Welcome to our educational library. Here you will find helpful, easy to understand information that you can access at your convenience. The information provided herein should not be used as a substitute for medical advice in any way. A licensed medical professional should be consulted for any and all medical conditions and symptoms.
Degenerative Disc Disease
Degenerative disc disease refers to when the disc itself is the source of back pain or neck pain as a result of a damaged and degenerative disc. Degenerative disc disease may be treated with medications, ice/heat, active physical therapy/exercise, or behavioral and lifestyle changes, or require spinal fusion or artificial disc replacement surgery for uncontrollable, severe pain that has not responded in time to previous non-surgical care and when an anatomical cause of the pain has been identified.
- Degenerative Disc Disease Health Center
- What Is Degenerative Disc Disease?
- Degenerative Disc Disease Video
A herniated disc can produce lower back pain and/or leg pain (sciatica) or less often neck pain and/or arm pain as a result of the disc’s soft, inner core extruding through its tough, outer core, and coming in contact with and irritating a nearby spinal nerve. A herniated disc may be effectively treated with pain medications, injections, chiropractic care, physical therapy and exercise, or require surgery for symptoms that have been unresponsive to non-surgical care.
- Herniated Disc Health Center
- What’s a Herniated Disc, Pinched Nerve, Bulging Disc…?
- Lumbar Herniated Disc Video
- Cervical Herniated Disc Video
Sciatica describes symptoms of leg pain and possible tingling, numbness or weakness that travels from the lower back down the sciatic nerve in the back of the leg, often as a result of a pinched nerve from a herniated disc or other conditions like degenerative disc disease, spinal stenosis or spondylolisthesis. Sciatica symptoms may be treated with heat/ice, over-the-counter or prescription medications, epidural steroid injections, acupuncture, massage therapy, manual manipulation, physical therapy or exercise, or require surgery for severe pain that has not responded to non-surgical care.
Spinal stenosis can produce leg pain, tingling, weakness or numbness, or arm pain as a result of compression of the spinal nerve roots in the lumbar spine (lower back) or the spinal cord in the cervical spine (neck), respectively. Spinal stenosis is often managed through non-surgical treatments like exercise, epidural injections, non-steroidal anti-inflammatory drugs (NSAIDs) and activity modification, but can require a decompression surgery for symptoms that have not improved following non-surgical care.
- Spinal Stenosis Health Center
- Spinal Stenosis: Symptoms, Diagnosis and Treatment
- Spinal Stenosis Video
Spondylolisthesis refers to when one vertebral body slips forward over another, often as a result of a defect in a small segment of bone (the pars interarticularis) that joins the facet joints in the back of the spine, possibly leading to back pain and leg pain that restricts normal activity levels. Another common cause of spondylolisthesis is degeneration within the facet joints (degenerative spondylolistheisis). Typically recommended treatments for spondylolisthesis include non-surgical care like bracing that immobilizes the spine for short periods of time, pain medications and/or anti-inflammatory medications, hamstring stretches and other controlled, gradual exercises. Surgery combining a decompressive laminectomy with a spinal fusion is rarely needed for spondylolisthesis symptoms that are not healing or have neurological components.
- Spondylolisthesis Health Center
- Isthmic Spondylolisthesis
- Degenerative Spondylolisthesis
- Spondylolisthesis Video
Scoliosis is an abnormal curvature of the spine that usually occurs in adolescents and develops in the upper back or in the area between the upper back and lower back. Most cases of scoliosis have no known cause and may go unnoticed until the curve has significantly progressed. For adolescents, scoliosis treatment typically includes simple observation and/or the use of back braces that are designed to stop the curve. A corrective surgery from the anterior or posterior of the spine is usually only recommended for adolescents with curves that are more than 40 to 45 degrees and progressing.
Osteoporosis and Vertebral Fractures
Osteoporosis is a thinning of the bones that occurs with aging (more often in women than men, especially after menopause), leaving the bones porous, fragile and susceptible to vertebral fractures that are frequently dismissed as general back pain. Osteoporosis is treatable with non-surgical treatments like exercise, medications and education on diet and nutrition aimed to slow bone loss and prevent fractures. Osteoporotic vertebral fractures may be treated with rest, rigid back braces that support the spine, ice and heat, pain medications or surgeries such as kyphoplasty or vertebroplasty when the fracture is causing severe pain and deformity and has failed to respond to non-surgical care.
- Osteoporosis Health Center
- The Definitive Guide to Osteoporosis
- When Is Back Pain A Fracture?
- Osteoporosis Video
Osteoarthritis is a very common form of arthritis that occurs when the cartilage between aligning facet joints in the back portion of the spine mechanically breaks down over time, leading to common symptoms like inflammation, stiffness and pain in these joints, and possibly resulting in bone spurs that irritate or trap the spinal nerves. Non-surgical care such as medications, exercise, physical therapy and chiropractic is typically the first line of osteoarthritis treatment. In rare cases, osteoarthritis may require a spinal fusion surgery when the joint is severely unstable or a lumbar laminectomy surgery when the spinal nerves are affected.
Over-the-counter and prescription pain medications are one of the most common non-surgical treatments for temporary relief of spinal conditions that cause both acute and chronic back pain and/or neck pain. Pain medications may include acetaminophen (Tylenol), NSAIDS (non-steroidal anti-inflammatory drugs like ibuprofen, naproxen and celebrex), oral steroids, muscle relaxants, narcotic drugs and anti-depressants.
- Pain Medications Health Center
- Pain Medications for the Back and Neck
- Cold Therapy for Back Pain Relief
- Heat Therapy for Lower Back Pain
Heat and Cold Therapy
Heat and cold is commonly used separately or in combination as part of professional or at-home, non-surgical treatments of back pain, neck pain and other symptoms related to the spine. Cold therapy works to slow inflammation and swelling, numb sore tissues, slow nerve impulses in injured areas and decrease tissue damage. Heat therapy works to stretch the soft tissues; increase the flow of blood, oxygen and nutrients to the muscles; stimulate the skin’s sensory receptors; decrease transmission of pain signals; and accelerate the body’s natural healing processes.
Exercise, as opposed to resting, is most often a more necessary and effective non-surgical treatment for rehabilitating the spine and reducing related back pain and neck pain. While stretching, strengthening and low-impact aerobics exercises are often a part of exercise programs for sciatica, herniated discs, degenerative disc disease, spinal stenosis and other spine conditions, it is generally advised to check with your doctor first and an exercise professional trained in your specific spine disorder.
Physical therapy is a non-surgical treatment option for spine conditions that have impaired or immobilized movement and flexibility, and involves guidance from a physical therapist who teaches patients how to use their own muscles to improve flexibility, range of motion, muscular strength and endurance. Physical therapy can include the use of modalities like hot packs, TENS units and ultrasound (described as passive physical therapy), incorporate different stretching, strengthening and aerobic conditioning exercises (active physical therapy), or utilize the practitioner’s hands to put pressure on and manipulate the joints and muscles (manual physical therapy).
Chiropractic is a drug-free, non-surgical healthcare profession that traditionally treats back pain, neck pain, sciatica, osteoarthritis, herniated discs and other spinal conditions via manual therapy involving manipulation or mobilization of the spine with the goal of providing effective pain relief and stimulating the body’s natural healing processes. Chiropractic care has expanded beyond spinal adjustments to include other evidence-based treatments that incorporate physical modalities, exercise, nutrition and postural programs.
Injections are a more aggressive form of conservative treatment that can be used to help relieve pain by allowing the patient to more fully participate in a rehabilitative program. They may also serve as a diagnostic tool that identifies the source of the pain or a pain relief provider that directly delivers medications to those areas of the spine responsible for the patient’s symptoms. Epidural steroid injections, medial branch nerve blocks, radiofrequency neurotomy and prolotherapy are just some examples of injections that may be used in the non-surgical treatment of back pain and neck pain.
- Cervical Herniated Disc Video
- Cervical Spinal Stenosis Video
- Degenerative Disc Disease Interactive Video
- Discography Video: Non-Surgical Back Pain Diagnostic Procedure
- Kyphosis Video: What is Kyphosis?
- Lumbar Herniated Disc Video
- Metastatic Cancer Video
- Osteoarthritis of the Spine Video
- RACZ Caudal Neurolysis Video
- Sciatica Causes and Treatments Video
- Sciatica Interactive Video
- Scoliosis Video: What is Scoliosis?
- Spinal Infection Video
- Spinal Stenosis Symptoms and Diagnosis Video
- Spine Anatomy Interactive Video
- Spondylolisthesis Symptoms and Causes Video
- Thoracic Spinal Stenosis Video
- Back Pain Video: When Should I See a Doctor for Treatment?
- Coccydynia (Tail Bone Pain) Video
- Degenerative Disc Disease Interactive Video
- Video: Is Spinal Stenosis Causing My Leg Pain?
- Kyphosis Video: What is Kyphosis?
- Lumbar Herniated Disc Video
- Metastatic Cancer Video
- Osteoarthritis of the Spine Video
- Osteoarthritis Video: Inflammation, Pain and Treatment Options
- Osteoporosis Video: Diagnosis and Treatment of Painful Spine Fractures
- Sciatica Causes and Treatments Video
- Sciatica Interactive Video
- Scoliosis Video: What is Scoliosis?
