SPINE
Cervical spine
The cervical spine is the uppermost part of the spine (the neck). The levels of the cervical spine are referred to by numbers, from C1 to C7. There are 7 cervical vertebrae and 8 cervical nerve roots. Between the bones, or vertebrae, there are intervertebral discs. Behind the vertebrae and discs is the spinal canal. The spinal cord travels within the spinal canal, situated just behind the spinal column.
Cervical spine
The cervical spine is the uppermost part of the spine (the neck). The levels of the cervical spine are referred to by numbers, from C1 to C7. There are 7 cervical vertebrae and 8 cervical nerve roots. Between the bones, or vertebrae, there are intervertebral discs. Behind the vertebrae and discs is the spinal canal. The spinal cord travels within the spinal canal, situated just behind the spinal column.
Cervical disc herniation
The intervertebral discs consist of an outer layer that forms a fibrous capsule around the softer, inner part of the disc. This capsule can tear or rupture, allowing the softer, inner part of the disc to rupture, or herniate out of the disc space. Alternatively, the capsule may stay intact and the disc can bulge posteriorly. This usually causes less severe symptoms.
Frequently, the disc herniates back to one side producing symptoms in one arm, shoulder, or hand. Symptoms may include neck pain or pain between the scapulae. Often the pain is accompanied by numbness and tingling, perhaps even weakness. Broad disc bulges can produce bilateral symptoms by compressing the exiting nerve roots.
Less commonly, larger midline disc herniations can cause compression of the spinal cord. This can lead to weakness, numbness, and tingling in the hands, arms, and occasionally the legs. Clumsiness and difficulty walking may ensue, and longstanding or severe spinal cord compression can lead to incontinence and inability to stand or walk. For details, see the section titled "Cervical Stenosis."
How do disc herniations occur? Occasionally they are related to a specific trauma (motor vehicle accident, heavy lifting, etc). More often, however, disc herniations are spontaneous. It is common for someone to just wake up one day with symptoms and say that they felt like they just "slept wrong."
Fortunately, most cervical disc herniations will not require surgery. With time, most disc bulges or less severe herniations will resolve. Anti-inflammatories, muscle relaxants, and other medications can help alleviate the symptoms. Spinal decompression (DRX), physical therapy, and other non-surgical modalities can also expedite recovery from cervical disc disease. Spinal decompression treatments can relieve the pressure from bulging, degenerated, and herniated discs without surgery.
However, larger disc herniations and in those cases where symptoms do not improve, surgery is an option. Disc herniations that are far off to one side can be addressed posteriorly (cervical hemilaminotomy/microdiscectomy), whereas most disc herniations are addressed from an anterior approach (anterior cervical discectomy).
Cervical spondylosis (bone spurs and neuroforaminal stenosis)
Bone spurs or osteophytes can occur almost anywhere in the spine. They often form where the nerve root exits the spinal canal, referred to the foramen (or neuroforamen). Like a disc, this can cause impingement of the exiting nerve root and the symptoms are essentially the same as for a cervical disc herniation. Since bone spurs take some time to develop, symptom onset is usually more gradual than for a disc herniation. Treatment is as described in the Cervical Disc Herniation section. Often, a foraminotomy is performed. This refers to surgical decompression or widening of the foramen in order to give the exiting nerve root more room.
Cervical stenosis
Spinal stenosis refers to when the spinal canal becomes too narrow and causes compression of the contents within it. Cervical stenosis can be congenital (developmental) or degenerative, as a result of arthritis, disc herniations, or thickening of the ligaments. In some cases, the ligament becomes calcified or ossified (referred to as OPLL, or ossified posterior longitudinal ligament).
In the cervical spine, compression of the spinal cord can result in weakness, numbness, and tingling in the hands, arms, and occasionally the legs. Clumsiness and difficulty walking may ensue, and longstanding or severe spinal cord compression can lead to incontinence and inability to stand or walk. In some cases, the arms and legs become stiff or spastic.
