Category: <span>Conditions and Treatments</span>

Dr. Sekhon has performed hundreds of cervical foraminotomies. For an appointment call 775-657-8844
Background

Cervical disc protrusions, if they compress the nerves in the neck typically cause arm pain. There are a number of operative ways that this can be managed but, if suitable, a posterior cervical foraminotomy is a vastly under-rated operation which avoids some of the shortcomings of other disc operations and yet still has an excellent outcome in terms of symptom relief, in a minimally invasive fashion.

The typical patient presents with pain down one arm which may radiate to the hand. Cervical disc problems are exceedingly common and it is important to realize that in the vast majority of cases non-operative management works very well. Most patients settle within 6-12 weeks after the onset of symptoms. The pathophysiology of why a patient gets symptoms is disc protrusion is complex, as not all disc patients get pain.

A posterior cervical foraminotomy is a minimally-invasive procedure designed to enlarge to space through which the nerve root exits from the spinal cord (the so-called neural foramen) and at the same time try to remove any piece of disc which is pushing on the nerve. Interestingly, sometimes the foraminotomy alone can alleviate symptoms without a discectomy being needed. The whole disc is not removed, just the fragment pressing the nerve root. A fusion is not performed and most patients typically do not require a neck collar after the surgery.

A disc protrusion per se may not cause symptoms. If the annulus is acutely torn, neck pain may result, but the management is usually not operative. If the disc pushes on a nerve, as shown in the previous  scans, then symptoms down one or occasionally both arms may result. The symptoms can include pain, numbness, “pins and needles”, and weakness.

Anatomy

The anatomy of a typical intervertebral disc as shown below:

(Below): The intervertebral disc lies in front of the spinal nerves and is situated between the vertebral bodies. It carries 80% of the load transmitted through the neck and is the shock absorber for the spine. The lowermost discs of the neck (C56 and C67) are most prone to wear and tear and potential rupture.

Note that there is an outer shell, called the annulus fibrosis and an inner core called the nucleus pulposus. The annulus is the consistency of a pencil eraser, whereas the nucleus is gel-like and, as we get older, dehydrates and becomes like crabmeat. The discs act as shock absorbers and flexing the spine loads the disc. A tear in the outer annulus can consequently cause severe neck pain. Once an annular tear occurs, it may heal, or it may allow nucleus to come out of the centre of the disc, into the spinal canal, where it may compress nerves. This is usually called one of a number of terms, including “disc prolapse”, “ruptured disc”, “slipped disc”,  “extruded disc” etc etc.  All these terms essentially mean the same thing. Once nerves are compressed, surgery may be complicated. It is important to know that the prolapsed disc cannot be pushed back into place and nothing but time will heal the annular tear. Thus, in general, any surgery using this approach is aimed at improving the arm pain, not the neck pain.

Reason For Operation

Cervical disc protrusions are not usually operated upon early, but there are some clear situations when a surgeon may recommend early surgery. If there is evidence of severe weakness, early surgery may be offered. If the pain in the arm is so severe that narcotic analgesia is not controlling the pain, early surgery may again be an option. Finally, if there is a suggestion of spinal cord compression, and myelopathy, early surgery is advocated. A posterior cervical foraminotomy is not the operation of choice if a disc protrusion is causing myelopathy as this typically indicates that the compression of the spinal cord is from disc material in front of the cord. Consequently, a posterior approach such as for a cervical foraminotomy is not suited for spinal cord compression and myelopathy.

If a patient has pain, but it is not too severe, then typically conservative management is initiated. It must be remembered that the vast proportion of patients will settle with time and as long as improvements are noted at 6 weeks, there is minimal or no weakness, and the pain is not excruciating and is livable with oral analgesia, then waiting and continuing with conservative therapy is a good option.

If weakness occurs and is not improving, surgery is usually offered. Similarly, if symptoms are not improving at 6 weeks then surgery is an option.

In most cases, when managing just arm pain, surgery is a treatment option that speeds up the rate of recovery, remembering that most cases will get better by themselves. Again, specific recommendations are tailored to the patient. In the vast number of cases, the goal is control of pain, and any intervention that achieves this and is less invasive than surgery is a reasonable option.

Technique

If surgery is undertaken, it is usually performed as a minimally-invasive procedure. The procedure can be performed as a day stay surgery, but most patients stay in hospital for 1-2 nights. General anesthesia is utilized and the surgery is performed through an incision of 2-4 cm. Much emphasis is placed on performing the surgery through tiny incisions. Usually a small window is made on one side of a spinous process, at the junction of the lamina and facet joint, through the removal of some bone and ligament to allow visualization of the  involved root. Using a high speed drill and microinstruments, once the nerve root affected is identified, the whole out of which the nerve passes is enlarged. This is the foraminotomy. (see below):

nerve root exposed      bony drilling       lamina

The amount of bony removal (in red) is shown below:

The nerve root is then gently elevated and if there is a disc bulge this is palpated. If identified, the disc bulge is incised and typically a tiny piece of disc is removed. The whole disc is not removed. The operation is then complete and after placing cortisone over the nerve root, closure is effected, typically, with dissolving sutures for skin. Typically this takes 1-2 hours to perform.

(Above): A preop and postop CT to shoe the extent of bone removal (arrowed) in order to effect an adequate foraminotomy.

Risks

The greatest risk is injury to one or more nerves or spinal cord and this is typically 1-2%. The risks of infection, bleeding etc. etc. are similar to those for a any other spinal operation as are the risks of general complications. A small proportion of patients will have a recurrent disc protrusion, either at the same side and level or at different levels or the opposite side. This operation will not alter the future likelihood to get neck pain.

The small but real risks from surgery are the reason why all patients with disc protrusions do not immediately have surgery.

Expectations

In uncomplicated cases the likelihood of good/excellent relief of arm pain is 80-90%. Numbness is slow to recovery and may persist. Weakness also may take 6-12 weeks to return to normal. Pins and needles usually starts to improve immediately.

Recovery

After surgery, patients are monitored on the ward overnight. A soft collar is worn for comfort if desired, and typically patients are discharged within 1-2 days. At home, for the first 6 weeks, nothing greater than 5-10 lbs must be lifted and after this a return to normal activities can be effected. The sutures do not require removal and dissolve with time.

Non-Surgical Options

Despite the length discussion about surgery, most patients get better without surgery.

Conservative therapy comprises

• Analgesia with NSAIDs (e.g. Mobic, Voltaren or Celebrex)
• Analgesia with other medications such as Tramadol
• Avoidance of bending/lifting and ergonomics at work
• Physiotherapy (traction may help)
• Perineural steroid and local anesthetic injections (these can be very helpful)
• Possibly acupuncture

Other Points

A posterior cervical foraminotomy is an excellent operation for the patient with arm symptoms secondary to a cervical disc protrusion that avoids implantation of foreign devices and spinal fusion. Not all patients are suitable for this operation but those who are generally do very well.

Lumbar Anatomy

The lower back or lumbar spine is composed of 5 bones, called vertebrae and the sacrum. Each vertebrae is connected to each adjacent vertebrae by 3 joints, 1 at the front (anteriorly) and 2 at the back (posteriorly). The joint at the front is called an intervertebral disc and is a common cause of surgical pathology. The joints at the back are called facet joints and are present as pairs straddling the midline. In addition to these 3 joints and bony structures, there are numerous ligaments and muscles. One of the more important ligaments is called the ligamentum flavum.  This yellow ligament bridges between adjacent vertebrae and can thicken with age and cause compression of nerves. The spinal cord sits inside a bony tunnel in the posterior half of each vertebrae which is called the spinal canal. The ligamentum flavum lines the back half of this canal. The back half of the spinal canal is formed by wing shaped pieces of bone called laminae. At each level, 2 lamina united and form a spinous process which is like a midline keel of bone and can be felt in the midline through the skin in the back. Holes at regular levels on each side of the spinal canal form intervertebral foramina. Each foramen allows 1 nerve to exit and in the lumbar spine there are 5 on each side. The spinal cord finishes at the lower border of the first lumbar vertebra and then becomes a leash of nerves (the cauda equina). Below this point only nerves are present and no spinal cord is present. Consequently most surgery on the lower back is on and around nerves rather than spinal cord. The spinal nerves in the lumbar spine supply strength in the legs, sensation from the groin down and bladder and bowel function. Injury to one nerve may cause no problem or may affect some or all of the previously mentioned modalities.

