Learning more about your specific condition, its common symptoms, methods of diagnosis, and range of treatments is the first step. On this page, you'll find links to videos and information detailing several of the most common back and neck conditions that cause people chronic pain and discomfort. So have a look around and simply click on any one of the links below to learn more about a particular condition.
If needed, please refer to spine anatomy to better understand the areas of the spine listed below.
Cervical Disc Disease
By age 40, about 60% of us have already developed some form of degenerative disc disease (DDD). Our spines, after enduring several decades of twisting, turning, and the occasional trauma, often reflect this wear and tear by manifesting symptoms that are, quite literally, "a pain in the neck." The primary reason for this is, as we age, the natural disc "shock absorbers" that separate and cushion the seven bones in our neck, called cervical vertebrae, can become damaged or begin to wear out. This, in turn, can irritate or pinch surrounding spinal column nerve roots—resulting in Cervical Disc Disease.
Cervical Disc Disease can initially present itself as something as simple as a neck that's occasionally stiff or sore. It can then evolve into a radiating pain, numbness, and/or weakness in the shoulders and/or arms that can sometimes even extend to the hands. As the disease progresses, it can result in loss of reflex or motor function.
Methods of Diagnosis
A basic physical or neurological exam and imaging tests, such as X-rays or MRI and CT scans, are typically used to diagnose Cervical Disc Disease.
Methods of Treatment
Usually, Cervical Disc Disease can be effectively treated with a regimen of regular exercise and over-the-counter medications. In more severe cases, physical therapy and steroid medications are used in combination. Surgery is rarely needed. However, in those instances when it is, there are now a number of effective, minimally invasive procedures worth considering.
Radiculopathy is when a spinal nerve root is irritated and/or compressed by either a herniated disc, osteophyte (bone spur), or both.
Symptoms of radiculopathy may include:
- Pain in extremities
- Tingling in extremities
- Numbness in extremities
- Muscle weakness
- Reflex loss
- Neurapraxia – temporary loss of function
Procedural solutions include decompression of the nerve root through:
- Anterior Cervical Discectomy
- Anterior Cervical Discectomy and Fusion
- Anterior Cervical Discectomy and Artificial Disc Replacement
- Posterior Cervical Foraminotomy
Cervical Spondylotic Myelopathy
Cervical Spondylotic Myelopathy results from spinal cord compression due to the narrowing of the spinal canal. It can be caused by either congenital conditions or by degenerative changes over time. These degenerative changes, also known as "spondylosis", result in the growth of bone spurs (osteophytes) which may compress the spinal cord.
Symptoms of myelopathy may include:
- Loss of fine motor control of hands
- Motor weakness in the upper and/or lower extremities
- Gait/walking difficulties
- Pain in the neck and/or shoulder area
- Sensory changes in the lower extremities
- Upper and lower motor neuron findings such as bowel and bladder dysfunction
Procedural solutions include:
- Anterior Cervical Decompression and Fusion
- Posterior Cervical Laminectomy with or without Fusion
- Posterior Cervical Laminoplasty
When a tumor is found on the cervical spine it may be removed. Removal of a tumor may cause mechanical instability in the cervical spine. Symptoms may include: pain, weakness, numbness, sensory changes, gait/walking difficulty. Procedural solutions include: anterior tumor removal and fusion, posterior laminectomy and tumor removal with fusion.
Trauma in the Cervical Spine
Trauma or fractures occur when an injury occurs to the cervical spine.
This results in mechanical instability of the vertebral column and possible neurological injury.
Fractures can be classified as stable or unstable. A stable fracture involves no significant displacement of the bone or soft tissue. An unstable fracture involves deformity of the spine.
- Pain in the area of the fracture
- Neurological defects
Procedural solutions include:
- Bracing or traction and observation
- Anterior Cervical Discectomy and Fusion
- Posterior Cervical Fusion
- A burst fracture is when the vertebra breaks and displaces into the spinal canal.
- A compression fracture is when a small portion of the anterior vertebral body is compressed but no bone is displaced into the canal. They usually are shaped like a teardrop or wedge.
- A Jefferson's fracture is a burst fracture of the C1 ring vertebral body.
- A Hangman's fracture is a fracture of the posterior (back) side of the C2 vertebral body.
Herniated Cervical Disc
This is a quite common condition. It causes arm pain and shoulder and neck pain. Shoulder pain may be most intense. The pain may be associated with weakness and numbness in the arms. C5 C6 and C6 C7 disc herniations are most common. Depending on the level and location of the disc herniation various symptoms may arise. C7 T1 disc herniations often go undiagnosed for a while as diagnosis is difficult at times. It causes severe weakness and numbness of the hand. C6 C7 disc herniation usually causes radiating numbness into the index finger. C5 C6 disc herniation causes numbness into the thumb. Most comfortable position may be palm of the hand behind the head with elbow flexed as that position may take the tension off the nerve root.
If disc herniation is centrally located it may press on the spinal cord and may cause paralysis or paresis--so called myelopathy. C7 T1 central disc herniation may present as paraplegia as all of the upper extremity function is intact. Urgent surgery is required if acute central disc herniation is causing myelopathy or disturbance of spinal cord function.
Many of cervical disc herniaitons get better on their own especially in nonsmokers. Serial MRI scans may show reabsorption of the disc herniation. If herniation causes severe neurological deficit then urgent surgery is indicated. If the pain is the only issue then cervical epidural steroid injection or nerve root injection may be tried to buy time so that patients can get better on their own.
If the herniation affects the dominant hand and is associated with significant neurological deficit then more likely surgery will be recommended on more urgent basis.
Most of the surgeries for cervical herniated discs take the form of anterior cervical decompression and fusion with instrumentation. Usually allograft is used. If the herniation does not affect the spinal cord and is mostly in the foraminal location lateral to the spinal cord then posterior cervical disectomy is also an option. Anterior cervical surgery is relatively painless surgery whereas posterior surgery is quite painful. There is a risk of recurrent disc herniation with posterior surgery and there is risk of transitional syndrome occurring with anterior surgery. Transitional syndrome is wearing out of discs adjacent to solid fusion and can take the form of either herniation or stenosis. If the level adjacent to the disc herniation is significantly stenotic and has significant herniation then that level may be incorporated also into the fusion mass.
Please refer to section on patient information on surgeries for specific information on anterior cervical decompression and fusion and posterior cervical micro decompressions.
Cervical Foraminal Stenosis
This can cause arm pain on chronic basis. Depending on the level one sided shoulder pain or neck pain may result. It is due to pinched nerve in the narrowed channels caused by usually bone spur and disc degeneration. Diagnosis is usually made with oblique views of cervical spine utilizing plain x ray machine, MRI scan, or CT scan. Confirmatory test of cervical nerve root injection may be performed. Sometimes a form of steroid is injected as well giving some therapeutic benefit of pain relief that may last for a few weeks or many months.
Usually conservative treatment is tried first to treat this condition including physical therapy and cervical traction and nonsteroidal anti-inflammatory medications. If all conservative nonoperative measures fail a procedure call posterior cervical mircoforaminotomy is usually curative. If there is significant cervical kyphosis or bending forward of the neck at the same time then anterior cervical decompression and fusion may be recommended.
Cervical Central Stenosis
This is narrowing of the main conduit for the spinal cord in the cervical spine due to arthritis or disc herniation. A condition called Ossified Posterior Longitudinal Ligament can also cause this condition.