Some people are born with a narrow cervical spinal canal, and this is referred to as congenital stenosis. People with congenital stenosis have less "reserve" when it comes to disc bulges or other sources of compression, so they may develop symptoms sooner or more severe symptoms compared to people with normal spinal canals.
Surgery is the treatment of choice for symptomatic cervical stenosis. Anterior compression from disc herniations or thickened ligament can be addressed from an anterior approach, whereas multilevel stenosis, particularly congenital stenosis, and some cases of foraminal/neuroforaminal stenosis can be treated with a posterior decompression.
Cervical spine
trauma and fractures (non-osteoporotic)
There are a wide variety of traumatic fractures and subluxations, and treatment varies on a case-by-case basis. Treatment may range from simple observation or wearing a collar or halo (specialized brace) to major reconstructive surgery of the spine.
Thoracic spine
The thoracic spine is the middle part of the back that corresponds to the area between the neck and the low back, associated with the rib cage. It is the longest but most stable segment of the spine.
Thoracic disc herniations
Unlike the cervical and lumbar spine, the thoracic spine has a much more restricted range of motion. This is due primarily to the rib cage and torso. There are other anatomical considerations that make the thoracic spine unique and actually more difficult to deal with in regards to surgical approaches. Fortunately, thoracic disc herniations are much less common than cervical and lumbar discs.
The spinal canal is much narrower in the thoracic spine, leaving relatively little room to work in. The spinal cord nearly fills the entire canal, so there's little reserve when it comes to disc herniations, fractures, and other sources of compression. Posterior approaches to the disc space are limited because of these considerations. Anterior approaches require large exposures that go through the chest or upper abdomen.
Like other disc herniations, symptoms usually arise when the nerve is compressed or "pinched." In this part of the spine, that usually means pain that "shoots" or radiates across the chest or abdominal region. There is often accompanying numbness or a "tingling" sensation. There may or may not be back pain, which is usually higher up than the common low back pain.
Larger disc herniations can cause compression of the spinal cord. This can lead to difficulty walking, incontinence, and decreased sensation below the level of the spinal cord affected. The legs may become stiff or spastic and difficult to control. Similar symptoms can occur when the thoracic spinal cord is compressed due to stenosis (narrow canal), fracture, tumor, cyst, or any other mass or lesion.
Fractures: Thoracic osteoporotic fractures
Compression fractures of the thoracic and lumbar spine are most commonly seen in the elderly and usually occur as a result of osteoporosis. In these cases, the bones become soft. When the patient with osteoporosis falls or sustains even minor trauma, the vertebral body (main bones in the spinal column) compresses, usually more so in the front. This can cause a loss of height and integrity of the spinal column. It can also cause a deformity in the alignment of the canal, often referred to as a kyphosis. This can result in a "hunched over" posture.
Unfortunately, this can also result in a great deal of pain. The pain may be just in the back where the fracture occurred, but also may involve the nerve and result in a shooting pain across the chest or abdomen. Oftentimes, this pain will settle down with time. If not, a minimally invasive procedure referred to as a kyphoplasty can be performed to restore the height of the collapsed vertebral body as well as the proper alignment. Improvement in pain symptoms is often immediate. The procedure works best if done soon after the fracture occurs. Patients are not excluded because of age- in fact, most patients are elderly.
Thoracic spine fractures (non-osteoporotic)
There are a wide variety of traumatic fractures and subluxations, and treatment varies on a case-by-case basis. Treatment may range from simple observation or wearing a brace to major reconstructive surgery of the spine.
Lumbar spine
The lumbar spine is the lowest part of the spine, also known as the low back. It spans from the bottom of the rib cage to the sacrum. Due to its mobility and the degree of stress placed on it, the lumbar spine is a very common site for a variety of conditions.
There are a wide variety of traumatic fractures and subluxations, and treatment varies on a case-by-case basis. Treatment may range from simple observation or wearing a collar or halo (specialized brace) to major reconstructive surgery of the spine.