Definition

Fusion literally translates “to join” and in spine surgery this means that 2 vertebrae are joined together to make one. There are many reasons why one would perform a fusion (see below) but in essence the surgeons endeavors to trick the body into thinking that the two bones to be fused are a single bone that has broken and then sets up the right conditions so that in healing the bones heal as one. Just as if you broke your arm, 2 bones with sticky ends would become one. In the arm’s case, a plaster cast is applied to hold things in place until the bones are healed, typically 6 weeks. In the lower back screws, plates, rods, cages and an external brace take the place of the plaster cast, and full fusion occurs after 3 months. The “sticky ends” in the case of the spine are the roughened surfaces of bone. Typically bone graft, usually the marrow, is taken from the hip and placed between the roughened surfaces. Nowadays bone morphogenic protein can enhance fusions by stimulating bone growth. When bone healing occurs, new bone comes out of the roughened surfaces and migrates along the transplanted bone to bridge the area to be fused. Ironically, at 6-12 months all the transplanted bone or BMP has been replaced by new bone. Understanding all of the above, it becomes clear that although there are a lot of screws and hardware involved, the operation essentially joins bone to bone and it takes a full 12 months to heal. In all my patients they cannot smoke for 1 month prior and 3 months after the surgery as the healing rate of the bone (i.e. the success of the fusion) drops from 90% to 40-50%. Similarly NSAIDs such as Celebrex or Mobic must not be taken for 3 months after surgery as they also reduce the fusion rate by 20%.

Anatomy

Looking at the anatomy section, fusions are typically done in one of 3 places. The typical fusion is a posterolateral fusion where bone is placed in the bony gutters between the transverse processes. This is the commonest fusion done and involves a large amount of muscle dissection. Interbody fusions involve the removal of the whole intervertebral disc and bone chips or cages are placed into the cavity. These can be done from in front or behind. This is a fusion that is technically more demanding to perform but has a higher fusion rate and, for technical reasons, is more versatile. Facet joint fusi are usually done to supplement interbody fusions and involve the removal of the facet joint capsule and packing the joint with bone graft.

Reason For Operation

Anterior lumbar interbody fusions (ALIFs) are essentially performed for back pain that is thought to be coming from the discs. The workup for this is quite extensive and patients need to have failed conservative therapy for at least 6 months. The type of pain may be mechanical, meaning that it is worse when you bend forward and the there may be leg pain.

In terms of diagnosing the cause of pain an MR scan (see below where all the discs look normal except the lowest one) and a discogram is typically performed.

A discogram is an invasive study that looks for a pain generator. A pain specialist under local anesthesia places needles into 3 or 4 discs spaces. He then puts saline into each one in turn. A positive result produces pain at the same disc that is abnormal on the MR scan and this is said to be concordant. If more than 1-2 are positive that’s not good. Ideally only one or perhaps two should be painful. A normal disc should cause no pain. The type of pain produced is also important. It should be close to or exactly like the bad pain that is trying to be addressed. If it is significantly different that is not a good prognosticator.

Typical discogram results are shown below:

Technique

In order to perform the surgery a general surgeon is utilized to perform the anterior exposure. This is because the biggest risk from the procedure is injury to the big vessels that go to and come from the legs and the general surgeon moves the abdominal organs and vessels out of the way. The picture below shows the typical anatomy before and after an exposure.
 

Once the disc space is exposed the disc space is then cleaned out by the spine surgeon. surgeon. The back of the disc is not usually removed so the nerves are not seen. I then place a plastic cage into the space full of BMP and place a plate on the front. A one level case takes about an hour. 2 levels take between 2 and 3 hours. Below are xrays showing how a before and after.Note the height of the disc before and after surgery:
       

BMP (Bone Morphogenic Protein)
Bone morphogenic protein (BMP) is a substance commonly used when fusion surgery is done that is synthetically produced and stimulates bone growth. BMP is commonly used in all manner of fusion surgery and has reduced the incidence of fusions not taking as well as reducing the need to take bone graft from the top of the hip bone.

For years, scientists have been searching for ways to stimulate the human body to generate and repair bone more reliably and more quickly.  No one appreciates the importance of such research more than the spinal surgeon.  More than half of the thousands of bone fusion operations performed annually in the United States involve fusion of the spinal column.  Traditionally, spinal fusion requires the transplant of bone chips from a patient’s pelvis to the spinal vertebrae to help “fuse” them together.  Although this procedure can be very effective for the treatment of certain spinal disorders, the bone transplantation procedure (bone grafting) can prolong surgery, increase blood loss, increase hospital stay, increase recovery time, and increase recovery pain.  Moreover, the bone grafting technique does not always reliably result in successful fusion of the vertebrae because of occasional inadequate bone growth.

Recently, scientists and spinal surgeons have demonstrated that a genetically produced protein, recombinant human bone morphogenetic protein-2, or rhBMP-2, has the ability to stimulate a patient’s own cells to make more bone.  This finding has obvious beneficial implications for the treatment of many bone fractures and bone defects.  More importantly, though, rhBMP-2 can be tremendously beneficial to patients undergoing spinal fusion.  It will eliminate the need for bone transplantation from the pelvis.  It may more reliably and more quickly produce fusion of spinal vertebrae.  It may even reduce the need for the implantation of spinal rods and screws.

The process of stimulating bone growth within the body is known as osteoinduction.  One of the pioneers in the science of osteoinduction was Dr. Marshall Urist, Professor Emeritus of the Department of Orthopaedic Surgery at the UCLA school of Medicine.  More than 35 years ago, Dr. Urist discovered that the proteins that directed bone to heal itself were contained within its own matrix, or substance.  It was not until 1988 that these proteins were individually identified and genetically reproduced.  Thereafter, it was quickly discovered that rhBMP-2 could, by itself, direct the repair and regeneration of bone in various parts of the skeleton.  In several laboratory experiments performed from 1993 to 1997, rhBMP-2 was shown to effectively stimulate bone growth along spinal vertebrae.

In 1997, rhBMP-2 was used for the first time in patients undergoing spinal fusion.  In this initial clinical trial, all eleven patients who had been implanted with rhBMP-2 achieved successful fusion within 6 months from the time of surgery.  In fact, 10 of these 11 patients had achieved their fusions within 3 months of surgery.  Because theses patients did not require bone grafting from the pelvis, their hospital stays were shorter and their post-surgical pain was less than typically seen with the traditional bone grafting techniques.  These promising initial findings are now being studied in several larger clinical trials throughout the United States.

There is little doubt that powerful biologic proteins such as rhBMP-2 will eventually help all surgical specialists treat a variety of common as well as complex spinal disorders.  These osteoinductive factors will enable surgeons to modify their techniques to minimize the invasiveness of their operations.  Ultimately, the goal will be reduce the pain associated with surgery and recovery, improve the effectiveness of the surgical treatments, and hasten the return of patients to productive and healthy lifestyles.

RhBMP-2 has recently received clearance from the Food and Drug Administration (FDA) for specific uses.

Risks

There are 3 types of risks from this surgery:

1. Exposure complications: this is the commonest and most serious and this is why a general/vascular surgeon does the exposure. Anything from damage to the abdominal contents to injury to the blood vessels can occur and although uncommon can be life-threatening and require a blood transfusion
2. Disc/nerve complications: Generally the fusion rate is 95%. It drops in smokers and those with immune suppression such as kidney failure. Occasionally new neurological symptoms can develop after this surgery which may be due to stretching of nerves.
3. General complications: pneumonia, clots in the legs, infections etc can happen in all patients. These are all higher in obese patients and diabetics.

The overall complication rate is less than 5% but no guarantees can be made.

Expectations

It is difficult to look at likely success rates when the indications for surgery are quite varied. This is something that the surgeon will discuss with the patient prior to surgery. As a rule of thumb there is about a 70% chance of some improvement in back pain symptoms which can range from complete relief to not as many bad attacks.

Recovery

My patients spend 2-4 nights in hospital. This operation is not as sore as one done from the back but it may take some time for the bowels to get working again. Patients are mobilized in a lumbar brace (which is basically a support for the lower back and is worn like a girdle) every time they are out of bed for a total of 3 months. At discharge all my patients do is walk. They do not bend, lift, twist or sit for prolonged periods of time. Bending and lifting are particularly bad as they can lead to screw breakage and failure of fusion. Physical therapy is not started for 12 weeks after surgery although in hospital the therapist will teach you how to get out of bed and do your daily activities. Patients are reviewed 2 weeks after surgery, then at 6 weeks, 3 months, 6 months and 1 year with x-rays. Typically I advise my patients not to rub any creams on the incision and to keep it dry. Bathing is to be avoided, as is swimming but showering is OK. It is important that the wound is allowed to heal. Any signs of redness, discharge, swelling, etc. etc. needs to be reviewed by a doctor.   Typical x-rays showing a solid fusion of the spine are shown below:

As stated in the introduction to this section, it is important not to smoke or take NSAIDs for 3 months after surgery as bone healing is occurring.  Good back care is the rule for life after this surgery as, and this must be stressed, the back has not been returned to normal after a fusion.

