a short-term basis partially due to their addiction potential. When low back pain is caused by muscle spasm, a muscle relaxant may be prescribed. These drugs have sedative effects. Depression can be a factor in chronic low back pain. Anti-depressant drugs have analgesic properties and may improve sleep.
Today manipulation is performed by Chiropractors and Physical Therapists. For patients without radiculopathy (pain stemming from a spinal nerve root), manipulation may be effective during the first month. Thereafter, benefits are unproven. Manipulation is believed to be effective because of its effect on spinal mobility. Acute low back pain, chronic low back pain, and DDD without nerve compression may respond to manipulation.
Usually during the first six weeks, acute low back pain is treated with a couple of days of bed rest (slightly longer with herniated disc) and appropriate medication. Muscle relaxants are seldom used for longer than one week. Early ambulation is encouraged to increase circulation (aids healing), improve flexibility, and build strength. Generally, during the first two to three weeks the acute symptoms subside. Aerobic (no/low impact) exercise may be started three times per week along with daily back exercises. Some patients may be referred to physical therapy or a supervised work-conditioning program.
Beyond Six Weeks: If the symptoms of DDD and low back pain persist despite non-operative treatment, further diagnostic tests may be necessary. These tests may include an MRI, CT Scan, Myelogram, or possibly Discography. Although most DDD patients with herniation respond well to non-operative treatments, a small percentage do not. Disc herniation is the most common indication for spinal surgery. In fact, 75% of all spinal surgeries are for a herniated disc. Although degenerative disc disease is relatively common in aging adults, it seldom means a surgical sentence. When medical attention is warranted, the majority of patients respond well to non-operative forms of treatment. By eliminating tobacco and maintaining a fitness regiment along with a good diet, most people can enjoy the benefits of a healthy spine.
SCIATICA (RADICULOPATHY)Sciatica is characterized by pain in the lower back and gluteal region. This pain can radiate down one or both legs into the thigh, calf, ankle and foot. Genuine sciatica occurs when pain travels below the knee. Sciatic pain results when the base of the spine is compressed or when injury or pressure have compressed the spinal roots of the sciatic nerve. The sciatic nerve systems are located in the lumbar and the sacral regions of the spine. Sciatic pain can be described as sharp, dull, burning, tingly, numb, continuous or intermittent and usually only affects one side of the body. It can radiate the entire length of the nerve, in some cases all the way down to the toes. Sciatic pain is most often the result of a herniated disk, spinal stenosis (an overgrowth of bone in the spinal canal) or in extremely rare cases, infection or tumor.
Back Pain: The causes of back pain are nearly as numerous as terms used to describe the symptoms. Back pain is a primary reason people seek medical attention. Considering that almost 80% of the adult population will encounter some form of back pain, it could be said that back pain is a universal epidemic. Back pain recognizes no age, economic, or ethnic barriers.
ACUTE - CHRONIC - EPISODIC: Typically back pain originates in the neck (cervical), mid back (thoracic), low back (lumbar). Depending on the source of the pain, certain types of pain may be indicative of disease or a particular disorder. Pain may be described as sudden, sharp, persistent, or dull. Symptoms may be localized to a specific area of the back (e.g. neck) or may radiate into the shoulders, arms, low back, buttocks, legs, and even the feet. Sometimes pain is accompanied by neurologic symptoms such as numbness, tingling, or weakness. Back pain is either acute or chronic. Acute pain may begin suddenly with intense pain usually lasting a short period of time. Chronic pain is persistent long-term pain, sometimes lasting throughout life. Even chronic pain may present episodes of acute pain. Certain neurologic symptoms may indicate the need for immediate medical attention. These 'red flags' include bowel or bladder dysfunction, extremity weakness or numbness, severe symptoms that do not subside after a few days, or pain that prohibits everyday activities.
A MYRIAD OF CAUSES: A cause of back pain is muscle strain and spasm. Strain may result from the 'weekend warrior syndrome', heavy physical work, awkward bending or twisting, even poor posture.