This usually causes disturbance of spinal cord function called myelopathy. This may entail symptoms such as weakness of arms and legs and frequent falling episodes. It may cause clumsiness of hands and arms. Patients report frequent dropping of objects. Numbness may be present in the arms and legs. Shakiness or jumpiness of legs may be present.
Diagnosis is made with MRI scan or CT scan. CT myelogram may be recommended.
If there is no kyphosis and cervical spine is neutral the treatment of choice is procedure called laminoplasty. If kyphosis is present then anterior cervical decompression and fusion is recommended.
Without surgical intervention the myelopathy may progress causing gradual paralysis.
This is usually a condition brought on by disc degeneration with collapse with neck going forward. This can cause neck pain. After cervical laminectomy this condition can develop due to lack of check rein effect of the bone in the back of neck and disruption of muscles in the back of the neck. Extreme form can occur in ankylosing spondylitis resulting in chin on chest deformity in which patients have difficulties looking up at all.
The malalignment puts the neck in biomechanical disadvantage so that the muscles in the neck cannot work effectively causing neck pain. Sometimes the spinal cord may get draped over the "hump" leading to spinal cord malfunction or myelopathy.
Laminectomy or laminoplasty is contraindicated in patients with cervical kyphosis as the kyphosis can get much worse with these posterior procedures.
This condition is commonly brought on by rear end collisions in motor vehicle accidents. Other positions of impact such as T boning and front end collision can result in the similar injury. The more severe the impact the more likely that more energy is absorbed in the cervical spine resulting in more severe symptoms.
Imaging studies such as MRI scan may be completely normal. Flexion and extension lateral x ray of cervical spine should be obtained to rule out posterior ligament tear. If the tear is severe posterior cervical fusion may be required but that is very rare.
Various symptoms can arise despite "normal" MRI scan. They include neck pain, headaches, arm pain, numbness and tingling in the hands, shoulder pain, hearing difficulties, blurred vision, facial pain, and inability to concentrate.
In mild cases symptoms resolve rapidly with conservative care such as physical therapy and chiropractic treatments and some mild pain medications. However symptoms can persist in many cases for many months or for many years.
In these latter group of patients with persistent chronic pain workup with cervical medial bundle branch block and treatment with percutaneous radiofrequency ablation has proven effective.
Headaches may respond to medications such as midrin. Chronic usage of narcotic medications is discouraged as it can be habit forming.
Ossified posterior longitudinal ligament
This condition is quite common in Japanese. The neck ligament in front of the cervical spinal cord calcifies and starts pressing on the spinal cord causing spinal cord dysfunction or myelopathy with weakness and numbness of arms and legs causing gradual paralysis.
If there is no kyphosis the condition is readily treated with cervical laminoplasty.
If there is kyphosis then the condition should be treated with anterior cervical decompression and fusion.
Causes of neck pain or cervicalgia is multiple. Acute neck pain is common and goes away without treatment in matter of a few days or few weeks. Persistent chronic neck pain can be caused by a variety of causes such as whiplash injury or disc degeneration. Treatment depends on the cause of the pain.
C1 C2 facet arthrosis
This causes neck pain and headaches. It is usually one sided. Open mouth view of cervical spine x ray is diagnostic and the diagnosis is further confirmed with C1 C2 facet joint injection. The facet joint injection may be therapeutic. If the pain persists despite the injection C1 C2 posterior fusion may be indicated. This disease usually affects the elderly.
This is a very common complaint. It maybe a referred pain from the cervical spine irritation. It could be due to upper thoracic disc herniation or compression fracture. It is difficult to treat. Physical therapy, cervical or thoracic epidural steroid injection or percutaneous radiofrequency facet block in the area of the pain may be tried.
Cervical spine fractures can manifest in a variety of forms. Simple minor fall in elderly can cause C2 fracture. High velocity trauma can case cervical burst fracture causing quadriplegia. Cervical spine x rays are usually diagnostic. MRI or CT scan may be further required to make further diagnosis. Bracing or halo and at times cervical spine surgery in the form of fusion alone or decompression and fusion may be required. The subject is very complex. Dr. Kim is ready to provide all the treatments required to treat any type of cervical spine fractures.
This is usually incidentally found. It could be result of blockage of CSF flow in a condition called Arnold Chiari Malformation. It could be posttraumatic. That is after damage to cervical spinal cord in a cervical spine fracture the spinal cord may liquefy causing a cavitation in the middle of the spinal cord. The syrinx then may gradually enlarge causing progressive spinal cord dysfunction. Then the cyst needs to be drained and shunted.
Spinal fusion puts stress on the adjacent levels. The adjacent levels may be exposed to excessive stress leading to disc degeneration and wearing out of facet joints. If the facets are sufficiently worn out or discs degenerate in addition this may lead to spinal stenosis and pinched nerves at those levels. At times at the stressed level disc herniation can occur and pinch the nerves. The more levels are fused the higher likelihood of transitional developing sooner. Patients usually complain of progressive low back pain or leg pain depending on the type of abnormality that develops at the transitional level.
At first conservative measures such as epidural steroid injection may be tried but patients eventually have to undergo extension of the fusion to include the abnormal transitional level. Decompression without the fusion of the transitional level will invariably lead to failure and therefore both decompression and fusion are recommended for stenosis and disc herniations that develop at the transitional level. The problem can develop after either lumbar or cervical fusion or after fusion for spinal deformities such as scoliosis. Depending on the health of the adjacent level the transitional zone problem can develop at various times after a spinal fusion.
Reflex Sympathetic Dystrophy or Regional Pain Syndrome
Another word for this condition is causalgia. This causes severe pain in the arms or hands or legs or feet. It can be a result of nerve damage such as intraoperative nerve trauma. Blunt trauma on extremities can also set it off. At time manipulation of the nerve center or so called dorsal root ganglion such as in lumbar foraminal disectomy can set it off. Intraoperative manipulation of nerve root can it set it off as well. The pain can be quite severe and persistent and there could be swelling and hypersensitivity associated with the condition. The earlier the condition is recognized and treated the better is the prognosis.
Treatment modalities include serial sympathetic blocks, oral steroids, and physical therapy to restore the function to the affected extremity. Early aggressive intervention is required.
Thoracic disc herniation
This condition can cause thoracic pain, bandlike radiating pain around the chest, and at times pseudoradicular pain down the legs. Small thoracic disc herniations are common and do not require any surgery. Once thoracic disc herniation occurs it does not tend to resolve on its own unlike lumbar or cervical disc herniations due to kyphosis. If the disc herniation is large enough to cause spinal cord compression with neuro deficit or pseudoradicular pain then it may require surgery. If thoracic radicular pain is persistent despite conservative measures without accompanying lower extremity neuro deficit it may also require surgical intervention.
Conservative management of the pain accompanying thoracic disc herniation consists of physical therapy, medications, bracing, thoracic epidural steroid injection, dorsal root ganglion block, and at time intercostal block.
Most of the surgeries for thoracic disc herniation involves anterior thoracic approach unless the herniation is lateral to the spinal cord in which case posterolateral approach or transpedicular approach or constotransversectomy approach may be used. Anterior approach does carry high morbidity as rib resection is necessary and patient sometimes develops post thoracotomy pain syndrome which may require intercostal nerve root block and possible ablation.
