spine

Spine Conditions

Back pain affects 80% of Americans at some time in their lives. Common causes include degenerative disc disease, arthritis, and muscle and nerve problems. The skilled neurosurgeons at Arkansas Surgical Hospital can help diagnose and treat your chronic pain, returning you to work and other activities.

Compression Fracture (Trauma)

Trauma, the result of physical injury to the spine, can lead to compression of one or more vertebrae and injury to the spinal cord or nerves. Vertebrae weakened due to osteoporosis can also fracture (break) with low-level trauma.

The most common symptom of spinal trauma is the sudden onset of pain following a traumatic episode.

Compression of the vertebrae can occur as a result of a severe injury or trauma. In some cases, osteoporosis can cause weakening of the vertebrae, causing them to fracture. Affected vertebrae can cause damage to the spinal cord or nerves.

Fractured vertebrae are most commonly found in the middle of the back or the lower back. The most common causes of spinal trauma are car crashes or falls.

Degenerative Disc Disease

Step 1: Introduction
Degenerative Disc Disease, or DDD, occurs in many people as part of the normal aging process. It is sometimes referred to as arthritis of the back. The condition results from changes in the compressible spinal discs, which act as and shock-absorbing cushions between the vertebrae. With age, the discs can lose fluid, making them less flexible and more compressed, or they can develop tiny tears in the outer layer (annulus), which can cause pain by themselves or allow the jellylike inner layer (nucleus) to bulge, causing pressure on the spinal cord and/or nerves.

Step 2: Symptoms
The most common symptom of DDD is deep aching lower back pain that can radiate to the top of the thighs. Pain in the morning is usually described as stiffness in the lower back. The condition can occur anywhere along the spine, but is most common in the neck (cervical) and lower back (lumbar) regions. The resulting neck or lower back pain is usually made worse by certain activities or prolonged sitting and standing. There may be bouts of severe pain, lasting from a few days to several months, before returning to a milder long-term, chronic pain. Many people don’t realize they have disc degeneration because it frequently causes no pain at all.

Step 3: Causes
The cause of DDD is typically the normal wear and tear that occurs in the discs as a person ages. However, it can occasionally be caused by trauma (injury) or repetitive lifting. The affected disc becomes thinner and loses its cushioning ability. These changes affect the way the vertebrae in the spine move and bone spurs can result as well as bulging or disc leakage, all of which can cause pain when they contact the spinal nerves. Smoking, obesity, heavy lifting, and hereditary factors also lead to advanced degeneration.

Step 4: Summary
DDD causes lower back pain in most people at some point in their lives. Symptoms usually resolve on their own; occasionally, medications and non-operative treatments (physical therapy) are needed. Surgery is performed for those whose symptoms do not improve.

Osteoarthritis

Step 1: Introduction
The term osteoarthritis is a general term that describes changes in the joints that occur as a person ages. Osteoarthritis of the spine causes joints along the spine to deteriorate and may result in the formation of bone spurs, cysts, and a narrowing of the disc space.

Step 2: Symptoms
The most common symptom of spinal osteoarthritis is low back pain that may radiate and be felt in the pelvis, buttocks, groin, and down the front of the thighs. Osteoarthritis in the cervical region is also common, and the associated neck pain may also be felt along the shoulders and between the shoulder blades. Both low back and neck pain tend to be worse in the morning and late in the evening, and are often described as stiffness. A minor, steady or intermittent ache that may be aggravated by motion, loss of flexibility, and tingling or sensations of numbness around the spine may also be symptoms.

Step 3: Causes
The primary cause of osteoarthritis is normal wear and tear on the body due to the aging process. Repetitive motion and injuries from sports or employment and excessive body weight can also accelerate the degenerative process. The joints become irritated and inflamed as cartilage surrounding the facet joints of the spine breaks down over time. The discs between the vertebrae also degenerate, and the decreased disc height affects how the joint moves. Pain may result from friction between the joints and the body often produces bone spurs and cysts that may also cause pressure on the spinal cord and/or nerves.

Step 4: Summary
Patients can often play an active role in treating osteoarthritis to avoid deterioration and a worsening of their symptoms. Treating osteoarthritis generally involves avoiding damaging activities, managing the inflammation, reducing pain, controlling one’s weight, and maintaining flexibility with exercise.