Herniated Disc: A disc herniation is a disc rupture. This may occur if the nucleus pulposus (gel-like center) erupts through the annulus fibrosus (protective disc wall) or if the annulus fibrosus fragments. The progression to an actual herniation varies from slow to sudden onset of symptoms. There are four stages: (1) disc protrusion (2) prolapsed disc (3) disc extrusion(4) sequestered disc. Stages 1 and 2 are referred to as incomplete, where 3 and 4 are complete herniations.
Sciatica: The term 'sciatica' is commonly used to describe pain that travels along the sciatic nerve, the largest nerve in the body. The pain may be sharp, dull, burning, or accompanied by intermittent shocks of shooting pain beginning in the buttock traveling downward into the back of the thigh and leg. The most common cause of sciatica is a herniated disc in the lumbar spine.Spinal StenosisSpinal stenosis results when the small neural passageways termed 'foramen' narrow. The narrowing of the foramen may compress and entrap nerve roots. Nerves react to pressure by swelling, which further reduces foraminal space. Stenosis can cause excruciating pain, numbness, tingling, or burning in the involved extremity (e.g. leg, arm). Stenosis can also occur with compression from a disc, osteophytes (e.g. bone spurs), and ligaments. Whiplashis neck pain, which commonly occurs following an auto accident. This is typically caused by hyperextension and/or hyperflexion because the head is forced to move backward and/or forward rapidly beyond the neck's normal range of motion. The unnatural and forceful movement affects the muscles and ligaments in the neck. Muscles may react by tightening and contracting, creating muscle fatigue, resulting in pain and stiffness.
Osteoarthritis (Spondylosis): Spinal osteoarthritis, or spondylosis, is a degenerative disorder that may cause loss of normal spinal structure and function. Although aging is the primary cause, the location and rate of degeneration is individual. The degenerative process may impact the cervical, thoracic, and/or lumbar regions of the spine affecting the discs and spinal joints. Osteoporosis Osteoporosis commonly affects the thoracic and thoracolumbar regions of the spine and may cause debilitating pain. This disorder is caused by a loss of bone mineral density resulting in fragile bones, which may fracture. Osteoporosis may cause vertebral compression fractures, loss of height, stooped posture, even a humped back. The patient can control some of the risks for osteoporosis. These include poor diet, smoking, excessive intake of alcohol, and inactivity.
Compression Fracture: A compression fracture is a common fracture of the spine that may range from mild to severe. Each vertebral body is separated from the other with a disc. When an external force is applied to the spine, such as from a fall or carrying a sudden heavy weight, the forces may exceed the ability of the bone within the vertebral body to support the load. This may cause the vertebral body to crush. This is known as a compression fracture. If the entire vertebral body breaks, this is considered a burst fracture.
Scoliosis: Scoliosis causes the spine to curve laterally to the left or right and affects children and adults. Scoliosis is a complex three-dimensional disease. To understand this concept, consider that in some cases, as the spine abnormally curves, the involved vertebrae are forced to rotate. At the thoracic level, vertebral turning impacts the rib cage and may result in rib prominence on the opposite side of the curve. Deformity is the primary complaint. Back pain from scoliosis is uncommon.
Spinal Infections (Osteomyelitis): Osteomyelitis is a bone infection usually caused by bacteria. In the spine it is commonly found in the vertebrae, although the infection can spread into the epidural and/or intervertebral disc spaces. Typically, symptoms include persistent and severe back pain exacerbated by movement, swelling, fever, sweating, weight loss, and malaise.
DETERMINING THE CAUSE: Back pain is not always indicative of a spinal problem. Rarely is back pain an emergency or serious medical condition. A proper diagnosis is paramount to determine the best course of treatment. A thorough physical and neurologic assessment may reveal the cause of the pain. The examination begins with the patient's current condition and medical history. The oral segment of the examination often includes many questions such as "when did the pain start?" - "what activities preceded the pain?" - "previous treatment" - "does the pain radiate or travel into another part of the body?" - "what makes the pain less or greater?" - and so on.This examination includes observation of the patient's posture, range of motion, and physical condition. Any movement generating pain is noted. The physician will palpate or feel the curvature of the spine, vertebral alignment, detect muscle and tender points. Abdominal palpation may be performed to determine if the cause of low back pain is possibly internal organ related (e.g. pancreas).The neurological examination tests the patient's reflexes, muscle strength, detects sensory and/or motor changes, and determines pain distribution. If nerve damage is suspected, the physician may order special tests to measure the rate at which nerves conduct impulses.These tests are termed Nerve Conduction Velocity (NCV) and Electromyography (EMG). Typically these studies are not performed immediately because it may take several weeks for nerve impairment to become apparent. If infection, malignancy, fracture, or other risk factors are suspected, routine lab tests may be ordered. These tests may include complete blood count (CBC), erythrocyte sedimentation (ESR), and urinalysis. Plain radiographs (x-rays), CT Scan, and/or MRI studies are performed when fracture or disc disease is suspected, or to evaluate neurologic dysfunction. An MRI represents the gold standard in imaging today. An MRI renders high-resolution images of spinal tissues such as the spinal cord and intervertebral discs. X-rays are still the imaging method of choice to study the bony elements in the spine.