- Spinal Infection Video
- Spinal Stenosis Symptoms and Diagnosis Video
- Spine Anatomy Interactive Video
- Spondylolisthesis Symptoms and Causes Video
- Thoracic Spinal Stenosis Video
- Treatment for Back Pain Flare-Ups Video
- Video: What is Neuralgia?
- Cervical Epidural Steroid Injection Video
- Cervical Facet Radiofrequency Neurotomy Video
- Cervical Selective Nerve Root Block Video
- Cervical Transforaminal Epidural Steroid Injections Video
- Costovertebral Block Video
- Epidural Steroid Injections for Back Pain and Leg Pain Video
- Facet Joint Injections for Back Pain Relief Video
- Lumbar Sympathetic Block Video
- Medial Branch Block Video
- Myelography-Myelogram Video
- RACZ Caudal Neurolysis Video
- Sacroiliac Joint Steroid Injection Video
- Trigger Point Injections Video
A cervical discectomy may be performed when a herniated disc pinches a nerve in the neck and non-surgical treatment has not resulted in sufficient relief. The primary symptoms of a cervical disc herniation are usually numbness, weakness and/or pain in the arm, and/or neck pain. The goal of the cervical discectomy is to remove the disc that is pinching the nerve, eliminating the cause of the pain and numbness.
The surgical approach is through the front of the neck which provides exposure from the second cervical vertebrae to where the cervical spine meets the thoracic spine.
The discectomy is commonly done in conjunction with an anterior cervical fusion, which involves placing bone graft/intervertebral spacer into the disc space between the vertebrae. The bone graft helps the vertebrae above and below it grow into a single unit. This ‘fusion’ prevents local deformity (kyphosis), and helps prevent collapse of the disc space, thereby providing adequate room for the nerve roots and spinal cord.
Most cervical fusions are performed between the C5-C6 levels or C6-C7 levels. Fusion surgeries are most effective when they involve only one vertebral segment. Since two vertebral segments need to be fused to stop the motion, a C5-C6 fusion would be a one level fusion. Multilevel fusion may be necessary in cases of severe instability/or multilevel spinal stenosis but most cases require only a one or two level fusion.
Indications for anterior cervical discectomy
Surgery is generally considered for patients who have not responded to six to twelve weeks of non-surgical treatment (such as medications, physical therapy), or acutely in those patients with severe arm pain. Generally, if the pain starts to subside during this period of time, continued non-surgical treatment is advisable. Surgery is more for the arm pain than for the numbness/weakness. Pain is a result of pinching or the nerve, and if the pain resolves, one can assume that the nerve is in a good healing position and will heal with time, leading to partial or complete resolution of the numbness/weakness.
Overall, reports reveal a significant improvement of symptoms for most patients who undergo an anterior cervical decompression and fusion. For example, 95-98% of patients will experience significant relief of their arm pain. Relief of neck pain is not quite as reliable. The limited amount of muscle dissection helps limit postoperative pain. There is little chance of the disc herniation recurring following this surgery because most of the disc is removed during the operation.
The surgery is much more reliable for alleviating arm pain, or arm pain combined with other symptoms, than for neck pain alone (such as neck pain from degenerative disc disease).
An anterior cervical discectomy is a relatively common surgery that follows an established process to remove the affected disc.
- The skin incision is about one inch, horizontal and can be made on the left or right hand side of the front of the neck to establish a path to the disc.
- The disc causing the pain is then identified by inserting a needle into the disc space and doing an x-ray to confirm that the surgeon is at the correct level of the spine.
- The disc is removed by first cutting the outer annulus fibrosis (fibrous ring around the disc) then removing the nucleus pulposus (soft inner core of the disc).
- The nerve root is then decompressed directly by removing any disc material or bone spurs.
- Using the same incision, bone graft or an intervertebral spacer is then inserted into the space between the vertebral bodies where the disc used to be. Over the course of several months (3 to 18 months), the patient’s own bone will grow into and around the bone graft/intervertebral body spacer and incorporate the graft as its own. This process creates one continuous bone surface between the two vertebrae.
- An anterior cervical plate is used in many cases for further stabilization. It is a small, thin plate that is applied to the front of the vertebral bodies above and below the graft. Two screws hold the plate onto each of the vertebral bodies.
There are several bone graft options for the fusion:
- Autograft bone. The bone is taken from the patient’s hip, but the extra incision required can cause postoperative pain and increase surgical complications.
- Allograft bone. No additional incision is required, but fusions are generally slower to set-up than with autograft bone. They eventually yield success rates equivalent to autograft bone in one level fusions. To enhance the healing rate – especially if more than one level is fused – allograft may be combined with anterior plating of the spine, which yields a fusion rate equivalent to autograft bone.
- Bone graft substitutes and support instrumentation. Although synthetic bone products are not FDA-approved specifically for an anterior cervical interbody fusion, there are products that mimic the structure of bone and are especially effective when combined with bone marrow aspirate taken through a needle from the iliac crest.
Potential risks and complications:
Anterior cervical discectomies can result in the following potential complications:
- Temporary difficulty in swallowing (common but usually not severe)
- Temporary hoarseness (1%)
- Bleeding or infection (very rare)
- Damage to the trachea/esophagus (extremely rare)
- Continued pain
- Nerve root damage (about 1 in 10,000 chance)
- Damage to the spinal cord (about 1 in 10,000 chance)
Anterior cervical fusions can result in continued pain if the fusion does not fuse completely, requiring surgery to re-fuse the segment. Other complications include:
- Bone graft dislodgment or extrusion if instrumentation is not used (1 – 2%)
- A slight risk or infection if allograft (cadaver) bone is used for the fusion
After fusion surgery, it can take three to six months (and sometimes up to 18 months) for the fusion to successfully set up. During the first weeks to months, patients’ activities may be restricted so that the bone graft will not be put at risk. After initial maturity of the fusion is clear, restrictions will be relaxed and permanent restrictions are generally not needed or advisable, since the bone graft will get stronger with some level of stress.
The use of cervical braces after surgery is variable and is dependent mostly on the recommendations of the particular surgeon. After initial maturity of the fusion is clear, restrictions will be relaxed and permanent restrictions are generally not needed or advisable, since the bone graft will get stronger with some level of stress. The use of cervical braces after surgery is variable and is dependent mostly on the recommendations of the particular surgeon.
Cervical degenerative disc disease can be caused by a twisting injury to a disc space in the cervical spine. This can begin the degenerative process and lead to chronic neck pain. This degenerative condition is less common in the cervical spine than in the lumbar spine because there is substantially less torque and force across the cervical section of the spine.
It should be noted that the term degenerative disc disease is somewhat misleading. Although the disc will be likely to continue to degenerate with age, that does not mean the pain will worsen. In fact, the pain will usually diminish over time. Also, it is not really a disease, but instead it is a condition that will sometimes (but not always) cause pain resulting from a damaged disc or natural aging.
This disc degeneration is very common and will occur in most people as they age; however, not all will experience symptoms. In addition to natural occurrence of disc degeneration due to aging, other factors that can contribute to degenerative disc disease are:
- Poor nutrition
- Atherosclerosis (hardening and narrowing of the arteries)
- Physical activities
The main symptom of cervical degenerative disc disease is neck pain. Of course, there are many things that can cause neck pain, so having this symptom does not automatically indicate this condition. A patient with this condition can also experience some radicular pain (pain that radiates) in the arm and shoulder.
Most people will undergo some degree of degeneration of their discs as they grow older, simply as a function of aging, sometimes exacerbated by their lifestyle. However, not everyone with degenerative discs will experience symptoms.
Degenerative disc disease can often be seen with a Magnetic Resonance Imaging (MRI) scan. The MRI is very specific for diagnosing degenerative disc disease. A CT myelogram (CT scan and injected dye) may sometimes also be ordered if nerve root pinching is suspected from a disc herniation (disc material extrudes out and “pinches” or presses on a cervical nerve) or stenosis (narrowing of the cervical disc space) but is not well visualized on the MRI scan.
An imaging scan may show degeneration of a disc in a patient who isn’t experiencing any symptoms. Seeing normal degeneration due to aging is very common, and does not indicate a problem unless neck or shoulder pain or stiffness is being experienced. Therefore, a diagnosis of this condition must include a good history of the patient’s symptoms and a physical examination in conjunction with the imaging scan. As a matter of fact, myofascial pain syndromes such as fibromyalgia are more likely to cause chronic neck pain than degenerative disc disease of the cervical spine. The symptoms have to be well correlated with any imaging findings before a diagnosis can be confirmed.
The physician will probably also do a neurological examination to determine if there is any neurological damage, and also a study of the shoulders to be sure the pain isn’t originating there instead of in the spine.
Treatment for cervical degenerative disc disease
Treatment for cervical degenerative disc disease will usually be non-surgical. However, if conservative treatment fails, surgery may be a reasonable option. Surgery for neck pain is much less reliable than surgery for arm pain, as it is sometimes difficult to tell what is generating a patient’s neck pain. Nerve root compression causing arm pain is a more accurate diagnosis.
Conservative (non-surgical) treatments
The conservative treatment options are either passive (done to the patient) or active (done by the patient). Usually a combination of treatments will be used, as passive treatments are rarely effective on their own-some active component is almost always required.
Common passive treatments include:
- Medications. Over-the-counter pain medicine such as acetaminophen (e.g. Tylenol) can help decrease pain and can be used in conjunction with an anti-inflammatory medication such as ibuprofen (e.g. Advil, Nuprin and Motrin).