Thoracic spinal stenosis
This is relatively a rare condition. It may be present in DISH (diffuse idiopathic sclerosing hyperostosis) or may be due to calcification of ligamentum flavum or the ligament between the roofs of the spinal canal. The compression of the thoracic spinal cord may cause spinal cord dysfunction and lower extremity weakness and numbness. This condition is treated by thoracic laminectomy. Thoracic epidural is contraindicated as there is no room for spinal cord.
Scheurman's Disease of thoracic spine
This condition usually affects teenagers and diagnosis is made on lateral x ray of thoracic spine which shows more than 3 consecutive vertebras that are wedged. Intervening disc spaces have Schmorl's nodes. It causes thoracic kyphosis. Normal thoracic kyphosis may be up to 55 degrees. Kyphosis is usually 60 degrees or higher. In growing children bracing may be tried. If it exceeds 80 degrees or more surgery may be indicated. It causes roundback or hunch back deformity. Thoracolumbar junction may be affected rather than thoracic spine itself and then there is more pain associated with the disease. There is higher incidence of isthmic spondylolisthesis.
Juvenile Discogenic Disease
This is a very common condition affecting about 5% or more of population. There is multiple areas of Schmorl's node formation of the discs and there is premature degeneration of discs. These discs become often painful even after minor trauma. There is strong genetic component and family history is usually positive. Smoking adversely affects the condition rendering discs more painful and once the pain starts smokers have hard time becoming "unpainful" as opposed to nonsmokers. Patients do not know they have this condition until a trauma such as a fall, lifting injury, or motor vehicle accidents intervene and develops persistent back pain. Evaluation with MRI scan is diagnostic and shows multiple areas of disc degeneration and abnormal star shapes of discs.
Surgery is contraindicated in this condition as multiple level spinal fusion will only result in failure resolve the pain and put more stress on the adjacent abnormal discs.
Pain should be treated with physical therapy and nonsteroidal anti-inflammatory medications. Traction therapy of lumbar spine such as gravity lumbar traction may be beneficial. Pool therapy and swimming on regular basis work great.
Injection therapy such as percutaneous radiofrequency facet ablation may be tried in those who respond appropriately to the trial of medial bundle branch block of affected areas.
This can be a frustrating condition for both patient and medical providers involved as there is no "magic cure" for the condition.
This condition affects elderly osteoporotic patients. The vertebra if weakened enough collapses spontaneously from rectangular shape into a wedge shape. This is associated with pain and deformity. Multiple fractures may cause severe round back deformity or kyphosis. Prevention is the key. Anti-osteoporotic regimen including calcium, vitamin D, estrogen, fosomax and miacalcin nasal spray should be prescribed for prevention. Consultation with MD's knowledgeable in prescription of these medications are recommend. Bone density measurements may be performed to assess the severity of osteoporosis. Osteomalacia should be ruled out via appropriate blood tests.
Once compression fracture occurs patient has an option of wearing a rigid brace until the fracture heals. The process may take many months. Oftentimes patients poorly tolerate the rigid bracing. Pain medications are prescribed to combat the pain and may have to be prescribed on chronic basis.
Another option if conservative treatment fails is either vertebroplasty or kyphoplasty. In vertebroplasty cement is injected into the collapsed vertebra without restoring the height of the collapsed vertebra. In kyphoplasty a deflated balloon is introduced first into the collapsed vertebra and balloon is blown up and then let down. Into the cavity created by the balloon deflation cement is injected under very low pressure. Since the cement is injected under low pressure in kyphoplasty as opposed to vertebroplasty there is potentially less danger of cement leaking into the spinal canal causing neurological injury. In acute fractures height can be also restored with kyphoplasty whereas that is not possible with vertebroplasty.
Pain relief after kyphoplasty is almost immediate and it is theorized that the heat generated by the setting of the cement may denervate pain nerve fibers in the fractured bone. Restoration of the some height and structural stability may also play the role in reduction of the pain. Kyphoplasty is usually performed under general anesthesia.
This condition usually affects teenager girls. There is progression of the curve either in the thoracic or lumbar spine with growth. Once growth stops the curve does not progress. This is usually painless condition. The younger the patient and more growth remaining worse the prognosis for the progression. Surgery is usually recommended if the curve progresses beyond 50 degrees.
Clinically patient may present with asymmetric rib prominence and different shoulder height. Coronal decompensation or leaning to one side may be present in severe cases. Brace is prescribed if the curve progresses beyond 30 degrees in those who still has a lot of growth remaining. The brace has to be worn full time except taking it off for sports.
Surgery consists of posterior spinal fusion with instrumentation using neurological monitoring using both SSEP and MEP. Using both may obviate the need for wakeup test. Pedicle fixation of thoracic spine has obviated the need for anterior posterior spinal fusion in immature patients in preventing the crankshaft phenomenon.
Scoliosis up to 15 degrees are quite common in teenagers and should not cause any alarm for parents.
A variety of conditions can cause the pain in the thoracic spine. Common causes are painful disc degeneration and juvenile discogenic disease. Thoracic disc herniation and compression fractures need to be ruled out. In rare case tumors such as osteoid osteoma or metastatic cancer can cause the pain and in chronic cases MRI should be done rule out these serious conditions.
Often MRI scan is normal. Then intense physical therapy and swimming should be tried 1st. If that fails then a trial of thoracic medial bundle branch block and then more permanent radiofrequency facet block in those with initial favorite response to the medial bundle branch block may be tried. This treatment regimen may be also tried in those with painful juvenile discogenic disease or painful thoracic discs.
Thoracic discogram is rarely indicated as thoracic spinal fusion based on positive thoracic discogram has no proven benefit and discogram should not be done unless there is serious consideration of surgery. It may be indicated in cases in which there is question of thoracic disc impinging on the thoracic nerve root and MRI is inconclusive. Adding the contrast into the disc and then doing the CT scan may confirm the cause of the thoracic radicular pain in these cases.
A band like distribution of pain along the chest at times associated with numbness is indicative of compression of the thoracic nerve root. Causes include disc herniation, bone spur, tumor, or infection. MRI scan or CT scan or CT myelogram may be required for further diagnosis. Thoracic nerve root ganglion block may be used to confirm the diagnosis and if cortisone is injected at the same time may provide some therapeutic benefit. Condition such as shingles should be ruled out. Treatment depends on the diagnosis.
These fractures are usually due to high velocity trauma. In severe cases there may be neurological deficit. CT scan obtained in ER may underestimate the amount of the spinal canal compromise that occurred at the time of the injury. For example if CT scan shows canal compromise of 50% then it is likely that at the time of the accident "instantaneous canal compromise" could have been 80%. Therefore if patient is neurologically intact there is good chance that progressive neuro deficit will not occur with conservative treatment such as rigid TLSO bracing. Many burst fractures with kyphosis and significant canal compromise of more than 50% can be treated nonoperatively in rigid custom molded TLSO without resort to surgery. Patient should wear the brace all the time round the clock even in bed for about three months until the fracture heals.
If kyphosis is severe even in neurologically intact patients with burst fractures the kyphosis may progress after the fracture heals but this is mostly theoretical and if those cases where the kyphosis becomes symptomatic then surgery later on to correct the kyphosis such as pedicle subtraction osteotomy may be performed. Bone fragments in the canal often reabsorbs with healing of the fracture. Chance fractures in neurologically intact patient however may require posterior fusion and instrumentation if ligament injury is severe as ligament healing is not as reliable as bone healing.