NONSURGICAL - CONSERVATIVE TREATMENT: Seldom does back pain require surgical intervention. A conservative treatment plan may include bed rest for a day or two combined with medication to reduce inflammation and pain. Medications recommended by the physician are based on the patient's medical condition, age, other drugs the patient currently takes, and safety. The first choice for pain relief is often nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs should be taken with food to reduce the risk of stomach upset and stomach bleeding. Muscle relaxants may provide relief from muscle spasm but are actually benign sedatives, which often cause drowsiness. Narcotic pain relievers may be prescribed for use during the acute phase. A cervical collar may be recommended to help a patient with neck pain. Cervical collars limit movement and support the head taking the load off the neck. Lying down has a similar affect. Limiting neck movement and reducing pressure (weight) gives muscles needed rest while healing. Cervical traction may be prescribed for home use. This form of traction gently pulls the head, stretching neck muscles, while increasing the size of the neural passageways (foramen).Physical Therapy (PT) may be incorporated into the patient's treatment plan once activity can be tolerated. PT may include ice therapy to slow nerve conduction thereby decreasing inflammation and pain. Heat treatments may be used to accelerate soft tissue repair. Heat increases blood flow and speeds up the metabolic rate to assist healing. Heat also helps decrease muscle spasm, pain, and promotes a relaxed feeling. Ultrasound is a treatment used to deliver heat deep into soft tissues. Sometimes a heat treatment is given prior to a session of therapeutic exercise. Therapeutic exercise can help build strength, increase range of motion, coordination, stability, balance, and promotes relaxation. Therapists educate their patients about their condition and teach posture correction and relaxation techniques. Patients who participate in a structured physical therapy program often progress to wellness more rapidly than those who do not. This includes back maintenance through a home exercise program developed for the patient by the physical therapist.
RECOVERY and PREVENTION: First and foremost, follow the treatment plan outlined by the physician and physical therapist. Patients, who undergo a surgical procedure, may find the road to recovery a bit longer. However, that is not reason to become discouraged. It is normal to feel tired and emotionally down following surgery. During stress such as surgery, the body cranks out extra hormones - after surgery the level drops, which may result in a 'down' period. To enhance recovery from surgery, an episode of back pain, or to help minimize future exacerbation try to maintain good posture, be consistent in a home exercise program, and eat sensibly to maintain proper body weight.
SPINAL STENOSIS- LUMBAR AND CERVICAL
Spinal stenosis is a narrowing of the spinal canal, which places pressure on the spinal cord. If the stenosis is located on the lower part of the spinal cord it is called lumbar spinal stenosis. Stenosis in the upper part of the spinal cord is called cervical spinal stenosis. While stenosis can be found in any part of the spine, the lumbar and cervical areas are the most commonly affected.
What Causes Stenosis?
Some patients are born with this narrowing, but most often spinal stenosis is seen in patients over the age of 50. In these patients, stenosis is the gradual result of aging and "wear and tear" on the spine during everyday activities. There most likely is a genetic predisposition to this since only a minority of individuals develops advanced symptomatic changes. As people age, the ligaments of the spine can thicken and harden (called calcification). Bones and joints may also enlarge, and bone spurs (called osteophytes) may form. Bulging or herniated discs are also common. Spondylolisthesis (the slipping of one vertebra onto another) also occurs and leads to compression. When these conditions occur in the spinal area, they can cause the spinal canal to narrow, creating pressure on the spinal nerve.