Thoracic spine
The thoracic spine is the middle part of the back that corresponds to the area between the neck and the low back, associated with the rib cage. It is the longest but most stable segment of the spine.
Thoracic disc herniations
Unlike the cervical and lumbar spine, the thoracic spine has a much more restricted range of motion. This is due primarily to the rib cage and torso. There are other anatomical considerations that make the thoracic spine unique and actually more difficult to deal with in regards to surgical approaches. Fortunately, thoracic disc herniations are much less common than cervical and lumbar discs.
The spinal canal is much narrower in the thoracic spine, leaving relatively little room to work in. The spinal cord nearly fills the entire canal, so there's little reserve when it comes to disc herniations, fractures, and other sources of compression. Posterior approaches to the disc space are limited because of these considerations. Anterior approaches require large exposures that go through the chest or upper abdomen.
Like other disc herniations, symptoms usually arise when the nerve is compressed or "pinched." In this part of the spine, that usually means pain that "shoots" or radiates across the chest or abdominal region. There is often accompanying numbness or a "tingling" sensation. There may or may not be back pain, which is usually higher up than the common low back pain.
Larger disc herniations can cause compression of the spinal cord. This can lead to difficulty walking, incontinence, and decreased sensation below the level of the spinal cord affected. The legs may become stiff or spastic and difficult to control. Similar symptoms can occur when the thoracic spinal cord is compressed due to stenosis (narrow canal), fracture, tumor, cyst, or any other mass or lesion.
Fractures: Thoracic osteoporotic fractures
Compression fractures of the thoracic and lumbar spine are most commonly seen in the elderly and usually occur as a result of osteoporosis. In these cases, the bones become soft. When the patient with osteoporosis falls or sustains even minor trauma, the vertebral body (main bones in the spinal column) compresses, usually more so in the front. This can cause a loss of height and integrity of the spinal column. It can also cause a deformity in the alignment of the canal, often referred to as a kyphosis. This can result in a "hunched over" posture.
Unfortunately, this can also result in a great deal of pain. The pain may be just in the back where the fracture occurred, but also may involve the nerve and result in a shooting pain across the chest or abdomen. Oftentimes, this pain will settle down with time. If not, a minimally invasive procedure referred to as a kyphoplasty can be performed to restore the height of the collapsed vertebral body as well as the proper alignment. Improvement in pain symptoms is often immediate. The procedure works best if done soon after the fracture occurs. Patients are not excluded because of age- in fact, most patients are elderly.
Thoracic spine fractures (non-osteoporotic)
There are a wide variety of traumatic fractures and subluxations, and treatment varies on a case-by-case basis. Treatment may range from simple observation or wearing a brace to major reconstructive surgery of the spine.
Lumbar spine
The lumbar spine is the lowest part of the spine, also known as the low back. It spans from the bottom of the rib cage to the sacrum. Due to its mobility and the degree of stress placed on it, the lumbar spine is a very common site for a variety of conditions.
Lumbar disc herniation
Disc herniations in the lumbar spine are very common. As described above in other disc herniations, the outer capsule of the disc (annular fibrosus) can bulge or even rupture, allowing the softer, inner disc contents (nucleus pulposus) to herniate back into the spinal canal or onto the exiting nerve root. This can cause pain in one or both legs, along with numbness, tingling, and possibly weakness in more severe cases. Back pain may or may not be present.
Sometimes, the symptoms begin after a specific trauma or after heavy lifting. However, oftentimes no such event can be recalled.
Fortunately, most lumbar disc bulges and herniations improve with time and conservative measures. Decompression (DRX) treatments, epidural steroid injections, and physical therapy may alleviate symptoms without surgical intervention.
In those cases where there is no improvement or even worsening of symptoms, surgery is recommended. Likewise, surgery is recommended when there is evidence of weakness.
A small incision is made in the midline of the low back, and the procedure is performed through an operating microscope. A small opening is made in the bone over the spinal canal, and the disc herniation is removed. Additional intervertebral disc is removed as well, and the nerve roots are decompressed. The procedure is called a microdiscectomy.