In patients with burst fractures with neurological deficit then the spinal canal should be surgically decompressed and the area of the fracture needs to be fused. Usually anterior decompression is indicated. Cage may be used for anterior support and then posterior fusion and instrumentation is performed to give additional structural stability. Transpedicular decompression and cage placement and posterior fusion and posterior fixation may be also performed and may save patients anterior incision.
Fracture dislocation of thoracolumbar spine is rare and this is highly unstable injury with compromise of all three columns of spine and these should undergo posterior fusion and instrumentation first for stability and if decompression is required it may be performed secondarily via the anterior approach.
Syrinx in thoracic spinal cord
This may represent extension from cervical spinal cord syrinx. It may represent posttraumatic condition in which portion of the spinal cord dies and liquefies and cavitates. Treatment is the same as cervical syrinx.
This is a congenital condition in which spinal cord is tethered to the sacrum via a fibrous tissue to the sacrum. This can cause progressive neurological deficit with growth of spine. It becomes important to rule this out in patients where scoliosis correction is considered as stretching of the spinal cord unknowingly without detethering the spinal cord can result in paraplegia. Left sided thoracic scoliosis may be associated with condition among other abnormalities such as syrinx.
Lumbar Disc Disease
Everyone is familiar with the phrase, "Oh, my aching back!" And for good reason. By age 40, about 60% of us have already developed some form of degenerative disc disease (DDD). But more specifically, if the pain is chronic and centered in the lower back—below the ribcage—it could be caused by Lumbar Disc Disease. Over time, the gel-like "shock absorber" discs that separate and cushion the five bones in our lower spine, or lumbar vertebrae, can become damaged or begin to wear out. This, in turn, can irritate or pinch surrounding spinal column nerve roots—resulting in Lumbar Disc Disease.
Symptoms can range from stiffness or continuous low-grade pain in the lower back to a deep ache that radiates out to encompass the hips, buttocks, legs (above or below the knee), ankle, and foot. Discomfort often increases when sitting and is exacerbated by bending, twisting or lifting activities.
Methods of Diagnosis
A basic physical or neurological exam, plus imaging tests such as X-rays or MRI and CT scans, are typically used to diagnose Lumbar Disc Disease and pinpoint its cause(s).
Methods of Treatment
Usually, Lumbar Disc Disease can be effectively treated with a regimen of regular exercise and over-the-counter medications. In more severe cases, physical therapy and steroid medications are used in combination. Surgery is rarely needed. However, in those instances when it is, there are now a number of effective, minimally invasive procedures worth considering.
Lumbar Spinal Stenosis
Your spine provides a protective "tunnel" for the spinal cord. Sometimes, because of aging, illness, or an accident, a section of this "tunnel," the spinal canal, can become narrow. When this narrowing occurs, it can irritate or "choke" spinal nerve roots, the sciatic nerve, or even the spinal cord itself, resulting in a wide range of symptoms. Stenosis in the neck is called Cervical Spinal Stenosis. In the upper back, it's called Thoracic Spinal Stenosis. And in the lower back, the most common of all, it's called Lumbar Spinal Stenosis.
Symptoms generally develop slowly over time and can encompass weakness, numbness, and tingling and/or pain in the buttocks, legs, or even the feet—especially when walking. Typically, with Spinal Stenosis, the pain can be alleviated somewhat by resting or maintaining a flexed position. Symptoms can also fluctuate and may include bowel and bladder issues.
Methods of Diagnosis
Because many of its symptoms resemble those of other age-related conditions, Spinal Stenosis can be difficult to diagnose. In addition to a basic physical or neurological exam, a battery of imaging tests—including X-rays or MRI and CT myelogram scans—are typically used to diagnose Lumbar Spinal Stenosis.
Methods of Treatment
Treatment can range from pain relief medicine and exercise to physical therapy and/or corticosteroid injections. However, if symptoms become severe—or chronically restrict normal daily life—several effective, minimally invasive surgical procedures are now available.
About 90% of lumbar disc herniations occur in this manner. L4 L5 and L5 S1 levels are most commonly affected but as patient age increases it can move up to involve higher levels such as L2 L3 and L3 L4. The disc has to be structurally abnormal before the herniation can take place. It may be progression of annular tear or bulging disc. Extruded disc herniation means complete separation from the main body of the disc. Nonextruded disc herniation means attachment to the main body of the disc. The herniated disc fragment usually represent a few percentage of the main body of the disc. Usually the annulus tears and nucleus which is under high pressure comes out through the torn annulus.
At the time of herniation there is severe pain associated with it. Severe neurological compromise including foot drop and paralysis of other lower extremity muscles may be present. Rarely full blown cauda equina syndrome with bowel and bladder dysfunction may be the result. In cases of severe neurological deficit such as complete foot drop and cauda equnia syndrome urgent surgery is indicated. Many disc herniations can reabsorb on their own especially in nonsmokers. Serial MRI scans will show reabsorption of the disc materials. The larger the herniation and more extruded the herniation there is higher chance of reabsorption due to the inflammatory reaction mounted by the body's immune system. Smokers have much higher incidence of symptomatic disc herniation compared to nonsmokers. The pain is caused not only by the mechanical pressure on the nerve root but also by irritant chemicals that are released against the nerve root at the time of herniation.
As far as treatment conservative care such as physical therapy and pain medications and oral steroids and epidural steroid injections should be tried at least 6 weeks prior to surgery. Only exception is in the case of progressive neurological deficit, cauda equina syndrome, and in situations the pain is so severe that patient requires hospitalization to control the pain via intravenous narcotic medications. In those situations surgery is performed sooner.
The golden standard of surgery for herniated lumbar disc is lumbar microdisectomy. Success rate is greater than 90%. Nerve is directly visualized intraoperatively and the fragment is removed. In contained nonextruded disc herniations percutaneous disectomy may be tried but success rate is lower and may require lumbar microdisectomy secondarily. There is a 5 to 10% risk of recurrent disc herniation with lumbar microdisectomy and the risk is much higher in smokers. For the 1st recurrent herniation repeat lumbar microdisectomy is recommended. For the 2nd recurrent herniation concomitant fusion is recommended.
About 5 to 10% of patients after disectomy develop persistent low back pain, a condition called postlaminectomy low back pain syndrome and in those situations if prolonged conservative care fails then after appropriate workup with lumbar discography spinal fusion is recommended. In these situations spinal fusion has very high success rate in relieving the low back pain.
After microdisectomy pain relief may be instant but it may persist up to 6 weeks depending on amount of nerve injury due to the disc herniaiton before surgery and on the amount of nerve manipulation that was necessary to take out the disc herniation. If the sciatica persists more than 6 weeks then repeat MRI scan should be obtained to rule out recurrent disc herniation.
Lumbar Foraminal Disc Herniation
This represent about 10% of all lumbar disc herniations. It is much more painful condition than the posterolateral disc herniation as the herniated disc fragment is directly applied to the brain center of the nerve root or dorsal root ganglion. It can cause severe neurological deficit. Epidural steroid injection may not get the steroids out into the neural foramen. Transforaminal epidural steroid injection or nerve root injection may be more effective for palliative nonsurgical treatment.