- Chiropractic/osteopathic manipulations. These can be useful to relieve joint dysfunction that can be associated with the pain. Manipulations work best when combined with an active exercise program.
- Epidural injections. Epidural injections can be used to help decrease inflammation when there is severe pain. The injection is done by inserting a needle into the space around the thecal sac (epidural space) and then injecting a steroid medication. This helps reduce inflammation in the spinal canal and can reduce pain in about 50% to 70% of patients. The injection should be used as part of rehabilitation, as the pain relief can allow the patient to begin an exercise and physical therapy program. If the injection works, but the pain returns, it can be repeated up to three times in a 6-month period.
- Trigger point injections. Tender areas in the muscles can be injected with a small needle and lidocaine to relieve muscular stress and tension, which should relieve the tenderness.
- TENS units. Transcutaneous Electrical Stimulation (TENS) units can be used to provide electrical stimulation to the painful areas of the back. A low current electrical charge is transmitted to the skin. Although the mechanism for how this relieves pain is not exactly known, it has been proven effective for some patients and allows them to function better with less medication. It is suspected that the electrical signals help override the pain signals.
In addition, traction may be useful and a home traction unit may be prescribed for use at home.
Common active treatments include:
- Physical therapy. Exercises and stretching can be very helpful in strengthening and stabilizing the affected area, thus reducing pain. It is very important, however, to work with a professional health provider on the appropriate exercises as each person responds differently, and what helps one person may actually harm another.
- Quitting smoking. It has been proven that there is a link between smoking and the ability for the spine to heal. Since there is no benefit to smoking, quitting is highly advisable.
Rarely, a one (or possibly two) level fusion may be required to help control symptoms and allow a patient to function more fully. This should only be considered if non-surgical treatments have failed, and the pain the patient is experiencing is severe enough to limit his or her activity level or ability to function.
The goal of this surgery is to stop the motion at a painful motion segment. A small metal plate and a bone graft are placed between the affected vertebrae of the spine. As the bone fuses together, the spine stabilizes in that area and eliminates the movement, which in turn should decrease the patient’s pain.
A cervical disc herniation can be a cause of pain that radiates down the arm, sometimes accompanied by numbness and tingling down into the fingertips, and sometimes muscle weakness as well. It usually develops in men and women between 30 and 50 years old. This is one of the most common cervical spine conditions treated by spine specialists. The herniated disc may occur from an injury or trauma to the spine, but it most commonly is a spontaneous development.
The arm pain occurs as a result of a disc in the cervical spine (the neck) pinching or pressing on a nerve, which causes pain to radiate down that nerve. Most cervical disc herniations extrude out to the side of the spinal canal and pinch the exiting nerve root at the next lower level of the spine.
Depending on which part of the cervical spine is affected, any of the following may be symptoms of a cervical disc herniation:
- Weakness in the deltoid muscle in the upper arm
- Weakness in the biceps (muscles in the front of the upper arms) and wrist extensor muscles
- Weakness in the triceps (muscles in the back of the upper arm and extending to the forearm) and the finger extensor muscles
- Weakness with handgrip
- Numbness and tingling along with pain can radiate to the thumb side of the hand, down the triceps into the middle finger, or down the arm to the little finger side of the hand
- Shoulder pain
This list covers some of the typical symptoms, but others may also occur. It is possible to have a cervical disc herniation with symptoms completely different from these.
Discs in the cervical spine are usually not very large. However, even a small disc herniation can pinch the nerve and cause pain. The pain is usually greatest when the nerve is first pinched.
Since the symptoms vary widely, often, the best way to correctly diagnose a cervical disc herniation is with a diagnostic imaging test such as the following:
1. MRI Scan
- The best test to use is an MRI (Magnetic Resonance Imaging) scan. An MRI scan can usually see any nerve root pinching caused by a herniated cervical disc.
2. CT Scan with Myelogram
- A CT (computed tomography) scan with myelogram may also be ordered, because it is more sensitive than the MRI and can see subtle pinching that might be hard to see on an MRI. This test is not usually the first one ordered because an injection is required to place an imaging dye into the patient. Therefore, it is best to try an MRI first in order to see if that will be enough. CT scans without myelogram will not do much good for diagnosing this condition so are not used.
- Occasionally, an EMG (Electromyography) may also be used. This is an electrical test that stimulates specific nerves to see if certain muscles may have been affected from a pinched nerve, which could indicate cervical disc herniation.
The pain from a cervical herniated disc can usually be controlled with medication, and conservative (non-surgical) treatments alone are often enough to resolve the condition.
Treatment is designed to resolve the pain initially, and the weakness, numbness and tingling will go away over time. Once the pain starts to improve it doesn’t usually return. It may be a little while before the other symptoms go away, but if the pain is under control there is no reason to move to a more aggressive (surgical) treatment, as there is no evidence that surgery helps the nerve root heal any faster. However, for patients with profound weakness due to a disc herniation, it may be reasonable to consider surgery earlier to give the nerve the best healing position (e.g. to relieve the pinching).
Generally, treatment will begin very simply with rest and medication. Anti-inflammatory medications such as ibuprofen (e.g. Advil, Nuprin or Motrin) or COX-2 inhibitors (e.g. Bextra or Celebrex) can help reduce the inflammation of the disc material, which will help reduce the amount of pain. If pain is severe, or continues for more than two weeks, stronger medication such as oral steroids may be considered.
While the medications diminish the amount of pain, if the condition doesn’t resolve on its own, there are several options that can be considered:
- Physical therapy for exercises to help relieve the pressure on the nerve root.
- Chiropracticor osteopathic treatments for gentle, low velocity manual manipulation to help relieve the pressure on the nerve root. However caution should be used with manipulation if the patient is experiencing any neurological problems.
- Manual traction to help open up the cervical foramen where the nerve root exits the spinal canal. If this therapy helps relieve the pain, a home traction unit can be prescribed. Traction should be initiated under a physical therapist’s supervision.
- Epidural injections may be considered if the pain doesn’t get better with medication and physical treatments. Epidural injections effectively relieve pain approximately 50% of the time, and if they do work they may be repeated every two weeks up to a total of three times within one year.
Most episodes of pain from cervical disc herniation will be taken care of with 6 to 12 weeks of conservative treatment. However, if it doesn’t get better in that time or if the pain is very severe, surgery may be considered. The success rate for using surgery to relieve arm pain from a cervical disc herniation is about 95 to 98%. Risk of complication is low with an experienced spine surgeon.
The disc may be removed from the back of the neck (posterior approach) or from the front (anterior approach). Generally, surgeons prefer the anterior approach for most cervical disc herniations.
- Anterior approach-This approach may be favored if there is any disc space collapse, as the approach allows the surgeon to open up the disc space and place a bone graft to keep it open. This procedure opens up the foramen, which gives the exiting nerve root more room.
- Posterior approach-This approach may be favored for a large soft disc that is lateral (to the side of) the canal. This approach is technically more difficult than the anterior approach, and also requires more manipulation to the spinal cord.
Both surgeries can usually be done with an overnight stay in the hospital.
An epidural steroid injection is a non-surgical treatment typically used to alleviate chronic low back and/or leg pain. While the effects from the injection tend to be temporary, providing relief from pain for one week to one year, an epidural can be very beneficial for patients during an episode of severe back pain. One important use is to provide sufficient pain relief to allow the patient to start (or progress in) a rehabilitation program.
An epidural injection significantly reduces pain for approximately 50% of the patients that receive one. It works by delivering steroids directly to the painful area to help decrease the inflammation that may be causing the pain. It is thought that there is also a flushing effect from the injection that helps remove or “flush out” inflammatory problems from around the structures that may cause pain.
As a disc degenerates, the inner core of the disc can extrude-or herniate-back into the spinal canal. The herniated disc material can irritate the nerve, which can cause pain to radiate down the path of the nerve-from the lower back through the buttocks and into the leg or even into the foot.
What is an epidural?
An epidural is an injection that delivers steroids directly into the epidural space. The epidural space is the space between the dura mater (a membrane) and the vertebral wall and is filled with fat and small blood vessels. It is located just outside the dural sac. The dural sac surrounds the nerve roots and cerebrospinal fluid (the fluid that the nerve roots are bathed in).
There are often inflammatory factors and other substances that generate pain (e.g. substance P) that are associated with lumbar disc herniation and this inflammation can cause significant nerve root irritation and swelling.
Steroids (corticosteroids) have been shown to reduce inflammation by inhibiting the production of substances that cause inflammation; the epidural injection can be highly effective because it delivers the medication directly to the site of inflammation.
When is an epidural recommended?
In general, epidural injections are used to help provide pain relief to enable patients to progress with their rehabilitation. Individuals who have less pain and feel more comfortable are generally able to work on the active therapies-such as stretching, strengthening and pain relief exercises and low impact aerobic conditioning-that are critical in rehabilitating the lower back.
Several common conditions-including lumbar disc herniation, degenerative disc disease, and lumbar spinal stenosis-can cause severe acute or chronic low back and/or leg pain. For these and other conditions that can cause chronic pain, an epidural steroid injection may be an effective non-surgical treatment option.
What are the benefits?
The benefits of the epidural steroid injections include a reduction in pain, primarily in leg pain. If a patient does not experience any pain relief from the first injection, further injections will probably not be beneficial. However, if there is some improvement in pain, one to two additional injections may be recommended.