Sciatica

Step 1: Introduction
Sciatica describes an irritation of the sciatic nerve, which is the largest single nerve in the human body. The sciatic nerve begins from several nerves in the lower lumbar vertebrae and the sacrum at the bottom of the spine. These nerves combine to form the sciatic nerve, which travel through the buttocks and down each leg. Sciatic nerve irritation can result from compression of the sciatic nerve roots or from inflammation.

Step 2: Symptoms
The primary symptom of sciatic nerve irritation is pain felt in the lower back or buttocks that travels down one leg, frequently to the foot. The pain can vary from a mild ache to a sharp, shooting pain and may sometimes feel like an electric jolt traveling down the leg. Muscular weakness, numbness or a tingling sensation down the leg and into the foot may also be symptoms. Pain in the leg is usually worse when sitting.

Step 3: Causes
Sciatica can be caused by a variety of conditions that cause inflammation or pressure on the nerve roots connected to the sciatic nerve. The most frequent cause of sciatica is the degeneration and rupture of a lumbar disc due to the normal aging process. The ruptured disc may herniate and push against a nerve, causing pain in the low back, leg, or both. Occasionally, trauma or an episode of heavy lifting causes sudden rupture of the disc and symptoms. Sudden twisting, such as when golfing, can also cause herniations.

Step 4: Summary
If symptoms include loss of bladder or bowel control, seek medical attention immediately. Minor sciatica will often disappear over time and it is rare for permanent nerve damage to result. If symptoms persist and worsen, or if they arise after a sudden injury, treatment may be necessary. Non-surgical treatments include controlling sources of inflammation and pressure, as well as physical therapy. Surgery is performed for those whose symptoms do not improve.

Spondylolisthesis

Step 1: Introduction
Spondylolisthesis is condition that occurs when one spinal vertebral body slips forward relative to another. It can occur anywhere along the spine, but typically occurs in the lumbar region. Spondylolisthesis is less common among young children, occurring primarily in adolescents and adults.

Step 2: Symptoms
Symptoms resulting from spondylolisthesis vary. Some people have no pain or other symptoms. In extreme cases, the deformity may be a visible increase in the curvature of the spine in the lumbar region, which can affect movement. Often there is mild to moderate low back pain, particularly after exercising. If the forward slippage compresses a nerve, leg pain often develops.

Step 3: Causes
Spondylolisthesis can be caused in several ways. The majority of cases occur in the elderly when the joints that allow the spine to bend forward (facet joints) wear with age and allow one vertebra to slip over another. In other cases, subjecting to spine to a sudden or repeated force may cause spondylolisthesis. Adolescent athletes that perform repetitive hyperextension, such as gymnasts, may be at increased risk for spondylolisthesis.

Step 4: Summary
Spondylolisthesis may or may not require treatment depending on whether symptoms include pain or disability. Non surgical treatments may include modifying activities to reduce stress on the spine, physical therapy, medications or injections to reduce pain and inflammation, or wearing a brace. In severe cases or those that are progressively worsening, surgery may be performed to correct the condition.

Herniated Disc - Cervical

Step 1: Introduction
A cervical disc herniation, or cervical radiculopathy, occurs when a small portion of a disc ruptures and causes pressure on spinal nerves in the neck. Small herniations are sometimes called bulges or protrusions, and people experiencing pain from the herniation often describe it as a pinched nerve.

Step 2: Symptoms
Depending on which cervical disc has herniated, the specific pain symptoms may vary. In general, pressure on a spinal nerve causes discomfort in various sites along one or both arms, frequently down to the hand. There can be shooting, burning pains, weakness, and/or numbness. In some instances, a cervical herniation can cause pressure on the spinal cord, a condition called cervical stenosis. Stenosis can lead to a medical condition called myelopathy. Myelopathy symptoms can include neck stiffness, numbness or heaviness in the arms and hands, or a shock-like feeling down the arms or legs. In severe cases, there can be difficulty using the arms and hands or difficulty walking.

Step 3: Causes
Cervical disc herniations are most frequently caused by degeneration due to the normal aging process. As small tears in the disc’s outer layer (annulus) develop and enlarge over time, the jellylike inner layer (nucleus) may bulge outward, causing pressure on the spinal cord and nerves. Occasionally, trauma or an episode of heavy lifting causes sudden rupture of the disc resulting in symptoms.