This procedure is minimally-invasive and patients are mobile soon after surgery. Patients may go home the same day or stay overnight. This technique has been used for generations with a good rate of success. More extensive surgery (lumbar fusion, lumbar disc replacement) is rarely indicated for a first-time disc rupture. These are much bigger procedures that are usually unnecessary in this situation.
Degenerative disc disease
Over time and with stress, the intervertebral discs can degenerate. This is a naturally occurring process, and is one of the reasons we get shorter as we grow older! Healthy discs are soft and contain a significant amount of water. The discs not only act as "shock absorbers," but they also maintain a certain height of the neuroforamen (area where the nerve root exits the spinal canal). As the disc degenerates, it becomes dehydrated and flattened. This can lead to a posterior bulging of the disc, possibly resulting in compression of the nerve. Treatment is often non-surgical, and spinal decompression (DRX) is a good treatment option. Physical therapy and pain management procedures may be helpful. In certain cases, surgery may be an option.
Fractures: Lumbar osteoporotic compression fractures
Compression fractures of the thoracic and lumbar spine are most commonly seen in the elderly and usually occur as a result of osteoporosis. In these cases, the bones become soft. When the patient with soft bones falls, the vertebral body (main bones in the spinal column) compresses, usually more so in the front. This can cause a loss of height and integrity of the spinal column. It can also cause a deformity in the alignment of the canal, often referred to as a kyphosis. This can result in a "hunched over" posture.
Unfortunately, this can also result in a great deal of pain. The pain may be just in the back where the fracture occurred, but also may involve the nerve and result in a shooting pain across the chest or abdomen, much like a thoracic disc herniation. Oftentimes, this pain will settle down with time. If not, a minimally invasive procedure referred to as a kyphoplasty can be performed to restore the height of the collapsed vertebral body as well as the proper alignment. Improvement in pain symptoms is often immediate. The procedure works best if done soon after the fractures occur. Patients are not excluded because of age- in fact, most patients are elderly.
Fractures and trauma (non-osteoporotic)
There are a wide variety of traumatic fractures and subluxations, and treatment varies on a case-by-case basis. Treatment may range from simple observation or wearing a brace to major reconstructive surgery of the spine.
Spondylolisthesis
Spondylolisthesis refers to an abnormal slippage of one vertebral body on another. Instead of the vertebral bodies (main bones of the spinal column) stacking directly on top of one another, adjacent bodies "slip" on each other. This can be stable, meaning that it doesn't move when the back moves, or it can be unstable. An unstable spondylolisthesis can cause compression of the nerves in the spinal canal and significant low back pain.
Stable asymptomatic spondylolisthesis does not require treatment. However, unstable symptomatic cases are treated with a fusion. This generally involves decompression of the spinal canal and stabilization with screws and rods.
Stenosis (lumbar stenosis, spinal stenosis)
Narrowing in the lumbar spine, or lumbar stenosis, causes compression of the nerves going into the legs. Typical symptoms include pain and often weakness in the legs worsened with prolonged standing or walking. Sometimes back or hip pain can occur as well. Oftentimes, the legs feel better with rest or when the back is flexed (bent forward), and patients will typically say they prefer to lean forward (i.e. on the grocery cart).
As with cervical stenosis, some people are born with a narrow spinal canal (congenital stenosis). Degenerative changes that accumulate over time can occupy the space in the spinal canal that usually is occupied by the nerves. Thickened ligament and enlarged joints can encroach on the spinal canal, as can disc bulges. In many cases, there's an element of both congenital stenosis (preexisting narrowing) and degenerative changes.
Conservative measures such as epidural steroid injections and physical therapy may improve symptoms, often temporarily. These modalities can provide symptomatic relief, but they do not directly treat the pathology. Definitive treatment involves surgical decompression. By removing the thickened ligament and bone, the spinal canal is "unroofed," making more room for the nerves within it.