The epidural steroid injection usually takes about 15 to 30 minutes to complete. The patient may sit and lean forward, or lie on his or her stomach or side with the back arched. Prior to the injection, the skin is numbed with lidocaine, a local anesthetic similar to the novacaine used by dentists. Then the physician will locate the appropriate spot for the injection.
Using fluoroscopy (live x-ray) for guidance, the physician directs a needle toward the epidural space. Fluoroscopy is considered important in guiding the needle into the epidural space, as controlled studies have found that medication is misplaced in 13% to 34% of epidural injections that are done without fluoroscopy. Once the needle is in the exact position, steroid solution is injected. At times a flushing solution, such as lidocaine or normal saline, is also used to help “flush out” inflammatory proteins from around the area that may be the source of pain.
Following the injection, the patient is usually monitored for 15 to 20 minutes before going home. Typically, patients are asked to rest on the day of the injection and allowed to return to their normal activities on the following day.
Potential risks and side effects
With all invasive medical procedures, there are potential risks. Generally, however, there are few risks associated with epidural injections and they tend to be rare. Risks may include:
- Infection. Minor infections occur in 1% to 2% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
- Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders.
- Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or secondarily from infection or bleeding.
- Dural puncture (“wet tap”). A dural puncture occurs in 0.5% of injections. It may cause a post-dural puncture headache (also called a spinal headache) that usually gets better within a few days. Although rare, a blood patch may be necessary to alleviate the headache.
Paralysis is not a risk since there is no spinal cord in the region of the epidural steroid injection.
In addition to risks from the injection, there are also potential risks and side effects from the steroid medication. These side effects tend to be rare. Risks and side effects may include:
|•||A transient decrease in immunity||•||Transient flushing|
|•||High blood sugar||•||Increased appetite|
|•||Stomach ulcers||•||Severe arthritis of the hips (avascular necrosis)|
Lumbar epidural steroid injections should not be performed on patients who have a local or systemic bacterial infection, are pregnant (if fluoroscopy is used) or have bleeding problems. Epidurals should also not be performed on patients whose pain is from a tumor or infection, and if suspected, an MRI scan should be done prior to the injection to rule out these conditions. Injections may be done, but with extreme caution, for patients with allergies to the injected solution, uncontrolled medical problems (such as congestive heart failure and diabetes), and those who are taking aspirin or other antiplatelet drugs (e.g. Ticlid, Plavix).
Spondylolisthesis is the Latin term for a slipped vertebral body, and Isthmic refers to the fact that the slip is due to a stress fracture through a piece of bone in the back (the pars interarticularis). Approximately 5% of the population experiences a stress fracture in the lowest lumbar vertebral segment (L5), usually between the ages of five and seven. That segment then slides forward, encroaching on the first sacral vertebral body (S1). This is almost never due to an injury. The L5-S1 segment is the most likely to slip but it can also occur at L4-L5 or L3-L4.
This condition is the leading cause of back pain in adolescents, though most adolescents that have the condition will not experience any back pain because of it. It is not a very dangerous condition as there are almost never any neurological problems associated with it.
Probably 80% of people who have this condition never have any symptoms, and therefore never even realize they have it. For those who do develop low back pain, the cause may be from the vertebrae sliding forward and compressing a nerve or from resulting disc degeneration. With the bony segments of the spine not working properly the disc has to work harder. The disc is designed to work very well under normal compression, but the forward force applied to the disc in the case of spondylolisthesis can cause the disc to break down.
In addition to the low back pain, some patients also experience leg and foot pain due to the nerve being pinched (almost always the L5 nerve). This leg pain will generally be worse when the patient stands or walks. Pain can also come from the fracture, and the tissue in that area may become irritated and painful. Within the pars interarticularis the nerve endings (nociceptors) can become sensitized and create pain. Most of the pain will be activity related. Pain with rest is not typical.
If, upon physical exam, symptoms indicate a possible isthmic spondylolisthesis, an imaging study will be needed to confirm the diagnosis. Isthmic spondylolisthesis can be seen on a regular X-ray, and on a Magnetic Resonance Imaging (MRI) scan. As noted, the spondylolisthesis will almost always occur at the juncture of the L5 and S1 vertebral segments, so that is where the most attention will be focused on the images. The imaging study can also detect if there is degenerative disc disease leading to a nerve root being pinched.
Treatment need only be considered if the pain limits the patient’s pain to any great extent. It is not a dangerous situation, and the pain is generally not progressive.
If a patient who has isthmic spondylolisthesis is being limited in activity to an unacceptable point, some form of treatment may be reasonable. Usually a non-surgical course of treatment will be recommended, and only if that is unsuccessful will the more aggressive surgical treatment be considered.
Conservative (non-surgical) treatments
Conservative treatment methods are designed to reduce the level of pain being experienced. Although it may not make the patient pain free, if it helps manage the pain and allows the patient to be more functional it should be considered successful. Attempts at controlling the pain may include the following:
- Rest. This would probably be limited to no more than a few days, to see if it helped alleviate the symptoms.
- Anti-inflammatory medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (e.g. Advil, Motrin, or Nuprin) and naproxen (e.g. Aleve or Naprosyn) can be used to reduce swelling and inflammation that may be causing pain in the affected area. Stronger therapies, such as oral steroids or epidurals, may be prescribed to treat severe flare-ups if needed.
- Pain reducing medications. Acetaminophen (e.g. Tylenol) can be used to reduce the pain. Because it acts in a different way than the anti-inflammatory drugs, the two types may be used together, and are often very effective when used that way. If the pain is severe, the doctor might prescribe a stronger medication such as codeine for short-term use.
- Physical therapy and exercise. With proper exercise and therapy the muscles around the affected area can be strengthened, which can reduce the amount of movement which causes pain.
- Injections. Depending on which structures is thought to be producing the pain, a pars interacticularis, selective nerve root, or epidural injection may considered to reduce the pain and allow the patient to progress further with their rehabilitation.
In some cases, conservative treatments are not enough to relieve the pain to a degree where the patient can maintain an acceptable level of activity. In those instances a surgical remedy might need to be considered.
The pain in isthmic spondylolisthesis is caused from the vertebrae sliding forward and a nerve being compressed. To successfully relieve this pain, the surgery needs to remove the pressure on the nerve and then fusing. If the motion is eliminated in a painful motion segment the pain should subside.
Spinal fusion involves using a bone graft and attaching it to the spine, often using instrumentation such an anterior cage and/or screws or rods. The bone graft can be taken from the patient’s hip (autograft bone) during the fusion surgery, or taken from cadaver bone (allograft bone). Bone graft substitutes may also be used. Over the course of about three months the bone will grow together and functionally spot weld the two vertebral bodies together. During that period of time the patient’s activity level should be limited to allow the bone to grow. Once it has grown together, activity will actually help the bone remodel. Bone is a live tissue, and when stressed it will become stronger.
The L5-S1 level does not move that much, so fusing it together does not change the biomechanics in the back all that much. Generally, after the fusion has taken, no activity restrictions are necessary, and the patient may do their activities as tolerated. They should also not notice any decrease in the range of motion of their back.
It should be noted that with any spine fusion surgery, one of the risks of the procedure is that despite a successful fusion the patient’s pain does not go away. However, a fusion procedure for an Isthmic Spondylolisthesis tends to be a very reliable procedure, and 90-95% of patients will be able to function better with less pain after they have healed.
Lumbar degenerative disc disease is a common cause of chronic lower back pain. This occurs when a disc weakens, often due to either general wear and tear or a torsional (twisting) injury to the disc space. The result is excessive micro-motion at the corresponding vertebral level because the disc cannot hold the vertebral segment together adequately. The resulting micro-motion, combined with the inflammatory proteins inside the disc that become exposed and irritate the local area, can create lower back pain.
There is some confusion over the term “degenerative”, which implies that the symptoms will worsen with age. Although the disc degeneration will likely progress, the symptoms (pain) that result from it typically does not worsen, but in fact usually gets better over time. A fully degenerated disc no longer has any inflammatory proteins and usually collapses into a stable position. While many people over the age of 60 have degenerated discs, it is highly uncommon for them to suffer from pain caused by this condition. The end stage of the disc degeneration is re-stabilization as the disc stiffens, and this can lead to less pain. It is, however, a process that typically takes many years (as much as 20-30 years).
The typical individual with degenerative disc disease is an active and otherwise healthy person who is in their thirties or forties.
- 1. The pain is generally made worse with sitting, since in the seated position the lumbosacral discs are loaded three times more than when standing
- 2. Certain types of activity will usually worsen the pain, especially bending, lifting and twisting
- 3. Walking, and even running, may actually feel better than prolonged sitting or standing
- 4. Patients will generally feel better if they can change positions frequently, and lying down is usually the best position since this relieves stress on the disc space
- 5. The degree of pain will usually fluctuate and may be quite painful at times (e.g. for a few days, or weeks) and then subside to a more tolerable level
In addition to low back pain, there may be leg pain, numbness and tingling. Even without pressure on the nerve root (a “pinched nerve”), other structures in the back can refer pain down the buttocks and into the legs. The nerves can become sensitized with inflammation from the proteins within the disc space and produce the sensation of numbness/tingling. Generally, the pain does not go below the knee. These sensations, although worrisome and annoying, rarely indicate that there is any ongoing nerve root damage. However, any weakness in the leg muscles is an indicator of some nerve root damage.