Non-Surgical Options

An ALIF is not a small operation. Just as in lumbar discectomy there are non-operative options that include any or all of the following and these should be aggressively pursued to try and expedite improvement in symptoms:

Conservative therapy comprises

• Analgesia with NSAIDs (e.g. Mobic, Voltaren or Celebrex)
• Analgesia with other medications such as Tramadol
• Avoidance of bending/lifting/twisting/sitting for prolonged periods
• Physical therapy
• Hydrotherapy
• Cortisone blocks
• Possibly acupuncture
• Weight loss
• Exercise
• Bracing

Other Points

Fusing 2 bones puts stress on adjacent levels and this can accelerate wear and tear at these levels. This is important as patients can develop symptoms months or years later, which may require further surgery. The anterior approach seems to have less of this than the posterior approach as the muscles and joints of the back are not disturbed.

Dr. Sekhon has performed hundreds of lumbar fusions. For an appointment call 775-657-8844
Definition

Fusion literally translates “to join” and in spine surgery this means that 2 vertebrae are joined together to make one. There are many reasons why one would perform a fusion (see below) but in essence the surgeons endeavors to trick the body into thinking that the two bones to be fused are a single bone that has broken and then sets up the right conditions so that in healing the bones heal as one. Just as if you broke your arm, 2 bones with sticky ends would become one. In the arm’s case, a plaster cast is applied to hold things in place until the bones are healed, typically 6 weeks. In the lower back screws, plates, rods, cages and an external brace take the place of the plaster cast, and full fusion occurs after 6-12 months. The “sticky ends” in the case of the spine are the roughened surfaces of bone. Typically bone graft, usually the marrow, is taken from the hip and placed between the roughened surfaces. When bone healing occurs, new bone comes out of the roughened surfaces and migrates along the transplanted bone or BMP (see below) to bridge the area to be fused. Ironically, at 12 months all the transplanted bone has been replaced by new bone. Understanding all of the above, it becomes clear that although there are a lot of screws and hardware involved, the operation essentially joins bone to bone and it takes a full 6-12 months to heal. All fusion patients should not smoke for 1 month prior and 3 months after the surgery as the healing rate of the bone (i.e. the success of the fusion) drops from 90% to 40-50%. Similarly NSAIDs such as Celebrex or ibuprofen must not be taken for 3 months after surgery as they also reduce the fusion rate by 20%.

Anatomy

Looking at the anatomy section, fusions are typically done in one of 3 places. The typical fusion is a posterolateral fusion where bone is placed in the bony gutters between the transverse processes. This is the commonest fusion done and involves a large amount of muscle dissection. Interbody fusions involve the removal of the whole intervertebral disc and bone chips or cages are placed into the cavity. This is a fusion that is technically more demanding to perform but has a higher fusion rate and, for technical reasons, is more versatile. Facet joint fusions are usually done to supplement interbody fusions and involve the removal of the facet joint capsule and packing the joint with bone graft.

Reason For Operation

The two least controversial reasons for a lumbar fusion are for cases that involve trauma or tumor.  In both of these cases, either the situation in the spine appears unstable (meaning the spine is prone to unusual movements under normal conditions which can damage tissues or cause pain or deformity) due to the underlying pathology or else the surgery required to decompress the neural structures is deemed to render the spine to unstable once this is achieved. Fusion for degenerative disease (so called “wear and tear”) is more controversial but is commonly performed. In this setting fusion can also be performed for many reasons. The commonest reason I will perform a fusion is for a spondylolisthesis. This is where one vertebrae is slipped forward in relation to another. Not only does this throw the back out of alignment  (so called “sagittal balance”) but it can cause pressure on nerves, particularly when they exit through their neural foramina. A typical spondylolisthesis is shown below:

The posterior edges should be aligned but as can be seen here, L5 (the top vertebrae) is approximately 50% of its width out of alignment with the sacrum.

One of the more common reasons to develop a spondylolisthesis is the development of pars defects. These are shown below:

Bilateral pars defects

Pars defects occur in 6% of the population and in the vast number of cases need no intervention. When they do become symptomatic, with either leg or back symptoms, surgery is often the end result. If the degree of slippage becomes progressively worse this may require intervention as well. Degenerative spondylolisthesis is also common, most commonly occurring at the L45 level. The decision to perform a fusion in addition to a laminectomy is more complex. Lumbar fusion for ‘discogenic’ back pain is also controversial. In general, orthopedic surgeons tend to believe this entity occurs with a greater frequency than neurosurgeons who generally believe that the disc is a primary pain generator in only a few select cases. In my practice, the decision to fuse for back pain is dependent on a number of factors including the history, physical examination, MRI result and discography result.
Recent Studies have shown better outcomes in these scenarios with surgery than conservative therapy in terms of relief of back pain relief.
Click here for more information.

Technique

A lumbar fusion is a big operation. Screws as shown below are placed between the vertebrae that are to be fused. The bone graft or BMP is placed around these. These screws are made of titanium and usually stay in for life.

These screws are typically placed into the pedicles at each level (see anatomy). In some cases hollow cages made of a plastic called PEEK are filled with bone graft or BMP. Further bone graft is placed in front and behind the cages.

Typical cages are shown below:

A PLIF involves placement of 2 cages from either side of where the nerves live into the disc space ( see below).

A TLIF involves an approach from one side with one cage only that is placed diagonally and then pushed across (see below).

BMP (Bone Morphogenic Protein)
Bone morphogenic protein (BMP) is a substance commonly used when fusion surgery is done that is synthetically produced and stimulates bone growth. BMP is commonly used in all manner of fusion surgery and has reduced the incidence of fusions not taking as well as reducing the need to take bone graft from the top of the hip bone.

For years, scientists have been searching for ways to stimulate the human body to generate and repair bone more reliably and more quickly.  No one appreciates the importance of such research more than the spinal surgeon.  More than half of the thousands of bone fusion operations performed annually in the United States involve fusion of the spinal column.  Traditionally, spinal fusion requires the transplant of bone chips from a patient’s pelvis to the spinal vertebrae to help “fuse” them together.  Although this procedure can be very effective for the treatment of certain spinal disorders, the bone transplantation procedure (bone grafting) can prolong surgery, increase blood loss, increase hospital stay, increase recovery time, and increase recovery pain.  Moreover, the bone grafting technique does not always reliably result in successful fusion of the vertebrae because of occasional inadequate bone growth.

Recently, scientists and spinal surgeons have demonstrated that a genetically produced protein, recombinant human bone morphogenetic protein-2, or rhBMP-2, has the ability to stimulate a patient’s own cells to make more bone.  This finding has obvious beneficial implications for the treatment of many bone fractures and bone defects.  More importantly, though, rhBMP-2 can be tremendously beneficial to patients undergoing spinal fusion.  It will eliminate the need for bone transplantation from the pelvis.  It may more reliably and more quickly produce fusion of spinal vertebrae.  It may even reduce the need for the implantation of spinal rods and screws.

The process of stimulating bone growth within the body is known as osteoinduction.  One of the pioneers in the science of osteoinduction was Dr. Marshall Urist, Professor Emeritus of the Department of Orthopaedic Surgery at the UCLA school of Medicine.  More than 35 years ago, Dr. Urist discovered that the proteins that directed bone to heal itself were contained within its own matrix, or substance.  It was not until 1988 that these proteins were individually identified and genetically reproduced.  Thereafter, it was quickly discovered that rhBMP-2 could, by itself, direct the repair and regeneration of bone in various parts of the skeleton.  In several laboratory experiments performed from 1993 to 1997, rhBMP-2 was shown to effectively stimulate bone growth along spinal vertebrae.

In 1997, rhBMP-2 was used for the first time in patients undergoing spinal fusion.  In this initial clinical trial, all eleven patients who had been implanted with rhBMP-2 achieved successful fusion within 6 months from the time of surgery.  In fact, 10 of these 11 patients had achieved their fusions within 3 months of surgery.  Because theses patients did not require bone grafting from the pelvis, their hospital stays were shorter and their post-surgical pain was less than typically seen with the traditional bone grafting techniques.  These promising initial findings are now being studied in several larger clinical trials throughout the United States.

There is little doubt that powerful biologic proteins such as rhBMP-2 will eventually help all surgical specialists treat a variety of common as well as complex spinal disorders.  These osteoinductive factors will enable surgeons to modify their techniques to minimize the invasiveness of their operations.  Ultimately, the goal will be reduce the pain associated with surgery and recovery, improve the effectiveness of the surgical treatments, and hasten the return of patients to productive and healthy lifestyles.