The diagnosis is often missed depending on the experience of the radiologist reading the MRI scan. CT scan shows foraminal disc herniation better than MRI scan due to contrasts of various structures in the foramen. Many MRI scans have been read as normal when patient has a large one pressing on the nerve root writhing in pain!
There is less chance of spontaneous resolution of foraminal disc herniation as compared to the posterolateral disc herniation. Most of acute foraminal disc herniations require surgery due to severe pain and accompanying neurological deficit.
Surgery is more technically demanding than standard posterolateral disc herniation. At L1 L2, L2 L3, L3 L4, and L4 L5 levels approach lateral to the facet joints so called paralateral approach is recommended to preserve the integrity of the facet joint. This is mostly soft tissue dissection lateral to the pars and lateral and superior to the superior articular process requiring minimal bone resection. Many surgeons are not familiar with this approach or has adequate experience. At L5 S1 level due to illiac crest midline approach is recommended. Medial facetectomy or resection of about medial one third to one half of the L5 S1 facet joint is required and standing on the opposite side of the disc herniation surgeon looks into the exiting L5 nerve root and the disc fragment is pulled out with a nerve hook inferior and ventral to the exiting L5 ganglion and nerve root.
Recurrence is more rare than posterolateral disc herniation. If it recurs then spinal fusion is recommended with 1st recurrence as opposed to posterolateral disc herniations in which spinal fusion is recommended with 2nd recurrence.
Central Disc Herniation
This problem can cause low back pain and bilateral leg pain. The problem can become chronic especially in young people. Physical therapy and epidural steroid injections may be tried to treat this conservatively initially. Patients may have pain on daily basis or intermittent basis. If symptoms become chronic and disabling and resist all attempts at conservative measures then resectoin of the herniation and spinal fusion is recommended. Resection of central disc herniation without spinal fusion usually result in clinical failure with patient complaining of persistent low back pain.
Lumbar Central Stenosis
This condition usually affects elderly. Younger patients may be affected if they are born with congenitally narrowed spinal canal. Disc degeneration and enlargement of the posterior joints called facet joints will over time dig into the spinal canal where the dural tube with nerve roots reside putting pressure on them. Nerves are pinched in the subarticular recess or at the corners of the spinal canal.
This condition causes neurogenic claudication or low back pain with radiation into bilateral buttocks into the lower legs worse with standing and walking and improved with sitting and lying down. The positional symptoms are due to further narrowing of the spinal canal in standing and walking positions. Severity of the stenosis may be measured by how many blocks patient can ambulate before they have to stop and sit down. Patients find it more comfortable if they ambulate pitched forward holding onto a shopping cart.
The condition is progressive as disc degeneration and facet joint degeneration are progressive.
Treatments consist of lumbar epidural steroid injections. If there is excellent relief with initial one then up to 3 or 5 per year may be tried. If epidural steroid injection becomes ineffective then spinal surgery in the form of lumbar laminectomy is recommended. If there is associated condition such as spondylolisthesis or degenerative scoliosis concomitant spinal fusion is recommended as well.
Neurogenic claudication should not be confused with vascular claudication or hip and knee pains due to degenerative joint disease of the hips and knees.
Lumbar Foraminal Stenosis
This condition causes one sided leg pain. It is due to calcified disc herniation or bone spur sitting in the neural foramen pinching off the nerve root as it exits neural foramen. It may be associated with other conditions such as degenerative spondylolisthesis or degenerative scoliosis. The leg pain may be positional or nonpositional.
Many cases of foraminal stenosis are incidental findings on MRI or CT scan. Foraminal stenosis may be asymptomatic if the nerve root is adapted to the environment of the small neural canal. Symptomatic patients require further workup with nerve root injection for further diagnosis and therapeutic benefit.
If the foraminal stenosis is resistant to the nerve root injection therapy then definitive surgical solution of lumbar foraminotomy or foraminotomy and fusion at the same time may be required. Uncinate spur in the L5 S1 foramen is quite frequent and may cause persistent L5 radiculopathy. Resection of the uncinate spur in the L5 S1 neural foramen is a technical surgery requiring a lot of surgical experience for successful result.
This is a condition that develops during early teenager years or childhood. The condition affects about 2 to 3% of the population. About 50% of Eskimos has the condition. It is due to the stress fracture of the pars or the waist of the root of the spinal canal. L5 area is most commonly affected but L4 or L3 levels may be affected. Due to the pars defect upper vertebra may gradually slip forward on the lower vertebra resulting in the condition spondylolisthesis or slippage of the spine. The defect is called spondylolysis. Slippage may compromise neural foramen causing nerve root impingement. Hypermobility at the site of the fracture may generate fibrous tissue than may also irritate the nerve root causing the leg pain.
Most of patients with the condition are asymptomatic. Once patient develops symptoms of low back and leg pain however the pain may persist requiring medical intervention. Physical therapy is usually unsuccessful due to the instability. Nerve root injection or epidural steroid injection or bracing may be tried. NSAID's may be tried.
If symptoms persist and compromise quality of life for the patient spinal fusion is a very good operation and is curative. Usually posterolateral fusion with pedicle fixation suffice but in smokers to increase the fusion rate interbody fusion may be added to increase the success rate of the spinal fusion. The interbody fusion can be done either anteriorly or posteriorly.
Reduction of the slip is unnecessary and may cause neurological deficit. In high grade slips posterior interbody fusion using fibular strut or long cage traversing the sacrum into the L5 vertebral body in addition to posterolateral fusion and posterior instrumentation is recommended.
This very common condition is caused by degeneration of facet joints usually at L4 L5 level. It usually affects woman between ages of 50 to 80. Facet degeneration causes instability of the facets resulting slippage of the upper vertebra over the lower vertebra. With the slip spinal canal is narrowed causing spinal stenosis. Beginning stage of degenerative spondylolisthesisi s manifest on MRI scan as facet hypertrophy or enlargement of the facet joint with fluid formation in the joints. Nerve roots may be pinched off in the subarticular recess or in the neural foramen. Facet synovial cyst may arise further causing nerve root impingement.
Activity modification, physical therapy, and lumbar epidural steroid injection may be tried. If there is no significant improvement from the conservative nonoperative care then surgery in the form of spinal stenosis decompression and spinal fusion with pedicle fixation is recommended. The success rate of surgery is greater than 90%. Smoking and nonsteroida anti-inflammatory medications such as Advil and aspirin adversely affect the fusion process. If the fusion is unsuccessful symptoms may return requiring further surgery.
Static supine MRI imaging may miss spondylolisthesis. Myelogram in standing position with flexion and extension may be necessary in those situations where there is clinical suspicision of this condition. Decompression alone without spinal fusion in degenerative spondylolisthesis will result in failure and repeat surgery.
Lumbar Discogenic Low Back Pain Syndrome
This is very common condition. Discs themselves are painful causing chronic low back pain. Lumbar discography will reproduce the patient's typical pain. Conservative care should be tried as much as possible including physical therapy, gravity lumbar traction, anti-inflammatory medications, and chiropractic treatments. Injection therapy such as percutaenous radiofrequency facet block may be tried if there is appropriate response to the lumbar medial bundle branch block. IDET of intradiscal thermal electrocoagulation is controversial. Percutaneous disectomy will not work and in fact may aggravate the condition.