A Magnetic Resonance Imaging (MRI) scan is the best test to determine whether or not there is disc degeneration. However, not all degenerated discs cause pain, so simply seeing the condition on the scan does not necessarily indicate the presence of this condition. Experiencing the above symptoms, in conjunction with findings from a clinical exam and MRI scan, is a good indication that this condition is causing the pain.
Conservative (non-surgical) treatments
In most cases, degenerative disc disease can be managed with conservative treatments. Patients with this condition tend to experience pain that occasionally intensifies, but as long as the pain is manageable overall, surgery can usually be avoided.
A consistent exercise program can help maintain stability in the problem area, so the excess movement and pain are lessened. Exercises that can be helpful include:
- Hamstring stretching
- Dynamic lumbar stabilization exercises and other strengthening programs
- Low-impact aerobic conditioning
Patients should consider visiting a physical therapist to learn how to do these types of exercises safely and effectively.
Non-prescription medications, such as ibuprofen (e.g. Advil, Nuprin, Motrin) to reduce inflammation, and acetaminophen (e.g. Tylenol) for its analgesic (pain-relieving) qualities, may be helpful in alleviating lower back pain. Stronger therapies, such as oral steroids or epidural steroid injections, may be prescribed to treat severe flare-ups of pain if needed. Narcotic drugs (e.g., Vicodin, Percocet, OxyContin) can also be used sparingly during severe flare-ups, but should generally be avoided as a primary means of controlling chronic pain.
Other common treatment options include manual manipulation by a chiropractor or other qualified health professional, electrical stimulation (e.g. a TENS unit), and application of ice and/or heat to the affected area.
In more serious cases, patients may be in severe pain and may be unable to function due to the pain. In such cases, lumbar fusion surgery or artificial disc replacement are options.
A spinal fusion surgery is designed to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. All lumbar fusion surgeries involve adding bone graft to an area of the spine to set up a biological response that causes the bone graft to grow (fuse), causing two vertebral bodies to grow together into one long bone, and thereby stop the motion at that segment. Bone graft can be taken from the patient’s iliac crest (autograft bone) during the fusion surgery, or harvested from cadaver bone (allograft bone). Synthetic bone graft substitutes (such as bone morphogenic proteins) are also being used for certain fusion procedures.
In general, a lumbar spinal fusion is most effective for treating only one vertebral segment. Most patients will not notice any limitation in motion after a one-level fusion. Fusing two segments may be a reasonable option for treatment of pain, but fusion of more than two segments is infrequently indicated because it removes too much of the normal motion in the back, placing too much stress across the remaining joints.
Artificial disc replacement is a newer surgery to treat pain and disability from lumbar degenerative disc disease. The theory is that replacing the disc, instead of fusing the disc space together, maintains more of the normal motion in the lumbar spine, thereby reducing the chance that adjacent levels of the spine will break down due to increased stress. This procedure is relatively new in the US, so long-term efficacy, and potential risks and complications, are still relatively unknown.
Surgery should only be considered after conservative treatment has been proven to be ineffective, and if the patient is truly limited by the degree of pain they experience.
As a disc degenerates, the inner core of the disc can extrude-or herniate-back into the spinal canal. The herniated disc material can irritate the nerve, which can cause pain to radiate down the path of the nerve – from the lower back through the buttocks and into the leg or even into the foot.
Anatomy of a herniated disc
Discs are positioned in between each vertebra (the bony building blocks of the spine) along the front of the spine. Each disc is composed of a tough outer ring and a soft inner core, which is the part that extrudes, or “herniates” out.
A lumbar (lower back) disc herniation typically occurs toward the back of the spine where there is a thinner boundary in the outer ring. This weak spot in the disc can be directly under the nerve root.
A lumbar herniated disc will typically cause one or a combination of the following symptoms:
- Dull or sharp pain that travels into the buttocks and back of the leg (sciatica)
- Numbness or tingling in different areas of the leg
- Muscle weakness in certain muscles of one or both legs
- Loss of some reflexes in the leg
Sitting or bending forward, and sneezing or coughing, will usually make the pain worse. If symptoms include any bowel or bladder dysfunction, or there is progressive weakness in the legs, immediate medical attention should be sought.
The specific symptoms of a herniated disc depend primarily on the location and degree of the herniation. Approximately 90% of lumbar disc herniations will occur at the following segments of the lower spine:
- L4-L5 herniation (between lumbar segment 4 and 5)-Can cause weakness in extension of the big toe and potentially in the ankle (foot drop). Numbness and pain may be felt on top of the foot, and the pain may also radiate into the buttocks.
- L5-S1 herniation (between lumbar segment 5 and sacral segment 1)-May cause loss of the ankle reflex and/or weakness with ankle push off (e.g. patients cannot do toe rises). Numbness and pain can radiate down to the sole or outside of the foot.
A detailed medical history and physical examination can usually differentiate a herniated disc from other possible conditions that can cause similar symptoms. An MRI scan is usually needed to confirm the diagnosis and understand the location and degree of the herniation, and additional diagnostic tests may be needed to rule out other possible causes of the symptoms.
Many disc herniations do not actually cause any symptoms, so an MRI scan that shows a herniated disc does not necessarily mean that the herniation is causing the pain. It is important to get an accurate diagnosis from a doctor that correlates the patient’s medical history and physical exam with the imaging tests.
Treatment for a lumbar disc herniation will largely depend on the length of time the patient has had his or her symptoms and the severity of the pain. For most patients, symptoms from a lumbar disc herniation will go away over time. While there are no hard and fast rules, this article reviews some general guidelines for non-surgical and surgical treatment options.
Generally, patients will start with 6 to 12 weeks of conservative (meaning non-surgical) treatment. Surgery may be considered if a course of conservative treatment does not provide pain relief, or if the pain is severe and the patient is having difficulty functioning.
Conservative (non-surgical) treatments
The primary goals of treatment are to provide pain relief and to allow the patient to return to a normal level of activity. If the symptoms start to abate within the six-week period, continued conservative treatment is warranted. Depending on the patient’s clinical situation and physician’s recommendations, one or several of the following non-surgical treatments may typically be considered:
- Physical therapy, exercise and gentle stretching to help relieve pressure on the nerve root
- Ice and heat therapy for pain relief
- Manipulation (such as by a chiropractor, osteopath, or appropriately trained physical therapist)
- Non-steroidal anti-inflammatory drugs, “NSAIDs” (such as ibuprofen or naproxen)
- Narcotic pain medications for pain relief
- Oral steroids or epidural steroid injections to decrease inflammation for pain relief
It may be necessary for a patient to try more than one or a combination of the above treatments. The recommended length of conservative treatment for patients needs to be individualized. For those patients who are not in severe pain and can function well, a longer period of conservative treatment is reasonable. The vast majorities of people with a lumbar disc herniation do not need surgery and will recover and return to their normal lifestyle within several weeks or months of conservative treatment.
The goal of surgery is to help alleviate the pain faster. If a patient has severe pain and is unable to function at a satisfactory level, surgery may be a reasonable option even before six weeks of symptoms. In recent years, the morbidity (or unwanted side effects, such as post-operative pain) of surgery for a lumbar herniated disc has decreased and the results have improved, so surgery is generally considered a reasonable option for relieving pain and other neurological symptoms more quickly.
The most common surgery to treat a lumbar herniated disc is a microdiscectomy (microdecompression). This is a minimally-invasive procedure (since the incision is small and muscles are moved rather than cut) to remove the herniated portion of the disc under the nerve root. By giving the nerve root more space, pressure is relieved and the nerve root can begin to heal. The microdiscectomy procedure is usually highly successful for relieving the leg pain (sciatica) caused by a herniated disc. Although the nerve root takes several weeks or months to fully heal, patients often feel immediate relief of their leg pain and usually have a minimal amount of discomfort following the surgery. Depending on the patient’s clinical situation and surgeon’s preference, a lumbar laminectomy (open decompression), arthroscopic lumbar discectomy (endoscopic percutaneous discectomy), or microendoscopic surgery may also be considered.
Any patient who has progressive neurological deficits or develops the sudden onset of bowel or bladder dysfunction should have an immediate surgical evaluation, as these conditions may represent a surgical emergency. Fortunately, these conditions are rare.
Lumbar laminectomy (open decompression) is a surgical procedure that is performed to alleviate pain caused by neural impingement (pressure on the nerves). The surgery removes a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the nerve root more space and an opportunity to heal.
A laminectomy is effective for decreasing pain and improving function for patients withlumbar spinal stenosis. Spinal stenosis is a condition that usually occurs in elderly patients, and is caused by degenerative changes that result in enlargement of the facet joints. The enlarged joints then place pressure on the nerves, and this pressure may be effectively relieved with a lumbar laminectomy.
Laminectomy surgical procedure
- A two-inch to five-inch long incision is made in the midline of the back
- The left and right back muscles (erector spinae) are dissected off the lamina on both sides and at multiple levels, allowing the surgeon access to the nerves
- The facet joints, which are directly over the nerve roots, may then be trimmed to give the nerve roots more room
Following the operation patients are in the hospital for one to three days. The patient’s ability to return to normal activity is largely dependent on his or her pre-operative condition and age. Patients are encouraged to walk directly following the procedure. It is recommended that patients avoid excessive bending, lifting or twisting for six weeks in order to avoid pulling on the suture line before it heals.