RhBMP-2 has received clearance from the Food and Drug Administration (FDA) for specific uses.

Risks

Lumbar fusions are big operations and the risks are much greater than simple laminectomies or discectomies. The risks are higher and the recovery is longer. Having said that the vast number of patients undergoing this operation do well. Because they are longer operations, there is more blood loss and blood transfusion is sometimes always required. A cell saver is used in surgery to reduce the need for this and bleeding is recycled with this.. The risks of nerve injury, hardware problems, infection etc. etc. are probably in the order of 2-10%. The risks of general complications are slightly higher than those for a simple laminectomy. Despite this daunting prospect, most patients do well. Typical operating time can be anywhere from 2-4 hours. Every operation is different. A bladder catheter is usually in place. The patient will usually have a button for pain control (PCA). The evening of or the day after surgery, the patient is mobilized in a lumbar brace, with the assistance of a physical therapist. Most  patients note that the first few weeks after surgery is tiring and painful, but by 6 weeks and 12 weeks after surgery most are usually very glad they had the surgery done.

Expectations

It is difficult to look at likely success rates when the indications for surgery are quite varied. This is something that the surgeon will discuss with the patient prior to surgery. It is important to remember that with cancer or trauma there is often little choice to having surgery but in degenerative disease surgery is always a treatment option. The patient must weigh up the risks and benefits of surgery and decide if they want to have the surgery.

Recovery

My patients spend 2-5 days in hospital. They are mobilized in a lumbar brace (which is basically a support for the lower back and is worn like a girdle) every time they are out of bed for a total of 3 months. The back is quite sore for 1-2 weeks after surgery but this improves. At discharge all my patients do is walk. They do not bend, lift, twist or sit for prolonged periods of time. Bending and lifting are particularly bad as they can lead to screw breakage and failure of fusion. Physical therapy is not started for 12 weeks after surgery although in hospital the therapist will teach you how to get out of bed and do your daily activities. Patients return for a followup appointment 2 weeks after surgery to ensure good wound healing. It important to look after the wound. Typically I advise my patients not to rub any creams on the incision and to keep it dry. Bathing is to be avoided, as is swimming but showering is OK. It is important that the wound is allowed to heal. Any signs of redness, discharge, swelling, etc. etc. needs to be reviewed by a doctor. Followup with the office is usually arranged for 6 weeks after surgery. Repeat x-rays of the spine are done at 6 weeks, 3 months, 6 months, 1 year and 2 years after surgery.  Typical x-rays showing realignment of the spine are shown below:

As stated in the introduction to this section, it is important not to smoke or take NSAIDs for 3 months after surgery as bone healing is occurring.  Good back care is the rule for life after this surgery as, and this must be stressed, the back has not been returned to normal after a fusion.

Non-Surgical Options

A lumbar fusion is not a small operation. Just as in lumbar discectomy there are non-operative options that include any or all of the following and these should be aggressively pursued to try and expedite improvement in symptoms:

Conservative therapy comprises

• Analgesia with NSAIDs (e.g. Mobic, Voltaren or Celebrex)
• Analgesia with other medications such as Tramadol
• Avoidance of bending/lifting/twisting/sitting for prolonged periods
• Physiotherapy
• Hydrotherapy (particularly if back pain is a problem)
• Perineural and intrafacet steroid and local anesthetic injections
• Possibly acupuncture
• Weight loss
• Exercise
• Bracing (controversial)

Other Points

Fusing 2 bones puts stress on adjacent levels and this can accelerate wear and tear at these levels. This is important as patients can develop symptoms months or years later, which may require further surgery. Redo surgery can be a very arduous in this scenario.

Definition

A lumbar laminectomy involves removal of the bone and ligaments that are causing compression of the spinal nerves in the lower back (spinal stenosis). Typically, when these nerves are being compressed, it is due to a combination of enlargement of the facet joints, thickening of the ligamentum flavum and bulging of the intervertebral discs. The classical symptoms are what is termed “neurogenic claudication” where there is pain on walking in the calves or buttocks. Usually back pain is not a feature, and the pain is related to standing or walking and relieved with rest. Sitting or lying improves the pain. Bending forward, such as with a shopping trolley also improves the pain. Occasionally the pain is almost entirely in one leg and typically this is due to lateral recess stenosis, where the nerves on one side are compressed more than the other side. If spinal stenosis is not treated, it may progress or it may stay the same. Rarely, it will improve. Like most degenerative conditions, it is not fatal and the patient is unlikely to end up in a wheelchair if not operated upon. Surgery is usually aimed at improving pain.

Anatomy

If we look at the typical anatomy of the region shown in the anatomy section, and then at the figures below, the features of spinal stenosis become clear.

(Below): Preop MRI scan showing spinal stenosis secondary to facet joint arthrosis and ligamentous hypertrophy at the L45 level.

(Below): Immediate postoperative CT scan showing the extent of bone and ligament removal.

Area of decompression ( the facet joints remain but the lamina and spinous processes are gone)

Reason For Operation

The indication for surgery is failure of conservative management for neurogenic claudication. It must be stressed that surgery is an option, not a necessity, once spinal stenosis is diagnosed. Typically a laminectomy is performed and the neural foramina, through which the nerves exit, are enlarged (foraminotomy).

Technique

The procedure is quite straightforward and involves the removal of the spinous processes, laminae and ligamentum flavum with a combination of biting instruments of various size and configuration, and sometimes small high speed drills. At the end of the decompression, the neural foramina are palpated to ensure the nerves move out easily. A multilevel laminectomy can lead to moderate blood loss and occasionally a blood transfusion is required. Typically, however, this is not the case.

Risks

The risks of the operation relate to specific risks from this kind of surgery, and general risks which are independent of the type of operation performed. General risks include the risks of death, heart or lung problems, pneumonia, bleeding, infection, clots etc. etc. Typically this is <5-10%. The specific risks include the risks of nerve injury, spinal fluid leakage, instability (increased ‘floppiness’ which may cause problems later on and require further surgery) etc. etc. would also be at approximately 5-10%. The risk of death or ending up in a wheelchair is however low, but both can and have happened.

Expectations

The likelihood of a good outcome is always tailored to the individual patient, but in a typical scenario, the chances of good or excellent improvement in symptoms, including possibly complete resolution of preop symptoms is 80-90%. No one can guarantee a 100% risk-free operation and no surgeon can perform an operation with no risk. Most patients do well from this surgery. This is not a good operation for back pain.

Recovery

Surgery typically takes 1-2 hours and in an uncomplicated case the patient is mobilized the next day. A tube may be placed in the bladder and this is usually removed once the patient is mobilized. After surgery, the patient is usually mobilized the the same night or following day, and all things going well is discharged from hospital 1-3 days after surgery. The back is sore where the incision is but this settles. Dissolving sutures are usually placed in the wound. Once home, it is important to avoid bending, lifting, twisting and prolonged sitting for 4 weeks postop. You should see your family doctor 1 week after surgery for an inspection of the wound. You need to look after the wound to ensure good healing. Typically I advise my patients not to rub any creams on the incision and to keep it dry. Bathing is to be avoided, as is swimming but showering is OK. It is important that the wound is allowed to heal. Any signs of redness, discharge, swelling, etc. etc. needs to be reviewed by a medical practitioner. Followup with the specialist is usually arranged for 6 weeks after surgery.

Non-Surgical Options

Unfortunately no good non-surgical options are available. Walking is certainly helpful and advisable and physiotherapy and hydrotherapy can help any associated back pain. Weight loss may also help and avoidance of bending, lifting and twisting is important as well. All the previous measures may help but in dealing with a structural lesion it is understandable why failure of conservative treatment can occur. Because spinal stenosis is not a life-threatening condition, the decision to have surgery is entirely up to the patient; if the patient can live with the pain then surgery can be avoided.

Other Points

Lumbar laminectomy is a common operation and is performed regularly in patients over the age of 65. Age itself is not a contraindication. Although no guarantees can be made, most patients do well, with no complications. The results are poorer and the risks higher with redo surgery, and each reoperation has greater risks and a worse outcome than the previous operation.

Dr. Sekhon has performed over a thousand lumbar discectomies. For an appointment call 775-657-8844

Definition

Lumbar discectomy encompasses a number of terms, including discectomy, microdiscectomy and laminectomy/discectomy. The typical patient presents with pain down one leg which may radiate from the buttock to below the knee. The usual pain is either to the back of the calf and to the sole of the foot, or to the outside of the shin and top of the foot. Back pain is not usually a feature, however it may initially occur. Lumbar disc problems are exceedingly common and it is important to realize that in the vast majority of cases non-operative management works very well. Most patients settle within 6-12 weeks after the onset of symptoms. The pathophysiology of why a patient gets symptoms is disc protrusion is complex. The anatomy of a typical intervertebral disc as shown below:

(Below): The intervertebral disc lies in front of the spinal nerves and is situated between the vertebral bodies. It carries 80% of the load through that level and is the shock absorber for the spine. The lowermost discs (L45 and L5S1) are most prone to wear and tear and potential rupture.