If symptoms last more than a year and if all types of nonoperative conservative modality fails and if discogram proves one or two painful discs with the remainder of the discs normal in morphology on discogram and nonpainful then spinal fusion in the form of interbody fusion either anteriorly or posteriorly with or without posterolateral fusion and instrumentation may be offered to patients with reasonable success rate. More than two level fusion based on discogram is not recommended as in many cases despite successful fusion pain may persist.
At this time there is too little experience with artificial discs to recommend them to treat this disease. Artificial disc is composed of metal backing and polyethylene spacer like in a total knee and replaces the disc. Anterior approach is used going retroperitoneally. Retraction of illiac arteries and veins are necessary. If the disc fails revision via the repeat anterior approach can be life threatening due to the blood vessels involved. I am not currently recommending this procedure to any patients until more experience and further long term followup data are available.
Lumbar degenerative disc disease
With aging discs degenerate. The degree of degeneration is more severe in some than others. Most of people with degenerated discs are pain free. The extent of disc degeneration is affected by genetics and amount of stress placed on the spine and smoking.
Farmers, carpenters, and manual laborers have more stress placed upon them others. This can result in accelerated degeneration of their spine. It is puzzling why some with degenerative disc disease are painful whereas others are not. Discs begin degenerating in early 20's.
Symptomatic patients with lumbar degenerative disc disease will typically complain of low back stiffness. The stiffness is worse in the mornings. With being in one position too long also aggravates stiffness. Once they are loosened up they feel better. Sitting and standing is much worse than walking. As long as they are engaged in continuous motion they feel better. There is no leg pain.
There could be two patterns of low back pain. One pattern is continuous pain everyday. The other pattern is intermittent bouts of severe low back pain with completely pain free interval.
This is nonsurgical disease. Physical therapy and nonsteroidal anti-inflmmatory medications such as advil and motrin are recommended.
Swimming on regular basis is also beneficial. Percutaneous radiofrequency facet block may be tried in select patients in which testing with preliminary lumbar medial bundle branch block temporarily dramatically relieves the discomfort.
This is incidentally seen in many lumbar MRI scans. Pain could be associated with it but many are asymptomatic. High intensity zone tear may be associated with low back or referred leg pain. Lumbar discography may reproduce the concordant pain. It may be a result of lifting injury or motor vehicle accident. We do not currently why some annular tears and painful and others are not.
Annular tear may progress to lumbar discogenic low back pain syndrome. The tear is in the annulus without herniation of the nucleus through the tear.
Bulging Lumbar Disc
This is quite common condition with diagnosis made on MRI scans. Most are asymptomatic that is there is no pain associated with it. It is normal aging process. We do not know currently why some bulging discs cause pain and other do not. Disc has to degenerate for it to bulge. Bulge with tear may progress to disc herniation causing sciatica. Running 100 people off the street who never had low back pain through MRI scan may show at least 40 to 50% of them may have bulging lumbar discs! Therefore bulging disc has no diagnostic significance. It may be associated with chronic low back pain as in lumbar discogenic low back pain syndrome.
Lumbar Degenerative Scoliosis
Wearing out of discs and facet joints in asymmetrical fashion may cause degenerative scoliosis. This is different from the scoliosis teenagers get. Surgery is not indicated unless it causes spinal stenosis resulting in sciatica. Spinal fusion is necessary to treat degenerative scoliosis with stenosis.
If patient has a lot of low back pain alone with this condition then lumbosacral corsette with metal stays may be tried. Facet joint injection or percutaneous radiofrequency facet block may be tried in appropriate candidates. Correction of the deformity is not necessary as in idiopathic scoliosis. Osteoporosis may aggravate the scoliosis and worsen the progression of the curve. Flatback syndrome may result if there is significant loss of lumbar lordosis or swayback.
Lumbar Flatback Syndrome
This is due to loss of lumbar swayback or lordosis. Patient notices gradual leaning forward as the day wears on. It can be caused by severe cases of lumbar degenerative scoliosis or by ankylosing spondylitis. Old lumbar fusions without pedicle screw instrumentation but with hooks also caused this condition. If the condition is severe then pedicle subtraction osteotomy is recommended but this is a major surgery with usually fair amount of blood loss. The low back pain can be severe in upright position as the lumbar muscles lose mechanical advantage in trying to keep the patient upright. One should make sure that patients do not have hip flexion contractures before attempting to do the surgery as patient will still lean forward after the pedicle subtraction osteotomy.
Lumbar Facet Syndrome
Facet joints may become painful causing chronic low back pain. MRI scan may show fluid formation in the facet joints and facet degeneration. Treatment is initially conservative. Facet joint injection or medial bundle branch block may confirm the diagnosis. In recalcitrant cases percutaneous radiofrequency facet block in appropriate candidates may be tried. It is very rare than spinal fusion is recommended for this condition.
With lumbar facet degeneration synovial cyst may occur compressing on a number nerve root usually at L4 L5 level causing leg pain. There may be associated degenerative spondylolisthesis. Facet joint cyst aspiration and instillation of steroid may be performed under fluroscopic guidance. The cyst may recur. Surgery is usually necessary. Even with surgical resection of the cyst it may recur as the underlying pathology of facet degeneration and instability has not been corrected. If there is no associated spondylolisthesis resection of the cyst alone without spinal fusion is recommended. If there is associated degenerative spondylolisthesis or recurrent cyst then spinal fusion should be performed.
This is persistent pain in the tailbone area. It may be caused by irritation of the sacrococcygeal nerve. It does not have to be associated with fracture of the coccyx. Conservative treatment with sitting donut and avoidance of sitting may be tried for a while. If the pain persists then sacrococcygeal nerve block with lidocaine and steroids may be performed. If there is good temporary response to it then cryosurgery for the denervation of this nerve may be tried. Coccygectomy or removal of coccyx is usually unsuccessful and is not recommended. Serious diagnosis such as rare chordoma should be ruled out with plain x rays prior to recommending any type of prolonged treatment for this condition. The pain may last many months or many years but it usually burns itself out on long term followup. It comes on mysteriously and goes away mysteriously.
SI Joint Syndrome
The SI joint is formed by the articulation between the sacrum and the illium. It has two parts: a true synovial lined cartilagenous joint and a fibrous articulation. The inferior one half to two thirds of the joint is the synovial portion. SI joint may be cause of low back pain and referred type of leg pain. On CT scan degeneration or destruction of SI joint may be seen but this is rare. IV drug abusers may present with the infection in the joint. Patients with ankylosing spondylitis will have obliteration of the SI joint.
Most of the time SI joint dysfunction is associated with no significant radiographic abnormality of the joint itself. The diagnosis of SI joint syndrome is made with SI joint injection of local anesthetic mixed with steroids. If there is dramatic pain relief then SI joint syndrome or dysfunction is noted to be present. SI joint fusion without any radiographic abnormality of the joint itself gives unpredictable clinical result and is therefore not recommended. Conservative treatment such as pelvic exercises and SI joint belts via physical therapy should be tried on long term basis.
This is very nebulous diagnosis. Very rarely is there actual abnormality of the piriformis muscle around the hip joint causing sciatic nerve compression. CT or MRI scan of the hip joint is invariably normal. Other causes of sciatica or leg pain should be ruled out. Diagnosis is certain only if there is EMG or nerve conduction abnormality and there is radiologic compression of the sciatic nerve by the piriformis muscle. In those highly selected cases so called piriformis muscle release may prove beneficial.