Symptoms of Stenosis
The narrowing of the spinal canal itself does not usually cause any symptoms. It is when inflammation of the nerves occurs at the level of increased pressure that patients begin to experience problems. Patients with lumbar spinal stenosis may feel pain, weakness, or numbness in the legs, calves or buttocks. In the lumbar spine, symptoms often increase when walking short distances and decrease when the patient sits, bends forward or lies down. Cervical spinal stenosis may cause similar symptoms in the shoulders, arms, and legs; hand clumsiness and gait and balance disturbances can also occur. In some patients the pain starts in the legs and moves upward to the buttocks; in other patients the pain begins higher in the body and moves downward. This is referred to as a "sensory march". The pain may radiate like sciatica or may be a cramping pain. In severe cases, the pain can be constant. Severe cases of stenosis can also cause bladder and bowel problems, but this rarely occurs. Also paraplegia or significant loss of function also rarely, if ever, occurs.
How Stenosis is Diagnosed
Before making a diagnosis of stenosis, it is important for the doctor to rule out other conditions that may have similar symptoms. In order to do this, most doctors use a combination of tools, including: · History: The doctor will begin by asking the patient to describe any symptoms he or she is having and how the symptoms have changed over time. The doctor will also need to know how the patient has been treating these symptoms including what medications the patient has tried.
· Physical Examination: The doctor will then examine the patient by checking for any limitations of movement in the spine, problems with balance and signs of pain. The doctor will also look for any loss of extremity reflexes, muscle weakness, sensory loss, or abnormal reflexes which may suggest spinal cord involvement.
· Tests: After examining the patient, the doctor can use a variety of tests to look at the inside of the body. Examples of these tests include:
X-rays - these tests can show the structure of the vertebrae and the outlines of joints and can detect calcification. MRI (magnetic resonance imaging) - this test gives a three-dimensional view of parts of the back and can show the spinal cord, nerve roots, and surrounding spaces, as well as enlargement, degeneration, tumors or infection.
Computerized axial tomography (CAT scan) - this test shows the shape and size of the spinal canal, its contents and structures surrounding it. It shows bone better than nerve tissue.
Myelogram - a liquid dye is injected into the spinal column and appears white against bone on an x-ray film. A myelogram can show pressure on the spinal cord or nerves from herniated discs, bone spurs or tumors.
Bone scan - This test uses injected radioactive material that attaches itself to bone. A bone scan can detect fractures, tumors, infections, and arthritis, but may not tell one disorder from another. Therefore, a bone scan is usually performed along with other tests.
Non-surgical Treatment of Stenosis
There are a number of ways a doctor can treat stenosis without surgery. These include:
· Medications, including non-steroidal anti-inflammatory drugs (NSAIDs) to reduce swelling and pain, and analgesics to relieve pain.
· Epidural steroid injections (corticosteroid) can help reduce swelling and treat acute pain that radiates to the hips or down the leg. This pain relief may only be temporary and patients are usually not advised to get more than 3 injections per 6-month period.
· Rest or restricted activity (this may vary depending on extent of nerve involvement).
· Physical therapy and/or prescribed exercises to help stabilize the spine, build endurance and increase flexibility.
Surgical Treatment of Stenosis
In many cases, non-surgical treatments do not treat the conditions that cause spinal stenosis, however they might temporarily relieve pain. Severe cases of stenosis often require surgery. The goal of the surgery is to relieve pressure on the spinal cord or spinal nerve by widening the spinal canal. This is done by removing, trimming, or realigning involved parts that are contributing to the pressure.
The most common surgery in the lumbar spine is called decompressive laminectomy in which the laminae (roof) of the vertebrae are removed to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disc. Various devices (like screws or rods) may be used to enhance fusion and support unstable areas of the spine.
Other types of surgery to treat stenosis include the following:
· Laminotomy - when only a small portion of the lamina is removed to relieve pressure on the nerve roots;
· Foraminotomy - when the foramin (the area where the nerve roots exit the spinal canal) is removed to increase space over a nerve canal. This surgery can be done alone or along with a laminotomy.
· Medial Facetectomy - when part of the facet (a bony structure in the spinal canal) is removed to increase the space.