Laminectomy success rate
Laminectomy surgery has a favorable success rate. Following surgery approximately 70% to 80% of patients have significant improvement in their ability to perform normal daily activities and a noticeably reduced level of pain and discomfort.
Results from this surgery are much better for relief of leg pain caused by spinal stenosis than for relief of lower back pain. Lumbar spinal stenosis is often created by the facet joints becoming arthritic, and much of the back pain is from the arthritis. Although removing the lamina and part of the facet joint can create more room for the nerve roots it does not eliminate the arthritis. Unfortunately, the symptoms may recur after several years as the degenerative process that originally produced the spinal stenosis continues.
In certain instances the success rate of a decompression for spinal stenosis can be enhanced by also fusing a joint. Fusing the joint prevents the spinal stenosis from recurring and can help eliminate pain from an unstable segment. Fusion surgery is especially useful if there is a degenerative spondylolisthesis associated with the stenosis. Generally speaking, if there is multi-level stenosis from a congenitally shallow canal a fusion is not necessary; however, if the stenosis is at one level from an unstable joint (e.g. degenerative spondylolisthesis), then a decompression surgery with a fusion is a more reliable procedure.
Laminectomy risks and complications
The potential risks and complications with a laminectomy procedure include:
- Nerve root damage (1 in 1,000) or bowel/bladder incontinence (1 in 10,000). Paralysis would be extremely unusual since the spinal cord stops at about the T12 or L1 level, and surgery is usually done well below this level.
- 1 to 3% of the time a cerebrospinal fluid leak may be encountered if the dural sac is breached. This does not change the outcome of the surgery, and generally a patient just needs to lie down for about 24 hours to allow the leak to seal.
- Infections happen in about 1% of any elective cases, and although this is a major nuisance and often requires further surgery to clean it up along with IV antibiotics, it generally can be managed and cured effectively.
- Bleeding is an uncommon complication as there are no major blood vessels in the area.
- In approximately 5 to 10% of cases, postoperative instability of the operated level can be encountered. This complication can be minimized by avoiding the pars interarticularis during surgery, as this is an important structure for stability at a level. Weakening or cutting this bony structure can lead to an isthmic spondylolisthesis after surgery. Also, the natural history of a degenerative facet joint may lead it to continue to degenerate on its own and result in a degenerative spondylolisthesis. Either of these conditions can be treated by fusing the affected joint at a later date.
General anesthetic complications such as myocardial infarction (heart attack), blood clots, stroke, pneumonia or pulmonary embolism can happen with any surgery. Although in the general population these complications are rare, laminectomy surgery for spinal stenosis is generally done for elderly patients and therefore the risk of a general anesthetic complication is somewhat higher.
Lumbar spinal stenosis is a condition in which the spinal canal is narrowed, causing the spinal cord or spinal nerve roots to be compressed. Spinal stenosis is related to degeneration of the spine, as the facet joints get larger and place pressure on the nerve roots. The condition usually affects patients over the age of 60.
Approximately 75% of spinal stenosis cases affect the lumbar area of the spine, and most will affect the sciatic nerve which runs along the back of the leg. Standing upright further decreases the space available for the nerve roots, and can block the outflow of blood from around the nerve. Congested blood then irritates the nerve and the pain travels into the legs.
The compression of lumbar spinal stenosis can produce the following symptoms, which radiate into the buttocks and legs:
- Weakness (rare)
These symptoms typically develop slowly over several years (although they do occasionally come on suddenly), they are intermittent as opposed to continuous, they occur during certain activities and in certain positions, and they are relieved by rest or any flexed forward position. The most common symptom of lumbar spinal stenosis is pain in the legs while walking, which is relieved only by sitting and resting (not simply by stopping walking).
The longer a patient with spinal stenosis stands or walks the worse the leg pain will get. Flexing forward or sitting will open up the spinal canal and relieve the leg pain and other symptoms, but they will recur when the patient gets back into an upright posture. Numbness and tingling can accompany the pain. Weakness is a rare symptom of spinal stenosis.
The nerve compression of spinal stenosis will vary, depending on the activity or position of the patient (standing, sitting, walking). Physical examination alone will not be enough to correctly diagnose stenosis.
Either a Magnetic Resonance Imaging (MRI) scan or a Computed Tomography (CT) scan with myelogram can be useful in diagnosing lumbar spinal stenosis. Sometimes both are used. A non-enhanced CT scan (without myelogram) is not useful in diagnosing this condition.
A spinal stenosis at two or even three levels can affect a single emerging nerve. If surgery is considered, a combination of anatomical and clinical examination is needed in order to make sure one surgical procedure will address all contributing components of spinal stenosis.
Lumbar spinal stenosis can be treated by non-surgical or surgical means. The key to deciding which one to choose is the degree of disability and pain resulting from the stenosis. If a patient can no longer walk well enough to be independent, then surgery may be recommended. Otherwise a non-surgical approach may be tried for a period of time, or indefinitely if the results are satisfactory.
Conservative (non-surgical) treatments
There are two common non-surgical treatments for lumbar spinal stenosis.
- Activity modification. Since patients are more comfortable when they are flexed forward, they can concentrate their activity in that position. Modifications can include changing exercise from walking to stationary biking, using a cane or walker for walking while flexed forward, and sitting in a recliner rather than a straight-back chair.
- Epidural injection. This is an injection of cortisone into the space outside the dura (the epidural space). Approximately 50% of patients will experience good pain relief after an epidural injection, although the results tend to be temporary. If the injection is helpful it can be done up to three times within a year. The action of the injection is not clearly known, but is probably a combination of the anti-inflammatory effect of the steroid and a flushing effect due to injecting a volume of fluid. Although the injection cannot be considered diagnostic, typically if the pain from spinal stenosis is relieved by an injection the patient can be expected to have a good result if they later choose to undergo a surgical procedure.
Anti-inflammatory medication (such as ibuprofen, aspirin or Cox-2 inhibitors) may also be helpful in treating spinal stenosis. Exercise is important to maintain strength, but usually does not relieve the symptoms.
If conservative treatments do not adequately increase the level of activity a patient is able to tolerate, a surgical procedure might be considered.
An open decompression or laminectomy is the only way to change the anatomy of the spine and give the nerves more room. Decompressing the nerves by removing a portion of the enlarged facet joint prevents the nerve from being pinched when the patient stands up. There are several methods, but there are key components common to all such approaches:
- A correct and very detailed anatomical diagnosis is required. The surgeon must consider the possibility of a double or triple location of choking of a nerve, on one or both sides.
- The surgery should not create a new problem, such as a nerve injury or a structural instability that might require additional surgeries.
- The approach to correcting spinal stenosis should be minimally destructive of normal structures. The surgeon should strive to leave as much as possible of the normal or slightly abnormal tissues alone. This again points to the importance of exactly identifying the stenosis.
- The metabolic and physical status of the patient is important. Even in experienced hands a decompressive procedure may require a few hours of anesthesia, and this is not well tolerated by some patients. Some surgeons will perform the spinal stenosis surgery using an epidural anesthetic instead of a general.
Decompression surgery for spinal stenosis is effective in approximately 80% of cases, but the results tend to deteriorate over a 5-year period. Patients generally do well and are able to increase their activity level and have a better walking tolerance. The results are just as effective whether the surgery is done right away, or delayed for years.
A microdiscectomy is typically performed in the case of a lumbar herniated disc. The center of the disc protrudes through the outer ring (annulus) and subsequently puts pressure on a nerve, causing pain to radiate down the patient’s leg and into the foot. In this procedure, a small portion of the bone over the nerve root and disc material from under the nerve root is removed to relieve the pressure and provide room for the nerve to heal.
A microdiscectomy surgery is more effective for treating leg pain (radiculopathy) than for lower back pain. The compression on the nerve root can cause substantial leg pain, and while it may take weeks or months for the nerve root to fully heal and for any numbness or weakness to get better, patients normally feel relief from leg pain almost immediately after a microdiscectomy surgery.
Who should have this surgery?
This procedure is usually recommended for patients who have experienced leg pain for four to six weeks and who have tried conservative treatment (such as oral steroids, epidural steroid injections, NSAID’s, and physical therapy) without successfully relieving the pain. However, it is not advisable to wait too long before having this surgery, because the results are not as good if the surgery is postponed more than three to six months. Besides time, one needs to also factor in the level of the pain and the amount of disability the patient is experiencing. If the symptoms are mild, a longer course of conservative treatment may be reasonable, whereas if the symptoms are severe more immediate surgery is reasonable.
Microdiscectomy success rate
A recurrent disc herniation may occur directly after back surgery or many years later, although they are most common in the first three months after surgery. Recurrence rates after a patient has a disc herniation are between 5 and 10%. If the disc does herniate again, generally a revision microdiscectomy will be just as successful as the first operation. However, after a recurrence, the patient is at higher risk of further recurrences (15 to 20% chance). If herniation continues to recur, a fusion procedure might be considered.
Recurrent disc herniations are probably due to the fact that within some disc spaces there are multiple fragments of disc that can come out at a later date. Through a posterior microdiscectomy approach, only about 5 to 7% of the disc space can be removed and most of the disc space cannot be seen. Also, the hole in the disc space where the herniation occurs (annulotomy) probably never closes because the disc itself does not have a blood supply. Without a blood supply, the area does not heal or scar over. There also is no way to surgically repair the outer portion of the disc space (the annulus).