Note that there is an outer shell, called the annulus fibrosis and an inner core called the nucleus pulposus. The annulus is the consistency of a pencil eraser, whereas the nucleus is gel-like and, as we get older, dehydrates and becomes like crabmeat. The discs act as shock absorbers and flexing the spine loads the disc. A tear in the outer annulus can consequently cause severe back pain. Patients will often be able to remember a time when they lifted poorly or twisted their back and had severe back pain prior to getting the leg pain. Once an annular tear occurs, it may heal, or it may allow nucleus to come out of the centre of the disc, into the spinal canal, where it may compress nerves. This is usually called one of a number of terms, including “disc prolapse”, “ruptured disc”, “slipped disc”,  “extruded disc” etc etc.  All these terms essentially mean the same thing. Once nerves are compressed, surgery may be complicated. It is important to know that the prolapsed disc cannot be pushed back into place and nothing but time will heal the annular tear. Thus, in general, any surgery is aimed at improving the leg pain, not the back pain.

Anatomy

If you study the MRI and CT scan shown below, the reason for symptoms from a disc protrusion become evident.

A disc protrusion per se may not cause symptoms. If the annulus is acutely torn, back pain may result, but the management is usually not operative. If the disc pushes on a nerve, as shown in the previous CT and MRI scan, then symptoms down one or occasionally both legs may result. The symptoms can include pain, numbness, “pins and needles”, and weakness.

Reason For Operation

Lumbar disc protrusions are not usually operated upon early, but there are some clear situations when a surgeon may recommend early surgery. If there is evidence of severe weakness, early surgery may be offered. If the pain in the leg is so severe that narcotic analgesia is not controlling the pain, early surgery may again be an option. Finally, if there is a suggestion of problems with the nerves that supply the bladder or bowel, early surgery is advocated. In this latter situation, an inability to pass urine may be evident, or there may be numbness in the crotch area, buttocks or when passing urine. This situation usually necessitates emergent or early surgery.

If a patient has pain, but it is not too severe, then typically conservative management is initiated. It must be remembered that the vast proportion of patients will settle with time and as long as improvements are noted at 6 weeks, there is minimal or no weakness, and the pain is not excruciating and is livable with oral analgesia, then waiting and continuing with conservative therapy is a good option.

If weakness occurs and is not improving, surgery is usually offered. Similarly, if symptoms are not improving at 6 weeks then surgery is an option.

In most cases, when managing just leg pain, surgery is a treatment option that speeds up the rate of recovery, remembering that most cases will get better by themselves. Again, specific recommendations are tailored to the patient. In the vast number of cases, the goal is control of pain, and an intervention that achieves this and is less invasive than surgery is a reasonable option.

Technique

If surgery is undertaken, it is usually performed as a minimally invasive procedure. The procedure can be performed as a day stay surgery. General anesthesia is utilized and the surgery is performed through an incision of 3-5 cm. Much emphasis is placed on performing the surgery through tiny incisions  (so called “microendoscopic” discectomy) although, for the most part, the surgery can be performed more safely and quickly via a standard approach, with little tangible gain through a slightly smaller incision. Usually a small window is made on one side of a spinous process through the removal of some bone (shaded red) and ligament (shaded yellow) to allow visualization of the disc bulge and involved root. This is shown below :

Through gentle dissection under illumination and magnification, the interface between the root and disc bulge is identified and the offending fragment is removed. Only a small portion of disc is removed. The whole disc is not removed, although any loose fragments felt through the hole in the annulus are removed. The tear in the annulus is not repaired. After the nerve is freed completely the operation is completed. Typically this takes 0.5- 1.5 hours to perform.

Risks

The greatest risk is injury to one or more nerves and this is typically les than 1%. The risks of infection, bleeding etc. etc. are similar to those for a laminectomy as are the risks of general complications. 10-15% of patients will have a recurrent disc protrusion, either at the same side and level or at different levels or the opposite side. The greatest risk for this is in the first 6 weeks after surgery.

The small but real risks from surgery are the reason why all patients with disc protrusions do not immediately have surgery.

Expectations

In uncomplicated cases the likelihood of good/excellent relief of leg pain is 80-90%. Numbness is slow to recovery and may persist. Weakness also may take 6-12 weeks to return to normal. Pins and needles usually starts to improve immediately.

Recovery

Patients who have a lumbar discectomy are typically in hospital for the day or one night. They are advised not to work for 2 weeks and recommendations on back and wound care are the same as for lumbar laminectomy. It is notable that bending, lifting and twisting may increase the recurrence rate in the first 6 weeks, so my patients do not do any other exercise other than walking for that time period. After 6 weeks a return to normal activities is initiated. It is important to remember that the back is not normal after disc surgery and that care needs to be taken in the future. Bending, lifting and twisting need to be avoided as these activities ultimately may have precipitated the initial event. Recovery from surgery is not a license to return to normal. Good back care is the rule for life.

Again, as is the case after lumbar laminectomy, no surgeon can guarantee risk-free surgery or a 100% good outcome.

Non-Surgical Options

Despite the length discussion about surgery, most patients get better without surgery.

Conservative therapy comprises

• Analgesia with NSAIDs (e.g. Mobic, Voltaren or Celebrex)
• Analgesia with other medications such as Tramadol
• Avoidance of bending/lifting/twisting/sitting for prolonged periods
• Physiotherapy (traction may help)
• Hydrotherapy (particularly if back pain is a problem)
• Perineural steroid and local anesthetic injections
• Possibly acupuncture

Your surgeon and primary care doctor can tailor a conservative management plan with some or all of the following, and for the vast number of sufferers, conservative management works. There are other alternative therapies available, but many have shaky scientific foundations and consequently are best avoided. Spinal manipulation is best avoided as it can entice more disc material to prolapse.

In the first 4 weeks after disc prolapse, a large amount of inflammation occurs around the nerve root and this can contribute to pain. NSAIDs at this time can reduce pain and are most effective for acute sciatica. Interestingly, over time the disc bulge tends to dehydrate and shrink. It never retracts back into the disc space but on subsequent imaging can be reduced in size. This shrinking phenomenon is most prevalent with large protrusions. The size of a disc bulge also has no correlation to symptoms; unless a cauda equina syndrome is present a large bulge does not-by virtue of its size-absolutely have to be removed.

Other Points

To emphasize, lumbar discectomy is a good operation for leg and buttock pain, not back pain and most of these disorders get better without surgery. In general if symptoms still persist in a fashion that interferes with a patient’s quality of life after 6-12 weeks, surgery is a definite treatment option.

Copyright © 2010  All rights reserved.

Introduction

Injections comprise a less invasive, relatively conservative treatment option for back pain. They are typically considered as an option to treat back pain after a course of medications and/or physiotherapy is completed, but before surgery is considered. Injections can be useful both for providing pain relief and as a diagnostic tool to help identify the source of the patient’s back pain.

For pain relief, injections can be more effective than an oral medication because they deliver medication directly to the anatomic location that is generating the pain. Typically, a steroid medication is injected to deliver a powerful anti-inflammatory solution directly to the area that is the source of pain. Depending on the type of injection, some forms of low back pain relief may be long lasting and some may be only temporary.

Diagnostically, injections can be used to help determine which structure in the back is generating pain. If lidocaine or similar numbing medication is used, and the patient feels temporary relief after an anatomic region is injected (e.g. facet joint or sacroiliac joint), it can then be inferred that the specific region is the source of the pain. When considered in conjunction with a patient’s history, physical exam, and imaging studies, injections used for diagnostic purposes can be very helpful in guiding further treatment for the patient.

Different kinds of injections for pain relief

Common types of injections for back pain relief include:

• Epidural
• Selective nerve root block (SNRB)
• Facet joint block
• Sacroiliac Joint Injections
• Vertebroplasty

Different kinds of injections for diagnosis

• Myelogram
• Discogram

Epidural steroid injections

Epidural steroids injections are most effective in the presence of nerve root compression. (Epidural – Space outside the dura or covering of the spinal cord. This space runs the length of the spine). The most commonly performed injection is an epidural steroid injection. In this approach, a steroid is injected directly around the dura, the sac around the nerve roots that contains cerebrospinal fluid (the fluid that the nerve roots are bathed in).