· Anterior Cervical Discectomy and Fusion - the cervical spine is reached through a small incision in the front of the neck. The intervertebral disc is removed and replaced with a small plug of bone, which in time will fuse the vertebrae.
· Cervical Corpectomy - when a portion of the vertebra and adjacent intervertebral discs are removed for decompression of the cervical spinal cord and spinal nerves. A bone graft, and in some cases a metal plate and screws, is used to stabilize the spine.
· Laminoplasty - a posterior approach in which the cervical spine is reached from the back of the neck and involves the surgical reconstruction of the posterior elements of the cervical spine to make more room for the spinal canal.
If nerves were badly damaged before the surgery, the patient may still have some pain or numbness after the surgery. Or there may be no improvement at all. Also, the degenerative process will likely continue, and pain or limitation of activity may reappear 5 or more years after surgery. Most doctors will not consider surgical treatment of stenosis unless several months of non-surgical treatment methods have been tried. Since all surgical procedures carry a certain amount of risk, patients are advised to discuss all treatment options with their doctor before deciding which procedure is best.
FACET JOINTS OF THE SPINE: A joint is where two or more bones are joined. Joints allow motion (articulation). The joints in the spine are commonly called Facet Joints. Other names for these joints are Zygapophyseal or Apophyseal Joints. Each vertebra has two sets of facet joints. One pair faces upward (superior articular facet) and one downward (inferior articular facet). There is one joint on each side (right and left). Facet joints are hinge-like and link vertebrae together. They are located at the back of the spine (posterior).
Facet joints are synovial joints. This means each joint is surrounded by a capsule of connective tissue and produces a fluid to nourish and lubricate the joint. The joint surfaces are coated with cartilage allowing joints to move or glide smoothly (articulate) against each other. These joints allow flexion (bend forward), extension (bend backward), and twisting motion. Certain types of movement are restricted. The spine is made more stable due to the interlocking nature to adjacent vertebrae.
SPONDYLOSIS (Spinal Arthritis)
Spondylosis (spinal osteoarthritis) is a degenerative disorder that may cause loss of normal spinal structure and function. Although aging is the primary cause, the location and rate of degeneration is individual. The degenerative process may impact the cervical, thoracic, and/or lumbar regions of the spine affecting the intervertebral discs and facet joints.
Spondylosis often affects the following spinal elements:
As people age certain biochemical changes occur affecting tissue found throughout the body. In the spine, the structure of the intervertebral discs (anulus fibrosus, lamellae, and nucleus pulposus) may be compromised. The anulus fibrosus (e.g. tire-like) is composed of 60 or more concentric bands of collagen fiber termed lamellae. The nucleus pulposus is a gel-like substance inside the intervertebral disc encased by the anulus fibrosus. Collagen fibers form the nucleus along with water, and proteoglycans.
The degenerative effects from aging may weaken the structure of the anulus fibrosus causing the 'tire tread' to wear or tear. The water content of the nucleus decreases with age affecting its ability to rebound following compression (e.g. shock absorbing quality). The structural alterations from degeneration may decrease disc height and increase the risk for disc herniation.
Facet Joints (or Zygapophyseal Joints)
The facet joints are also termed zygapophyseal joints. Each vertebral body has four facet joints that work like hinges. These are the articulating (moving) joints of the spine enabling extension, flexion, and rotation. Like other joints, the bony articulating surfaces are coated with cartilage. Cartilage is a special type of connective tissue that provides a self-lubricating low-friction gliding surface. Facet joint degeneration causes loss of cartilage and formation of osteophytes (e.g. bone spurs). These changes may cause hypertrophy or osteoarthritis, also known as degenerative joint disease.
Bones and Ligaments
Osteophytes (e.g. bone spurs) may form adjacent to the end plates, which may compromise blood supply to the vertebra. Further, the end plates may stiffen due to sclerosis; a thickening/hardening of the bone under the end plates.
Ligaments are bands of fibrous tissue connecting spinal structures (e.g. vertebrae) and protect against the extremes of motion (e.g. hyperextension). However, degenerative changes may cause ligaments to lose some of their strength. The ligamentum flavum (a primary spinal ligament) may thicken and/or buckle posteriorly (behind) toward the dura mater (a spinal cord membrane).