Usually, a microdiscectomy procedure is performed on an outpatient basis (with no overnight stay in the hospital) or with a one night stay in the hospital. Post-operatively, patients may return to a normal level of daily activity quickly. The success rates for pain relief are between 90 and 95%.
Some surgeons restrict a patient from bending, lifting, or twisting for the first six weeks following surgery. However, since the patient’s back is mechanically the same after a microdiscectomy, it is also reasonable to return to a normal level of functioning immediately following surgery. There have been reports in the medical literature showing that immediate mobilization (return to normal activity) does not lead to an increase in recurrent lumbar herniated disc. Although a patient may be technically allowed to resume their normal activities immediately, they should expect reduced activities due to incisional discomfort for one to three weeks.
Following a microdiscectomy surgery, a program of stretching, strengthening, and aerobic conditioning is recommended to help prevent recurrence of back pain or disc herniation.
Microdiscectomy surgical procedure
A microdiscectomy is performed through a small (1 inch to 1 1/2 inch) incision in the midline of the back.
- First, the back muscles (erector spinae) are lifted off the bony arch (lamina) of the spine. Since these back muscles run vertically, they can be moved out of the way rather than cut.
- The surgeon is then able to enter the spine by removing a membrane over the nerve roots (ligamentum flavum), and uses either operating glasses or an operating microscope to visualize the nerve root.
- Often, a small portion of the inside facet joint is removed both to facilitate access to the nerve root and to relieve pressure over the nerve.
- The nerve root is then moved to the side and the disc material is removed from under the nerve root.
Microdiscectomy risks and complications
As with any form of spine surgery, there are several risks and complications that are associated with a microdiscectomy procedure. Complications are quite rare in this procedure, but possibilities include:
- Dural tear (cerebrospinal fluid leak). This occurs in 1% to 2% of these surgeries. It does not change the results of surgery, but post-operatively the patient may be asked to lay recumbent for one to two days to allow the leak to seal.
- Nerve root damage (1 in 1,000)
- Bowel/bladder incontinence (extremely rare)
- Infection (1%)
- Recurrent disc herniations (5-10%)
Follow-up care for a microdiscectomy usually includes a combination of the following:
- Pain management. Immediate post-operative pain can be managed with a combination of non-steroidal anti-inflammatory drugs (ibuprofen such as Advil, Nuprin, or Motrin; or naproxen such as Naprosyn or Aleve) and a mild pain pill such as Darvocet or Vicodin. As the discomfort subsides (usually about 1 to 2 weeks) the patient can move toward substituting Tylenol for the narcotic pain medications. Ice may also be applied to the back to decrease pain within the first 48 hours after surgery.
- Stretching program. Most surgeons feel that to minimize tethering of the nerve root by scar tissue, gentle stretching exercises should be done in the early postoperative period. Scar tissue in and of itself is not painful, but if it tethers the nerve root short as the patient heals this can result in chronic pain. The stretching should be done about 5 to 6 times a day for 6 to 12 weeks, since this is the time period in which the scarring occurs. It is generally advisable to do the stretching exercises frequently and gently. Stretching too hard may result in pain, and one should only take the stretch to the point of pain to avoid inflaming the nerve. If a patient feels too much pain after surgery to do any stretching, it would be wise to wait until he or she is more comfortable.
- Back strengthening exercises. After the soft tissue has healed (usually 2 to 3 weeks after surgery), it is important to start back strengthening exercises.There are a wide variety of possible exercises to achieve the desired results, and it is important to choose exercises that are safe and well tolerated so that they will be done on a regular basis. About 15 minutes of appropriate stretching and strengthening exercises per day is advisable for the first one to three months.
- Early return to activity. Early mobilization may help patients heal sooner, as the pre-operative pain has usually caused patients to limit their motion, and limited motion is a common cause of pain. Walking is very gentle on the back, and a postoperative walking program with a goal of walking about 3 miles a day is advisable. Return to work is based on how quickly the patient feels better and on what type of work the patient does.
Generally, a patient’s exercise program (for active physical therapy) should encompass a combination of the following:
Most patients who have suffered from low back pain should stretch their hamstring muscles (in the back of the thigh) once or twice daily. Patients who have low back pain tend to have tight hamstrings, and patients with tight hamstrings tend to have low back pain. It is not known which comes first, but it is clear that hamstring tightness limits motion in the pelvis and can place it in a position that increases stress across the low back. Therefore, it follows that stretching the hamstring muscles typically helps decrease the intensity of a patient’s back pain and the frequency of recurrences.
Simple hamstring stretching does not take much time, although it can be difficult to remember, especially if there is little or no pain. Therefore, hamstring stretching is best done at the same time every day so it becomes part of a person’s daily routine. A hamstring stretching routine should include applying pressure to lengthen the hamstring muscle for 30-45 seconds at a time twice daily. The pressure on the muscle should be applied evenly and bouncing should be avoided, since a bouncing motion will trigger a spasm response in the muscle being stretched.
Strengthening/pain relief exercises
There are two primary forms of exercise for strengthening and/or pain relief that tend to be used for specific conditions: McKenzie exercises and dynamic lumbar stabilization exercises. When appropriate, these two forms of physical therapy may be combined.
McKenzie exercises are named after a physical therapist in New Zealand who noted that extending the spine could reduce pain generated from the disc space. With the McKenzie approach, physical therapy to extend the spine can help “centralize” the patient’s pain by moving it away from the extremities (leg or arm) to the back. Back pain is usually better tolerated than leg pain or arm pain, and the theory of the approach is that centralizing the pain allows the source of the pain to be treated rather than the symptoms.
For the dynamic lumbar stabilization exercises, the physical therapist first tries to find the patient’s “neutral” spine, or the position that allows the patient to feel most comfortable. The back muscles are then exercised to teach the spine how to stay in this position. This technique relies on proprioception, or the awareness of where one’s joints are positioned. Performed on an ongoing basis, these exercises can help keep the back strong and well positioned.
Low-impact aerobic conditioning
Reconditioning through low-impact aerobic exercise is very useful for both rehabilitation and maintenance of the lower back. The following types of aerobic exercise are gentle on the back and, when done on a regular basis, highly effective in providing conditioning:
- Walking. In general, walking is very gentle on the back, and walking two to three miles three times per week is very helpful for patients.
- Stationary bicycling. If walking is painful, stationary bicycling is also effective.
- Water therapy. Exercise in the water provides effective conditioning while minimizing stress on the back.
Even patients with a very busy schedule should be able to maintain a moderate exercise regimen that encompasses stretching, strengthening, and aerobic conditioning.
For lower back pain that has lasted between two and six weeks, or frequently recurs, physical therapy may be considered. Some specialists begin physical therapy sooner, especially if the pain is severe. Physical therapy can help decrease back pain and increase the patient’s ability to function, and provides a routine that can help prevent recurrence of the problem.
Physical therapy can be passive (something is done to the patient) or active (the patient engages in an exercise program).
Initially, therapists may need to focus on reducing the pain, which is often done with the following passive modalities:
Heat and ice are very commonly used to help reduce muscle spasm and inflammation, as well as reduce the amount of pain experienced, and also assist in healing. The therapist may apply this treatment, but if a non-professional is going to do it a medical care provider should be consulted before beginning to be sure it will be done correctly. Importantly, care should be taken with both ice and heat so as not to burn the skin.
Some patients experience better pain relief by using heat and others have better results with ice. Many find that the best approach is to alternate the two. Treatments should last ten to twenty minutes once every two hours, and are most useful in the first few days of a flare-up of pain.
Iontophoresis is a way to deliver steroids through the skin. The steroid is applied to the skin, and an electrical current is then applied that causes the steroid to migrate under the skin. The steroids then produce an anti-inflammatory effect in the area of the pain. This is especially effective in relieving acute pain.
A transcutaneous electrical nerve stimulator (TENS) unit emits electrical stimulation into the area of the lower back pain. This stimulation overrides the pain signals that are sent to the brain, and can be effective in relieving pain. Usually a therapist will do a trial with this therapy on a patient, and if substantial pain relief is experienced the unit may be sent home with the patient to be used as needed for long-term pain relief.
Ultrasound is a form of deep heating in which sound waves are applied to the skin and penetrate into the soft tissues. This modality is especially useful in relieving acute episodes of pain and may also enhance tissue healing.
Once the pain is lessened through passive therapies, active physical therapy (exercise) is needed to rehabilitate the spine. Therapists will work with patients to develop a proper exercise routine that will help patients avoid recurrences of low back pain, and help reduce the severity and duration of potential future episodes of low back pain.
Sciatica is a relatively common form of back pain that radiates along the sciatic nerve. The sciatic nerve is the largest single nerve in the human body; it runs from each side of the lower spine through deep in the buttock and back of the thigh, and all the way down to the foot, connecting the spinal cord with the leg and foot muscles.
The pain can be severe for some, for others it is infrequent and irritating, but has the potential to get worse. Sciatica usually affects only one side of the lower body, often radiating from the lower back down through the buttock and down the leg. The leg pain is often worse than the pain in the back. Depending on which part of the sciatic nerve is affected, the pain may also extend into the foot or toes.
The most common causes of sciatica are usually pressure on the sciatic nerve from a herniated disc (also referred to as a ruptured disc, pinched nerve, slipped disk, etc.) or spinal stenosis. The problem is often diagnosed as a “radiculopathy”, meaning that a disc has protruded from its normal position in the vertebral column and is putting pressure on the radicular nerve (nerve root).