Recurrent disc herniation
This is partly addressed under lumbar disc herniation both posterolateral and foraminal. The incidence after lumbar microdisectomy is up to 10%. Incidence is lower for foraminal disc herniation. It may occur immediately after the surgery or many years later. Only a small portion of the disc is removed during lumbar microdisectomy and more disc fragments can break away from the remaining structurally abnormal disc causing the recurrent disc herniation. There is poor correlation between postoperative activity level and recurrent disc herniation and after about 4 weeks of light duty activity after microdisectomy patients are released to unrestricted activities. Being further careful after that initial 4 week period of light duty activity does not prevent recurrent disc herniation.
Recurrent disc herniation appears to be more common among smokers and cessation of smoking is recommended. Due to the scar tissue from the previous surgery tethering the nerve root recurrent disc herniations tend to cause more pain than virgin herniations. There is also less chance of spontaneous resolution of the herniation due to the scar tissue from the previous surgery.
Surgery for recurrent disc herniation is somewhat more technical than virgin herniation but in experienced hands the success rate of the surgery is the same as the surgery for the virgin herniation. If the herniation occurs at the same level for the 3rd time--or 2nd recurrent herniation--then concomitant spinal fusion is also recommended. Currently there is no way to prevent recurrent disc herniation except doing spinal fusion.
Postlaminectomy Low Back Pain Syndrome
Up to 10% of patients after successful lumbar microdisectomy may develop persistent low back pain. Some of these patients have persistent pain despite conservative management of the low back pain including physical therapy and various spinal injections.
When the pain persists more than a year further workup with lumbar discography may be performed and it the disc in question reproduces concordant pain and other adjoining discs are healthy then spinal fusion may be beneficial.
Instability after lumbar laminectomy
Some patients after lumbar laminectomy for spinal stenosis usually central stenosis develops recurrent pain into the legs and also low back pain. Further studies may reveal recurrent stenosis or spondylolisthesis or forward slippage of one vertebra over another. MRI scan being nonweight bearing study may miss the diagnosis and therefore standing myelogram with flexion and extension should be carried out to confirm the diagnosis. It is amazing that many times "normal" nonweight bearing MRI scan misses significant stenosis detected on weight bearing standing myelogram.
Upright MRI scan in sitting position may not be as reliable as standing myelogram after contrast injection as patients are mostly symptomatic in standing position and not sitting position. Only true standing weight bearing MRI scan may be able to detect the significant stenosis that will account for patient's symptoms. Repeat surgery after laminectomy invariably involves spinal fusion whether or not there is spondylolisthesis.
Spinal fusion puts stress on the adjacent levels. The adjacent levels may be exposed to excessive stress leading to disc degeneration and wearing out of facet joints. If the facets are sufficiently worn out or discs degenerate in addition this may lead to spinal stenosis and pinched nerves at those levels. At times at the stressed level disc herniation can occur and pinch the nerves. The more levels are fused the higher likelihood of transitional developing sooner.
Patients usually complain of progressive low back pain or leg pain depending on the type of abnormality that develops at the transitional level. At first conservative measures such as epidural steroid injection may be tried but patients eventually have to undergo extension of the fusion to include the abnormal transitional level. Decompression without the fusion of the transitional level will invariably lead to failure and therefore both decompression and fusion are recommended for stenosis and disc herniations that develop at the transitional level. The problem can develop after either lumbar or cervical fusion or after fusion for spinal deformities such as scoliosis. Depending on the health of the adjacent level the transitional zone problem can develop at various times after a spinal fusion.
This refers to severe scarring of the nerve roots within the dural sac. It is usually caused by old oil-based myelogram dye pantopaque. More recently inadvertent injection of steroids intrathecally during epidural steroid injection has resulted in this condition. Patients usually complain of severe low back and leg pain. If leg pain is the predominant complaint then dorsal column spinal stimulator may be implanted to relieve the pain. Dr. Burton in St. Paul, MN is the national expert on this matter and more information is available at www.burtonreport.com.
This is incidentally discovered on lumbar MRI scan performed for other reasons. It rarely causes pain or neurological deficit. It is usually CSF filled. Once should be careful during spinal injection therapy that it is not accidentally injected. It may thin out the overlying lamina sometimes causing fracture. Continued expansion and compromise of nerve roots may require intrathecal extirpation using intrathecal autologous fat graft and tight fascial closure.
Most common tumor is metastatic tumor from other sites such as breast, lung, prostate, and thyroid gland. Multiple myeloma may be the presenting complaint in the spine with pathological fracture. Benign hemangioma is common in the vertebra and is incidental finding on MRI or CT scan. Osteoid osteoma and osteoblastoma is rare and affects the posterior elements of the vertebra such as lamina. Neurofibroma may affect nerve roots causing leg pain. Intrathecal ependymoma may be present causing nerve root compression and neurological deficit. Giant cell tumor of bone may arise usually affecting the posterior elements of the spine.
Reflex Sympathetic Dystrophy or Regional Pain Syndrome
Another word for this condition is causalgia. This causes severe pain in the arms or hands or legs or feet. It can be a result of nerve damage such as intraoperative nerve trauma. Blunt trauma on extremities can also set it off. At time manipulation of the nerve center or so called dorsal root ganglion such as in lumbar foraminal disectomy can set it off. Intraoperative manipulation of nerve root can it set it off as well.
The pain can be quite severe and persistent and there could be swelling and hypersensitivity associated with the condition. The earlier the condition is recognized and treated the better is the prognosis. Treatment modalities include serial sympathetic blocks, oral steroids, and physical therapy to restore the function to the affected extremity. Early aggressive intervention is required.
This condition is caused by various etiologies such as diabetes, vitamin B12 deficiency, lead poisoning, and nutritional deficiencies. On many occasions diagnosis is not clear cut. Electrodiagnostic tests such EMG and nerve conduction studies may show degeneration of the nerves. There could be pain, numbness, and weakness. This should not be confused with problems caused by pinched nerves in the spine.
If spine surgery is performed in patients with peripheral neuropathy the outcome is bound to be poor. Peripheral neuropathy is treated by treating the underlying condition such as diabetes and nutritional deficiencies. At times medications such as Neurontin or Tergetol is helpful. Consultation with neurologist is recommended.
This condition causes numbness along the outside or the thigh or front of the thigh. Patient typically complains of groin pain and numbness in the front part of the thigh. The condition is caused by irritation or compression of the tiny nerve called lateral femoral cutaneous nerve which passes in the groin area. The causes include compression of the nerve root due to being overweight. Irritation of the nerve root during prone position spine surgery due to positioning may also be a causative factor.
The diagnosis is typically made by history and clinical physical exam and is confirmed by electrodiagnostic testing of the nerve by so called nerve conduction velocity test. It may be also confirmed by injecting numbing medicine and steroids into the area of the nerve irritation. The injection may be also used to treat the condition. Weight loss can be also helpful.
Medications such as lyrica and neurontin that make the nerve less irritable may be helpful. In the worst case scenario where the pain persists despite above conservative measures dorsal column spinal cord stimulator implantation may be tried.