Scientific studies often demonstrate inflammation of the spinal nerves following prolonged compression, which leads to irritation and swelling. This irritation occurs at the level of the root of the lumbar nerves. The injection of steroids, which are potent anti-inflammatories, is made into the epidural space, close to the affected nerve roots. These injections must be given by experienced specialists who are well trained in this technique. Improvement of the symptoms appears to correlate well with the resolution of the nerve root inflammation. These injections are most effective when given in the first weeks of the onset of pain. Usually, two to three injections one to two weeks apart are required. Only a single injection is given if complete pain relief is achieved.

Doctors limit the number of epidural steroid injections to a maximum of three or four a yearto avoid systemic side effects of the steroids. Side effects are minimal and consist mainly of mild tenderness in the area of injection which disappears in 1-2 days. Success is dependant on the cause of the pain and how long the pain has existed. The sooner the treatment is instituted, the better are the chances of getting well. This treatment, along with analgesics and physical therapy has brought relief to thousands of patients, avoiding, in the majority of cases, the need for surgery. Prior to the injection, the skin is anaesthetized by using a small needle to numb the area in the low back (a local anaesthetic).

How is it done?

The patient is given a local anaesthetic.  The patient is placed lying on their side on the x-ray table and positioned in such a way that the doctor can best visualize the low back using x-ray guidance. The radiologist then locates, under X-ray guidance a specific spinal nerve root. A needle is introduced through the skin into the area adjacent to the nerve root. Medication is then injected into the area bathing the nerve root. The medications include an anaesthetic and steroid.

What happens after the procedure?

Patients are then returned to a waiting room where they are monitored.  Patients are then asked to record the relief they experience during the next week on a post injection evaluation sheet (“pain “diary”). This will be given to the patient when they are discharged home. A follow-up appointment will be made for a repeat block if indicated. These injections are usually done in a series of three (3), about two (2) weeks apart. The back or legs may feel weak or numb for a few hours. This is to be expected, however it does not always happen.

General Pre/Post Instructions

Patients can eat a light meal within a few hours before the procedure. If a patient is an insulin dependent diabetic, they must not change their normal eating pattern prior to the procedure. Patients may take their routine medications. (i.e. high blood pressure and diabetic medications). Patients should not take pain medications or anti-inflammatory medications the day of their procedure. A driver must accompany the patient and be responsible for getting them home. No driving is allowed the day of the procedure. Patients may return to their normal activities the day after the procedure, including returning to work.

Epidural steroid injection success rates

An epidural steroid injection is generally successful in relieving lower back pain for approximately 50% of patients. While the effects of the injection tend to be temporary (one week to one year), an epidural can be very beneficial in providing relief for patients during an episode of severe back pain and allows patients to progress in their rehabilitation.

Selective Nerve Root Block

As the spinal nerves emerge from the spinal cord, they travel laterally 1-2 cm before they exit the spine. It is at this exit (Intervertebral foramen) that these nerves are most likely compressed or “pinched” by either a herniated disc, bone spurs, narrowing of the exit secondary to calcification and decreased spacing between vertebrae (bones forming the spine).  This pressure on the spinal nerves causes inflammation and pain. The pain could affect the back alone or can irradiate to the legs, which is known as sciatica.

Another common injection, a selective nerve root block (SNRB), is primarily used to diagnose the specific source of nerve root pain and, secondarily, for therapeutic relief of low back pain and/or leg pain.

When a nerve root becomes compressed and inflamed, it can produce back and/or leg pain. Occasionally, an imaging study (e.g. MRI) may not clearly show which nerve is causing the pain and an SNRB injection is performed to assist in isolating the source of pain. In addition to its diagnostic function, this type of injection for pain management can also be used as a treatment for a far lateral disc herniation (a disc that ruptures outside the spinal canal).

In an SNRB, the nerve is approached at the level where it exits the foramen (the hole between the vertebral bodies). The injection is done both with a steroid (an anti-inflammatory medication) and lidocaine (a numbing agent). Ct Scan is used to ensure the medication is delivered to the correct location. If the patient’s pain goes away after the injection, it can be inferred that the back pain generator is the specific nerve root that has just been injected. Following the injection, the steroid also helps reduce inflammation around the nerve root.

Success rates vary depending on the primary diagnosis and whether or not the injections are being used primarily for diagnosis. While there is no definitive research to dictate the frequency of SNRB’s, it is generally considered reasonable to limit SNRB’s to three times per year.

Technically, SNRB injections are more difficult to perform than epidural steroid injections and should be performed by experienced radiologist. Since the injection is right next to the nerve root, sometimes an SNRB will temporarily worsen the patient’s leg pain.

Facet Joint Injections

Facet Joints are located in the posterior spine and help to enable spinal movement. The cervical, thoracic and lumbar vertebrae each have a pair of facet joints. The facets from the upper and lower vertebrae join together (like entwined fingers) to form a facet joint. Like other joints in the body, the articulating surfaces are coated with smooth cartilage to facilitate movement. The facet joints provide stability and guide motion in the spine. If the lumbar facet joints become painful they may cause pain in the low back, abdomen, buttocks, groin or legs. If the cervical facet joints become painful they may cause pain in the head, neck, shoulders, down between the shoulder blades or in the arms.

The Injection?

When back pain originates from the facet joints a specific type of injection called a facet joint injection may reduce inflammation and provide pain relief. This injection involves patients with primarily low back pain (unilateral or bilateral) and no root tension signs or neurologic deficits, the pain usually being aggravated by extension of the spine. The therapeutic objective of facet joint injections is temporary relief from motion–limiting pain so the patient may proceed into an appropriate exercise program.

Doctors use fluoroscopy or CT Scans to ensure the needle is correctly placed before the medicines are injected.

The Expected Results

A facet joint injection serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate pain relief experienced will help confirm or deny the joint as a source of pain. Additionally, the temporary relief of the numbing medicine may better allow a doctor or physical therapist to treat that joint. Also, time release cortisone (steroid) will help to reduce any inflammation that may exist within the joint(s).

The only test that can prove that the facet joint is the source of pain is a diagnostic facet joint block, as CT scan, X-Ray and MRI are usually unremarkable. In contrast to a treatment or therapeutic block (injection) in which a steroid is used, a diagnostic injection only uses a local anaesthetic. It is at all times preferable that the specific offending joint be identified so that a targeted therapeutic injection can be offered.

Sacroiliac Joint Injection

The sacroiliac facet joints are a small joint in the region of the low back and buttocks where the pelvis actually joins with the spine. If the joints become painful they may cause pain in the low back, buttocks, abdomen, groin or legs

Although not usually a primary pain generator, the sacroiliac joint is a common area of referred pain and can persist as the primary focus of pain. The typical pain referral pattern is to an area around and just caudal to the posterior superior iliac spine. The S-1 joint should therefore be treated within the context of the entire spine and kinetic chain, including the pelvis, hips, and lower extremities.

In patients who have failed four to six weeks of a comprehensive exercise program, local icing, mobilization/manipulation and anti-inflammatories, a sacroiliac joint injection can be helpful for both diagnostic and therapeutic purposes. In some patients, S-1 joint injections can provide significant pain relief.

When sacroiliac joint injections are employed, they should be performed with fluoroscopic guidance using contrast medium to ensure proper needle and medication placement. If helpful, they may be repeated; however, the frequency of these injections should be limited with attention placed on the comprehensive exercise program.

It should be noted that nerve blocks are not the best treatment for all pain problems. Even when they are appropriate, they are usually more effective as a part of a comprehensive treatment strategy. Such a strategy may involve medications, physical therapy, occupational therapy, stress management, relaxation training, acupuncture, or other treatments.

Vertebroplasty

Vertebroplasty is an image-guided, minimally invasive, nonsurgical therapy used to strengthen a broken vertebra (spinal bone) that has been weakened by osteoporosis or, less commonly, cancer. Vertebroplasty can increase the patient’s functional abilities, allow a return to the previous level of activity, and prevent further vertebral collapse. It is usually successful at alleviating the pain caused by a compression fracture. Performed as a day patient, vertebroplasty is accomplished by injecting an orthopaedic cement mixture through a needle into the fractured bone.

What are some common uses of the procedure?

Vertebroplasty is used to treat pain caused by osteoporotic compression fractures. After menopause, women are especially vulnerable to bone loss. More than one-fourth of women over age 65 will develop a vertebral fracture due to osteoporosis. Older people suffering from compression fractures tend to become less mobile, and decreased mobility accelerates bone loss. High doses of pain medication, especially narcotic drugs, further limit functional ability. Vertebroplasty is often performed on patients too elderly or frail to tolerate open spinal surgery, or with bones too weak for surgical spinal repair. Patients with vertebral damage due to a malignant tumor may sometimes benefit from vertebroplasty. In rare cases, it can be used in younger patients whose osteoporosis is caused by long-term steroid treatment or a metabolic disorder. Typically, vertebroplasty is recommended after simpler treatments, such as bedrest, a back brace or pain medication, have been ineffective, or once medications have begun to cause other problems, such as stomach ulcers.