Any of the following sensations may occur with sciatica:
- Pain in the buttock or leg that is worse when sitting
- Burning or tingling down the leg
- Weakness, numbness or difficulty moving the leg or foot
- A constant pain on one side of the buttocks
- A shooting pain that makes it difficult to stand up
While sciatica can be very painful, it is rare that permanent nerve damage (tissue damage) will result. Most of the pain results from inflammation and will get better within two weeks to a few months. Also, because the spinal cord is not present in the lower (lumbar) spine, a herniated disc in this area of the anatomy does not present a danger of paralysis.
Most cases of sciatica will get better with time and conservative care. However, some sciatica symptoms may indicate a potentially serious injury to the nerve:
- If weakness is present, the nerve may be damaged and it is important to seek attention from a health care professional. If the nerve is compressed and the pain and symptoms are severe, surgery may be warranted.
- If there is bowel or bladder incontinence (inability to control the bowel or bladder) and/or progressive weakness or loss of sensation in the legs, the condition may be serious and immediate medical attention should be sought.
Sciatica is a symptom and not a diagnosis. The term literally means that a patient has pain down the leg from compression on the sciatic nerve. The diagnosis is what is causing the compression (such as a disc herniation or spinal stenosis). The vast majority of sciatic episodes heal themselves within 6 to 12 weeks. If it doesn’t get better on its own, various treatment options can be considered.
There are a number of conservative treatment options available to help alleviate the pain and discomfort of sciatic pain.
- For acute sciatica pain, heat and ice packs are quite often the first step to try for relief. Usually ice or heat is applied for approximately 20 minutes, and repeated every two hours. Most people use ice first, but some people find more relief with heat. The two may be alternated.
- Over-the-counter or prescription medications may also be helpful in relieving sciatica pain. Non-steroidal anti-inflammatory drugs (NSAIDs) or oral steroids can be used to reduce the inflammation and pain.
Epidural steroid injections
- If the pain is severe, an epidural injection can be performed to reduce the inflammation. An epidural is different from oral medications because it injects steroids directly to the painful area around the sciatic nerve to help decrease the inflammation that may be causing the pain. While the effects tend to be temporary (providing pain relief for as little as one week up to a year), an epidural can be very effective in providing relief from an acute episode of sciatic pain. Importantly, it can provide sufficient relief to allow a patient to progress with a conditioning program.
Conservative care specialists
- Treatment with a physical therapist, osteopathic physician, chiropractor or physiatrist can be helpful both to alleviate the painful symptoms and to help prevent future recurrences of sciatica. These conservative care professionals can assist in providing pain relief and developing a program to condition the back.
If the pain is severe and has not gotten better within six to twelve weeks, it is reasonable to consider spine surgery. Depending on the cause and the duration of the sciatic pain, one of two surgical procedures may be considered: a microdecompression (microdiscectomy) or an open decompression (lumbar laminectomy).
- In cases where the pain is due to a disc herniation, a microdiscectomy may be considered after 4 to 6 weeks if the pain is not relieved by conservative means. Urgent surgery is only necessary if there is progressive weakness in the legs, or sudden loss of bowel or bladder control. A microdiscectomy is typically an elective procedure, and the decision to have surgery is based on the amount of pain and dysfunction the patient is experiencing, and the length of time that the pain persists. Approximately 90% to 95% of patients will experience relief from their pain after this type of surgery.
Lumbar laminectomy (open decompression)
- If the sciatica is associated with spinal stenosis, surgery may be offered as an option if the patient’s ability to maintain a normal level of activity falls to an unacceptable level. Again, surgery is elective and need only be considered for those patients who have not gotten better after conservative treatments. After a lumbar laminectomy (open decompression), approximately 70% to 80% of patients experience relief from their pain.
Lumbar spinal fusion is a type of back surgery in which a bone graft is inserted in the spine so that the bones in a painful segment of the spine fuse together. The fusion aims to stop the motion at a vertebral segment, which should decrease the pain caused by the joint. After the surgery it will take several months (usually 3 to 6, but sometimes up to 18 months) before the fusion is set-up. This surgery has been improved over the last 10 to 15 years, allowing for better success rates, and shorter hospital stays and recovery time.
Indications and contraindications for spinal fusion
The vast majority of people with low back pain will not need fusion surgery and will be able to manage the pain primarily with physical therapy and conditioning. A fusion surgery may, however, be recommended for patients with:
- Low back pain caused by degenerative disc disease that limits the patient’s ability to function (after non-surgical treatments, such as physical therapy and medication, have failed)
- Isthmic, degenerative or postlaminectomy spondylolisthesis
- A weak or unstable spine (caused by infections or tumors), fractures, or deformity (such as scoliosis)
Fusion is a major surgery. Consequently, it is very important that other possible causes of a patient’s back pain (e.g. facet or hip osteoarthritis, or piriformis syndrome) be ruled out prior to undergoing fusion surgery. Generally fusion should not be considered until the lower pack pain has persisted for more than six months, and a concerted effort at non-surgical treatment has not relieved the pain. The decision to have fusion surgery is almost always the patient’s choice as this is an elective surgery designed to help alleviate some of the patient’s pain and enhance his or her activity tolerance. It is exceedingly rare to have neurological consequences as a result of delaying or avoiding a fusion surgery.
Success rates for fusion
Fusion surgery success rates vary between 70% and 95%, and there are several factors that will impact the success rate of the surgery, including:
- Spine fusion for conditions that arise from gross instability (e.g. isthmic or degenerative spondylolisthesis) tends to be more successful than surgery done for pain alone (e.g. degenerative disc disease).
- Individuals with only one badly degenerated disc (especially L5-S1) but an otherwise a normal spine tend to fare better than those undergoing multilevel fusions. Fusion surgery is generally considered for one or possibly two levels, and multilevel fusions should be avoided except in cases of severe deformity.
- Individuals who have significant disc degeneration usually find more pain relief from a fusion than those with only minor degeneration on the MRI scan (e.g. still have a tall disc).
The most important success factor in fusion surgery is confirming that a patient’s back pain is truly caused by degenerative disc disease, rather than some other condition. This is done by a combination of a careful review of the patient’s history, a physical exam, and diagnostic tests (such as x-ray and MRI), and/or possibly a discogram.
Other health factors or activities can undercut the chances of obtaining a successful fusion, and should be treated or controlled prior to surgery if possible. These include smoking, obesity, malnutrition, osteoporosis, chronic steroid use, diabetes mellitus or other chronic illnesses.
A surgeon will consider different techniques and both anterior (from the front) and posterior (from the back) approaches to perform the fusion.
Posterolateral gutter fusion-the most common fusion technique, involves:
- Making a 3- to 6-inch midline incision in the low back
- Obtaining bone graft from the pelvis (the iliac crest)
- Elevating the large back muscles that attach to the transverse processes (small extensions of the vertebra) to create a bed for the bone graft to lay on
- Laying the harvested bone graft in the posterolateral portion of the spine, where it has the steady blood supply needed for the fusion to grow
- Moving the muscles over the bone graft to create tension to hold the bone graft in place.
Other commonly used fusion techniques include:
- Posterior lumbar interbody fusion (PLIF)-approached through the back, the surgery involves removing a portion of the facet joints, then removing the disc between two vertebrae and inserting bone into the space between the two vertebral (where the disc was)
- Anterior lumbar interbody fusion (ALIF)-similar to a PLIF, but approached through the front
- Anterior/posterior spinal fusion-this is done from the front and the back and combines the ALIF and posterolateral gutter fusion procedures
- Transforaminal interbody fusion (TLIF)-is essentially and extended PLIF in that in removes one entire facet joint (rather than a portion of the facet joints on each side of the spine) to gain access to the disc space
The type of fusion will depend largely on the patient’s diagnosis and surgeon’s preference. Regardless of which technique is used, the goal is to create a solid fusion in the affected motion segment, defined as the disc space in front of the spine and the paired facet joints in the back. Two vertebral segments need to be fused to stop the motion at one segment; thus an L4-L5 (lumbar segment 4 and lumbar segment 5) fusion is actually a one-level spinal fusion.
In addition, there are several types of bone graft options, including bone graft taken from the patient’s hip (autograft bone) during the fusion surgery, or from cadaver bone (allograft bone). The possibility of using synthetic bone graft substitutes (such as bone morphogenic proteins), which help the body create bone, may also be an option.
Potential risks and complications
The main potential risks of lumbar fusion include:
- Continued pain after surgery
- Solid fusion will not be obtained (nonunion) and further surgery to re-fuse the spine may be necessary
- Bone graft harvest site chronic pain
- Nerve damage (less than 1 in 10,000 chance)
- Infection or bleeding (rare)
- Anesthetic complications (rare)
- Cerebrospinal fluid leak (rare)
- Failure of the instrumentation (rare)
After a spine fusion surgery, it can take three to six months for the fusion to successfully set up and achieve its initial maturity. During these first months, patients should follow the surgeon’s postoperative care instructions and avoid activities such as high-impact exercise that may place the bone graft at risk. Permanent restrictions are only needed in a few cases, and since bone is a live tissue, after it has set up the bone graft will get stronger with some level of stress (activity). In general, a back brace after surgery should not be needed unless adequate fixation at the time of surgery was not acheived.