Spondylolisthesis is a Greek term, and it essentially means "slippery vertebra." While the name is long and foreign, the condition it describes is a relatively common one. Spondylolisthesis occurs when one vertebra slips forward over the vertebra below it. This condition occurs most often in the lower region of the back. It can be caused by many things, which include: a weak, degenerative joint; a stress fracture created by a demanding activity or sport; a fractured vertebra caused by an accident or trauma; a disease such as arthritis; and even congenital birth defects.
The slippage that occurs in Spondylolisthesis can often irritate or pinch surrounding spinal nerve roots and produce symptoms such as tenderness, stiffness, pain, or numbness in the lower back or buttocks and weakness in one or both legs. Frequently, symptoms range from non-existent to mild, with an intermittent shock of shooting pain down the back of the leg.
Methods of Diagnosis
Typically, a medical exam and X-rays are used to diagnose the condition. In more difficult cases, other imaging tests such as MRI and CT scans may be used to pinpoint the problem area(s) and guide treatment.
Methods of Treatment
Because the scope of both the problem and symptoms can vary so widely, treatment can range from physical therapy and over-the-counter anti-inflammatory medications to a rigid back brace and, occasionally, even surgery. For those considering surgery, several minimally invasive surgical procedures are available—including an advanced lumbar spinal fusion procedure called OLLIF (oblique lateral lumbar interbody fusion) Outpatient Back Surgery.
As we get older, a lot of changes can occur to the 23 gel-like "shock absorber" discs that help separate and cushion all bones, or vertebrae, that make up our spines. In fact, nearly everyone has had a family member or a friend complain about a disc that's "slipped," "ruptured," or "bulging." But medically speaking, these words all describe the same condition: a Herniated Disc. This condition can occur whenever one of our discs becomes damaged, diseased, or begins to wear out. When this happens, it can irritate or pinch surrounding spinal nerve roots and produce a variety of painful symptoms.
Symptoms can include pain, numbness, and/or weakness wherever the affected nerve travels. By age 40, about 60% of us have some form of degenerative disc disease. Often, a Herniated Disc is associated with low back pain or pain that radiates down the leg.
Methods of Diagnosis
Typically, a basic physical or neurological exam and imaging tests, such as X-rays or MRI and CT scans, are used to diagnose a Herniated Disc.
Methods of Treatment
Initially, treatment can include rest, heating pads, ice packs, and over-the-counter pain medications. In more advanced cases, physical therapy and corticosteroid medications are used. Usually, over time, a Herniated Disc will heal on its own. In fact, only about 1 in 10 patients end up requiring surgery. For those considering surgery, several minimally invasive surgical procedures are available.
The term degenerative disease refers to the loss of normal tissue structure and function as a result of the aging process. Degenerative disease may also result in pain. Degenerative disease involves the intervertebral disc, the vertebral body, and/or the facet joint. There are many types of degenerative disease including herniated disc, radiculopathy, facet joint pathologies, cervical spondylotic myelopathy, and osteophytes (also known as bone spurs).
A healthy spine has a slight "S" curve when viewed from the side and appears straight when viewed from the front or back. People with Scoliosis develop a lateral curvature in their spines when viewed from the front or back. While some causes of Scoliosis are readily identifiable—including congenital, degenerative, and neuromuscular—other causes are not as clearly understood. Scoliosis tends to develop during the growth spurt just prior to puberty and, by age 16, about 3% of all American teenagers have some degree of Scoliosis.
Symptoms of Scoliosis can include: an uneven waist or shoulders, a prominent shoulder blade, or leaning to one side.
Methods of Diagnosis
Scoliosis is most often detected by a pediatrician, family doctor, during a school physical, or during a sports program screening exam.
Methods of Treatment
Most cases of Scoliosis are mild. In fact, many cases require no treatment at all. When necessary, treatment options can range from physio- and occupational therapy to braces and even surgery. For those considering surgery, several minimally invasive surgical procedures are available.
Vertebral Compression Fracture (VCF)
Vertebral Compression Fracture is medical terminology for a broken back (or broken vertebra). Usually, this condition is caused by a severe trauma—for example, a bad fall, severe sports injury, or car accident. However, bones made more fragile by osteoporosis, infection, or cancer can also contribute to a Vertebral Compression Fracture.
Symptoms of a Vertebral Compression Fracture can include: sudden, severe pain in the neck or in the upper or lower back; loss of height; numbness, tingling, or weakness; pain when walking, bending over, and/or twisting; difficulty with breathing; and bladder and/or bowel control issues.
Methods of Diagnosis
A medical exam and imaging tests, such as X-rays or MRI and CT scans, are typically used to diagnose a Vertebral Compression Fracture, pinpoint the damaged area(s), and guide treatment.
Methods of Treatment
Treatment for a Vertebral Compression Fracture can include: bedrest, ice packs, pain management medication, hot compresses after the first week, a back brace, and stretches and strengthening exercises. In severe cases, especially if nerves or multiple vertebrae are involved, back surgery may be necessary. For those considering surgery, several minimally invasive surgical procedures are available.
What may be causing pain in the following areas:
- cervical disc degeneration
- cervical kyphosis--malalignement or deformity as in ankylosing spondylitis
- cervical facet arthropathy
- C1 C2 facet arthropathy
- whiplash injury or soft tissue neck injury
- infection such as discitis
- instability such as degenerative spondylolisthesis
- herniated cervical disc
- cervical stenosis foraminal or central
- RSD or reflex sympathetic dystrophy or regional pain syndrome
- Brachial plexopathy viral or idiopathic
- rotator cuff syndromes such as impingement syndrome
- lung cancer pressing on brachial plexus such as Pancost tumor
- peripheral neuropathy, either nutritional or toxic or metabolic
- peripheral entrapment syndromes such as cubital tunnel syndrome or carpal tunnel syndrome
- neurological disease such as multiple sclerosis
- lack of blood circulation to arms such as Reynaud's phenomena or blockage of arteries and veins of arms
- tumor of arm
- fracture of arm
- infection of arm
- Juvenile Discogenic Disease with multiple Schmorl's node formation
- Scheurman's Disease
- fractures such as senile osteoporotic compression fractures
- thoracic disc herniation
- thoracic spinal stenosis
- thoracic facet arthropathy
- scoliosis or other deformities
- tumor either benign or malignant
- infection of bone or disc space
- referred pain from cervical spine
Low back pain
- lumbar disc degeneration such as in Juvenile Discogenic Disease
- lumbar facet arthropathy
- severe central stenosis
- deformity such as in flatback syndrome
- annular tear
- painful bulging disc such as lumbar discogenic low back pain syndrome
- instability such as in isthmic or degenerative spondylolisthesis
- infection of disc space or vertebra
- soft tissue injuries to low back such as in car accidents
- disc herniation such as central disc herniation
- lumbar disc herniation
- lumbar stenosis
- ischemia to leg due to lack of circulation
- entrapment of nerves in the legs such as tarsal tunnel syndrome or at the fibular head
- RSD or reflex sympathetic dystrophy
- compartment syndrome either chronic or acute
- degenerative joint disease of hips and knees
- peripheral neuropathy either nutritional toxic or metabolic
- thoracic disc herniation can cause pseudoradicular leg pain
- cervical disc herniation with spinal cord pressure in the anterolateral tract can cause leg pain
- fractures such as stress fractures or femur
- neurological disease such as multiple sclerosis
- nerve damage from previous spine surgeries
- Reynaud's phenomenon with spasm of arteries in legs when exposed to cold
- venous stasis
- malpositioned pedicle screws