How is the procedure performed?

Vertebroplasty is generally performed in the morning. You will be sedated and receive a local anaesthetic to numb the skin and the muscles near the spinal fracture. Intravenous antibiotics may also be administered to prevent infection. Through a small incision and guided by a fluoroscope, a hollow needle is passed through the spinal muscles until its tip is precisely positioned within the fractured vertebra. Once the needle is shown to be in the proper location, the orthopaedic cement is injected. Medical-grade cement hardens quickly, over the next 10-20 minutes. A CT scan may be performed at the end of the procedure to check the distribution of the cement. The longest part of vertebroplasty involves setting up the equipment and making sure the needle is perfectly positioned in the collapsed vertebra.

Vertebroplasty usually takes less than two hours (longer if more than one site is being treated). Although you will not be allowed to drive after the procedure, you can go home with an adult.

How effective is the procedure?

Vertebroplasty is highly effective because after osteoporosis has made bones very porous, the cement fills the spaces and strengthens the bone so it is less likely to fracture again. After vertebroplasty, the cement stabilizes the fracture, which is thought to provide the pain relief. Patients begin regaining mobility within 24 hours and are usually able to reduce, or even eliminate, their pain medication.

For two or three days afterwards, you may feel a bit sore at the point of the needle insertion. You can use an icepack to relieve any discomfort, but be sure to protect your skin from the ice with a cloth; use the pack for only 15 minutes per hour. The tiny incision will be closed with a strip of tape, and covered with a bandage, which should remain on for several days. It’s important that the injection site remain clean. You can shower while the bandage is still on.

Bedrest is recommended for the first 24 hours following vertebroplasty, though you can get up to use the bathroom. Increase your activity gradually, and resume all your regular medications. If you take blood thinners, check with your doctor, but you may be able to restart them the day after the procedure.

What are the benefits vs. risks?

Benefits

Because the pain of a compression fracture is alleviated by vertebroplasty, patients feel significant relief almost immediately. After just a few weeks, two-thirds of patients are able to lower their doses of pain medication significantly. Many patients become symptom-free.
About 75% of patients regain lost mobility and become more active, which helps combat osteoporosis. After vertebroplasty, patients who had been immobile can get out of bed, reducing their risk of pneumonia. Increased activity builds more muscle strength, further encouraging mobility.

Risks

Usually, vertebroplasty is a safe and effective procedure.

• A small amount of orthopaedic cement can leak out of the vertebral body. This does not usually cause a serious problem, unless the leakage moves into a potentially dangerous location such as the spinal canal.
• Other possible complications include infection, bleeding, increased back pain, and neurological symptoms such as numbness or tingling. Paralysis is extremely rare. Sometimes, the procedure causes another fracture in the spine or ribs.

What are the limitations of Vertebroplasty?

• Vertebroplasty is not used for herniated disks or arthritic back pain.
• Vertebroplasty is not generally recommended for otherwise healthy younger patients, mostly because there is limited experience with cement in a vertebral body for longer time periods.
• The procedure cannot serve as a preventive treatment to help patients with osteoporosis avoid future fractures. It is used only to repair a known, non-healing compression fracture.
• Vertebroplasty will not correct an osteoporosis-induced curvature of the spine, but it may keep the curvature from worsening.
• It may be difficult for someone with severe emphysema or other lung disease to lie facedown for the one to two hours vertebroplasty requires. The healthcare team will try to make special accommodations for a patient with this type of condition.
• Patients with a healed vertebral fracture are not candidates for vertebroplasty.

Diagnostic Injections

Discography (Discogram)

What is the disc?

The disc is a soft cushion like pad, which separates the vertebral bones of the spine. A disc may be painful when it bulges, herniates, tears or degenerates and may cause pain in the neck, mid back, lower back and arms, chest wall, abdomen or legs. Other structures in the spine may also cause similar pain such as the muscles, joints and nerves. Before performing discography, it has usually been determined that these other structures are not the sole source of pain in a patient (through history and physical examination, review of X-rays, CT Scans and / or diagnostic injection procedures).

What is Discography

It is a test performed to review and assess the internal structure of the disc and determine whether it is the source of pain.

Utilising X-ray guidance, this procedure involves the placement of needles into the discs, with an injection of contrast dye. CT and MRI, whilst providing images of the anatomy, cannot absolutely prove the source of a patient’s pain. A disc could be abnormal on CT and MRI images and not necessarily be the source of pain for the patient. Only Discography can determine if the disc(s) themselves are a source of pain.

Anatomical picture of the disc

X-ray image of a needle in the disc

How is it done?

The patient is given intravenous medication as a relaxant and pain reliever. A local anaesthetic is injected into the patient’s skin in the area that is being examined.

Needles are inserted into the disc under X-ray control (Fluoroscopy). Radiopaque dye is injected into the disc or discs whilst pain response is monitored. X-rays and C.T. Scans are then obtained.

Patient Selection

Your specialist will assess the need for discography and discuss this with you.

Experienced Operator

Discography is an operator-dependent procedure in which the specialist doing the procedure must use his/her clinical judgment to ascertain the suitability of a patient for discography and the significance of pain reproduction through discography.

These criteria are generally used to determine whether a particular disc is responsible for a patient’s pain symptoms. First, the injection of that disc must cause significant pain. Second, the quality of the pain must be concordant with the patient’ usual quality of pain. Thirdly, a control disc must have a negative injection.

Expected Results

• Recreation of painful symptoms if the disc(s) is abnormal.
• Confirmation of a diagnosis and/or determination of which disc(s) is the source of pain.

Therefore discography is done to identify the painful disc(s) and help the surgeon to plan the correct surgery or avoid surgery that may not be beneficial.

Myelography

Myelography is an X-ray examination of the spinal cord and the space surrounding it, called the subarachnoid space. The x-ray film, or myelogram, is taken after injecting a radiopaque contrast material through a needle placed in this space.

Myelography can demonstrate distortions of the spinal cord, the spinal canal within which it lies, and the spinal nerve roots connected to it.

Why a Myelogram?

It is an effective means of identifying spinal lesions caused by disease or trauma. It is relatively safe and painless examination.

Often Myelography is performed when other tests—such as computed tomography (CT) scans or magnetic resonance imaging (MRI) have not provided adequate information. For patients who cannot have an MRI exam for any reason, Myelography may be performed, followed by a CT scan.

Myelography can identify a herniated or ruptured intervertebral disc. A myelogram can accurately located the disc(s) involved, and show whether disc tissue is pressing on nerves connected to the spinal cord. This information is especially important when surgical treatment is a possibility.

• People with spinal arthritis sometimes develop sharp outgrowths of vertebral bone called bone spurs; these may press on spinal nerves and cause pain. Here again, a myelogram can indicate whether surgery might help. The exam also can identify a condition called spinal stenosis where the entire spinal canal is narrowed.
• Tumours may develop within the spinal cord or surrounding tissues. In addition, cancer from elsewhere in the body may spread to the spine. A myelogram will accurately locate a tumor mass in this region and may suggest the most effective treatment.
• Other conditions that may be shown by a myelogram are abnormalities of blood vessels that supply the spinal cord, and traumatic injuries.

How should I prepare for the procedure?

Usually patients are advised to increase their fluid intake the day before a scheduled myelogram, as it is important to be well hydrated. Solid foods are avoided for three hours before the exam, but fluids may be continued. You should provide the radiologist with a list of drugs you are taking. Some drugs should be stopped one or two days before Myelography. They include certain antipsychotic medications, antidepressants, blood thinners, and drug that are used to treat diabetes. It is important that medical staff know if you have had seizures, or that you are—or might be— pregnant. If you smoke, stopping the day before the test will lessen the chance of your becoming nauseous or having headache after Myelography.

If you have had a severe allergic reaction to medication or anything else, or have a history of asthma, you will be watched especially carefully to check for a reaction when injecting the contrast material. Allergy to iodine-containing substances can be especially risky. If you have had kidney problems, tests should be done by your primary doctor prior to a referral for Myelography.

You will need to remove any jewellery near the area of your body being examined. After disrobing, you will be given a hospital gown to wear. Unless you are to spend the night in hospital, you should arrange to have a relative or friend take you home.

How is the procedure performed?

Myelography is done a hospital X-ray department. After lying face-down on the X-ray table, fluoroscopy is performed and images of the spine are projected onto the screen of a monitor. After locating the best placement for the needle, your skin will be cleaned and numbed with a local anaesthetic.