The complexity of the cervical anatomy and its wide range of motion make this spinal segment susceptible to disorders associated with degenerative change. Neck pain from spondylosis is common. The pain may spread (radiate) into the shoulder or down the arm. When a bone spur (osteophyte) causes nerve root compression, extremity (e.g. arm) weakness may result. In rare cases, bone spurs that form at the front of the cervical spine, may cause difficult swallowing (dysphagia).
Pain associated with degenerative disease is often triggered by forward flexion and hyperextension. In the thoracic spine disc pain may be caused by flexion - facet pain by hyperextension.
Spondylosis often affects the lumbar spine in people over the age of 40. Pain and morning stiffness are common complaints. Usually multiple levels are involved (e.g. more than one vertebrae). The lumbar spine carries most of the body's weight. Therefore, when degenerative forces compromise its structural integrity, symptoms including pain may accompany activity. Movement stimulates pain fibers in the anulus fibrosus and facet joints. Sitting for prolonged periods of time may cause pain and other symptoms due to pressure on the lumbar vertebrae. Repetitive movements such as lifting and bending (e.g. manual labor) may increase pain.
A thorough physical examination reveals a lot about the health and general fitness of the patient. The exam includes a review of the patient's medical and family history. Often laboratory tests such as complete blood count and urinalysis are ordered. The physical exam may include:
Palpation (exam by touch) determines spinal abnormalities, areas of tenderness, and muscle spasm.
Range of Motion measures the degree to which a patient can perform movement of flexion, extension, lateral bending, and spinal rotation.
A neurologic evaluation assesses the patient's symptoms including pain, numbness, paresthesias (e.g. tingling), extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes. Particular attention may be given to the extremities. Either a CT Scan or MRI study may be required if there is evidence of neurologic dysfunction.
X-Rays and Other Tests
Radiographs (x-rays) may indicate loss of vertebral disc height and the presence of osteophytes, but is not as useful as a CT Scan or MRI.
The CT Scan may be used to reveal the bony changes associated with spondylosis. An MRI is a sensitive imaging tool capable of revealing disc, ligament, and nerve abnormalities.
Discography seeks to reproduce the patient's symptoms to identify the anatomical source of pain. Facet blocks work in a similar manner. Both are considered controversial.
The physician compares the patient's symptoms to the findings to formulate a diagnosis and treatment plan. Further, the results from the examination provide a baseline from which the physician can monitor and measure the patient's progress.
Conservative treatment is successful 75% of the time. Some patients may think that because their condition is labeled degenerative they are doomed to end up in a wheel chair some day. This is seldom the case. Many patients find their pain and other symptoms can be effectively treated without surgery. During the acute phase, anti-inflammatory agents, analgesics, and muscle relaxants may be prescribed for a short period of time. The affected area may be immobilized and/or braced. Soft cervical collars may be used to restrict movement and alleviate pain. Lumbosacral orthotics may decrease the lumbar load by stabilizing the lumbar spine. In physical therapy, heat, electrical stimulation, and other modalities may be incorporated into the treatment plan to control muscle spasm and pain. Physical Therapy (PT) teaches the patient how to strengthen their paravertebral and abdominal muscles to lend support to the spine. Isometric exercises can be helpful when movement is painful or difficult. Exercise in general helps to build strength, flexibility, and increase range of motion. Lifestyle modification may be necessary. This may include an occupational change (e.g. from manual labor), losing weight, and quitting smoking.
Seldom is surgery used to treat spondylosis or spinal osteoarthritis. Conservative forms of treatment are tried first. If there is neurologic deficit, certain surgical procedures may be considered. However, before surgery is recommended, the patient's age, lifestyle, occupation, and number of vertebral levels involved are carefully evaluated. A spinal physician is able to determine if surgery is the best treatment for the patient.
Always follow the instructions provided by the physician and/or physical therapist. This includes:
> Take medication as directed. Report side effects to your physician immediately.
> Follow the home exercise program provided by the physical therapist.
> Avoid heavy lifting and activities that aggravate pain or other symptoms.
> Try to keep your weight close to ideal.
> Stop smoking.
Any doubts concerning vocational and recreational restrictions should be discussed with your physician and/or physical therapist. They will be able to suggest safe alternatives to help reduce the risk of further back problems.