Iodine-containing contrast material then is injected and the X-ray table is slowly tilted. During this time, the flow of contrast is monitored by fluoroscopy.  X-rays then are taken while you are lying facedown. You will be asked to lay as still as possible while the table is tilted at different angles. The exam focuses on the area where you are feeling symptoms: the lower back area, the middle part of the back, or the neck. A foot rest and straps or supports will keep you from sliding out of position. A computed tomography (CT) scan sometimes is done immediately after Myelography while contrast material is still present in the spinal canal. This combination of imaging studies is known as CT Myelography.

What will I experience during the procedure?

You will feel a brief sting when local anaesthetic is injected, and slight pressure as the spinal needle is inserted. Positioning the needle may cause occasional sharp pain. Although you may find the face-down position uncomfortable or have trouble breathing deeply or swallowing, the position is not usually maintained for very long.

When contrast material is injected you may feel some pressure or warmth. Headache, flushing, or nausea may follow contrast injection. Seizures are possible, but are rare.

Myelography itself usually takes 30 to 60 minutes, and a CT scan adds another 30-60 minutes to the total examination time. You will be encouraged to take fluids at this time to help eliminate contrast material from your body and prevent headache. You probably will be asked not to engage in strenuous physical activity or bend over for one or two days.

Disclaimer:

This booklet is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem.

Introduction

Back pain and back problems are exceedingly common disorders that affect the general community and up to 40% of the population will suffer this ailment at some time. The essence of the assessment and evaluation of patients with back problems centers around the following key issues. My approach to this problem is shown for residents and professionals, and also for patients so they realize the process undertaken in their evaluation and management.

Process

1. A careful history is taken
2. A thorough physical examination is performed
3. Appropriate investigations are ordered which are correlated to the clinical picture

There are 3 questions that are being asked:

1. What is the anatomic locus of the pathology on clinical grounds?
2. What pathological process is causing the dysfunction at that anatomic locus on imaging?
3. Is this amenable to surgical intervention?

By and large, the vast majority of back disorders can be managed non-surgically, with a very small subset requiring surgical referral and/or intervention. The conditions that can be helped by surgery comprise the following categories:

1. Compression e.g. disc, tumor, fractured bone fragments
2. Tension e.g. tethered cord
3. Instability e.g. Trauma, degenerative
4. Ischemia e.g. dAVF, compression

History

In general, up to 80% of back and spinal disorders can be diagnosed on history alone. In taking a back-related history, the following are important:

• Details of the onset of the illness
• What brought on the Sx
• Was there correlation to any activity?
• The effect of bed rest
• Did the patient awaken with Sx

Specific questioning should be done into the following areas:

• Pain
• Sensory symptoms
• Motor symptoms
• Gait
• Bowel function
• Bladder function

When questioning about pain, it is important to develop a pain history, encompassing the what, where, when and how.

It is important to understand some neuroanatomy in an attempt to correlate radicular symptoms to spinal pathology. In general, if the innervation of C6 and C7 (C6 supplies biceps and wrist extensors and supplies the thumb and index finger sensory regions as well as the biceps jerk; C7 supplies finger flexors, wrist extensors and triceps, as well as sensation to the dorsum of the hand and middle finger and triceps jerk) in the upper limb and L5 and S1 in the lower limb (L5 supplies the ankle dorsiflexors and sensation on the lateral aspect of the calf and dorsum of the foot; S1 supplies plantar flexion in the foot and sensation on the sole of the foot as well as the ankle jerk) are known, 90% of root lesions can be localized.

Important points about taking a pain history are:

Pain quality is important

• Neuropathic pain (burning in quality)
• Mechanical pain (worse on movement; relief with bed rest)

Constipation is a poor symptom of bowel dysfunction
More important questions about sphincters:

• Loss of feeling of fullness
• Loss of feeling of urethral stream
• Numbness on wiping

Physical Examination

The physical examination should not only encompass a general examination, but a thorough neurological examination should also be performed. To be as thorough as possible, the following regions need to be examined:

• Gait
• Back, neck
• Mechanical
• Roots, peripheral nerves
• Long tracts
• Rectal
• Joints
• Vascular
• Other

Sometimes differentiation between neurogenic and vascular claudication is required and an understanding of the differences between these 2 is required. In general the former is associated with back pain and is worse on standing of back extension and is unaffected by cycling, whereas the latter is unaffected by posture, may be associated with diabetes or peripheral stigmata of  vascular disease and is typically worsened by either walking or cycling  (see below):

Available Investigations

To simplify matters, it is convenient to focus on plain x-rays, bone scanning, CT scanning and MRI scanning

Plain x-rays still play some role in the investigation of back disorders, particularly in the background of possible metastatic spinal disease, or if spinal instability is suspected (e.g. in patients with rheumatoid arthritis). Dynamic x-rays are not, however, usually indicated as a primary screening test. Plain x-rays can also give an assessment of the severity of degenerative disease and exclude fractures/dislocations.

Bone Scanning allows for the exclusion of metastatic disease as well as occult fractures. This is a good screening the aforementioned pathologies in the face of cancer or osteoporotic disease.

CT Scanning is a good baseline investigation for myelopathy or radiculopathy. It is not so good for intradural disease and may miss subtle degenerative changes causing neural compression.

MRI Scanning is our current “gold standard” in the unraveling of spinal disorders. It allows for excellent soft tissue delineation, as well as allowing for the assessment of the craniocervical junction. MRI also allows for postoperative differentiation of scar tissue from disc material. MRI is also unparalleled in the assessment of intradural disease.

Surgical Pathologies

Although most back conditions to not come to surgery, it is important to understand those conditions that do benefit from surgical intervention. They may be subclassified into the following:

Compressive Lesions

• Disc
• Lumbar stenosis
• Disc, facet joint, ligament
• Tumor (intra/extradural)
• Fractures

Ischemic Lesions

• Spinal dural AVF
• Spinal dAVM

Instability

• Rheumatoid arthritis
• Trauma
• Degenerative
• Post-surgical

New Technologies

Over the past few decades, much progress has been made in the assessment and management of spinal conditions. Some of these newer technologies include:

• Ix: flex/ext MRI
• Mx: better techniques for instrumentation
• Minimally invasive approaches

Intraoperative tools to allow more precise surgery e.g. fluoroscopic navigation (see below)

Summary

The differential diagnosis of back pain is just too long. Instead, in the absence of neurological deficit, conservative management should be instituted and, on its failure further investigations or referral should be instituted.

For back pain:

• Need to adopt an initial conservative approach
• Avoid exacerbating factors
• NSAIDs, analgesia, physiotherapy
• Ix by x-rays and CT if neurological signs or unresolved
• Most get better!

For sciatica:

• If there is weakness or persistent Sx (>4 weeks of pain) or pain that is not settling then these should be Ix and referred if needed
• Surgery is best for:
• leg pain >weakness > numbness
• Surgery is not good for back pain
• Most get better also!

The ABCs of unraveling back problems are:

• Careful history
• Thorough physical examination
• Appropriate Ix at appropriate time
• Correlate Ix to clinical picture
• Refer when needed
  • Neurological deficit
  • Sciatica or arm pain that fails conservative Mx
  • Likely instability
• Education/reassurance
• Patience!

The lower back or lumbar spine is composed of 5 bones, called vertebrae and the sacrum. Each vertebrae is connected to each adjacent vertebrae by 3 joints, 1 at the front (anteriorly) and 2 at the back (posteriorly). The joint at the front is called an intervertebral disc and is a common cause of surgical pathology. The joints at the back are called facet joints and are present as pairs straddling the midline. In addition to these 3 joints and bony structures, there are numerous ligaments and muscles. One of the more important ligaments is called the ligamentum flavum.  This yellow ligament bridges between adjacent vertebrae and can thicken with age and cause compression of nerves. The spinal cord sits inside a bony tunnel in the posterior half of each vertebrae which is called the spinal canal. The ligamentum flavum lines the back half of this canal. The back half of the spinal canal is formed by wing shaped pieces of bone called laminae. At each level, 2 lamina united and form a spinous process which is like a midline keel of bone and can be felt in the midline through the skin in the back. Holes at regular levels on each side of the spinal canal form intervertebral foramina. Each foramen allows 1 nerve to exit and in the lumbar spine there are 5 on each side. The spinal cord finishes at the lower border of the first lumbar vertebra and then becomes a leash of nerves (the cauda equina). Below this point only nerves are present and no spinal cord is present. Consequently most surgery on the lower back is on and around nerves rather than spinal cord. The spinal nerves in the lumbar spine supply strength in the legs, sensation from the groin down and bladder and bowel function. Injury to one nerve may cause no problem or may affect some or all of the previously mentioned modalities.