Step 4: Summary
Arm pain and discomfort from a disc herniation can often be resolved with medication and non-operative treatments (physical therapy). When these treatments are successful, arm pain tends to disappear first and it may take longer for weakness or numbness to improve. Surgery is performed for those whose symptoms do not improve.

Herniated Disc - Lumbar

Step 1: Introduction
A lumbar disc herniation, or lumbar radiculopathy, occurs when a small portion of a disc ruptures and causes pressure on spinal nerves. Small herniations are sometimes called bulges or protrusions, and people experiencing pain from the herniation often describe it as a pinched nerve.

Step 2: Symptoms
In general, pressure on a spinal nerve from a lumbar herniation causes discomfort in one or both of the legs, frequently down to the ankle or foot. There can be shooting pains, weakness, and/or numbness. Pain in the leg is usually worse when sitting.

Step 3: Causes
Lumbar disc herniations are most frequently caused by degeneration due to the normal aging process. As small tears in the disc’s outer layer (annulus) develop and enlarge over time, the jellylike inner layer (nucleus) may bulge outward, causing pressure on the spinal cord and nerves. Occasionally, trauma or an episode of heavy lifting causes sudden rupture of the disc resulting in symptoms. Sudden twisting, such as when golfing, can also cause lumbar disc herniations.

Step 4: Summary
Lower back and leg pain from a disc herniation can often be resolved with medication and non-operative treatments (physical therapy). When these treatments are successful, leg pain tends to disappear first and it may take longer for weakness or numbness to improve. Surgery is performed for those whose symptoms do not improve.

Stenosis - Cervical

Step 1: Introduction
Spinal stenosis is a condition that causes a narrowing of the spinal canal, which can compress the spinal cord or nerves, resulting in pain, weakness, and/or numbness. When this condition occurs in the neck region it is referred to as cervical stenosis.

Step 2: Symptoms
A narrowing of the spinal canal typically doesn’t cause symptoms unless it progresses to a point where it significantly compresses the spinal cord or nerves. When this happens, intermittent or chronic pain, numbness, or weakness may be felt in the neck and shoulders and may extend down the arms to the hands. The neck pain is often described as stiffness, and people often complain of a numbness or heaviness in the arms and hands. When the spinal cord is compressed, there can be shock-like pain down the arms and legs, difficulty using the arms and hands, or difficulty walking.

Step 3: Causes
Cervical stenosis is most frequently caused by degenerative changes (osteoarthritis) in the neck. After years of normal wear and tear, cushioning between bones in the spine may break down, allowing bones to wear against each other. At these sites, the body produces growths called bone spurs that may narrow the spinal canal, causing pressure on the spinal cord and nerves. Occasionally, large disc herniations and spinal tumors can narrow the spinal canal enough to compress the spinal cord.

Step 4: Summary
Cervical stenosis may or may not require treatment depending on whether symptoms include pain or disability. Non-surgical treatments may include modifying activities to reduce stress on the spine, physical therapy, medications or injections to reduce pain and inflammation, or wearing a brace. In severe cases or those that are progressively worsening, surgery may be performed to correct the condition.

Treatments & Procedures

Cervical - Anterior Cervical Discectomy, Fusion - Instrumented

Anterior cervical discectomy procedures are usually performed to remove pressure on nerves from disc herniations. A disc herniates when the outer portion of the disc ruptures and some of the softer disc nucleus material squeezes out. The herniated disc pushes against the spinal cord or spinal nerves and tends to cause pain in the neck or arms. Removing the ruptured disc alleviates pressure on the nerves or spinal cord, which usually relieves the pain. A bone graft is usually inserted with instrumentation to keep the disc space at a normal height and fuse the vertebrae above and below the removed disc.

What is a discectomy?
“Discectomy” means the removal of a disc. When a disc needs to be removed from the spine, it is often because of injury or herniation.

Herniation occurs when the outer area of the disc ruptures, causing the softer inner material to squeeze out. Pain can occur in the neck or arms as the herniated disc puts pressure on the spinal cord or spinal nerves.

What happens during an anterior cervical discectomy?
In an anterior cervical discectomy surgery, an incision is made on the front (anterior) of the neck (cervical spine). A portion of the herniated disc is removed, and a bone graft is placed between the vertebrae where the disc was removed. A plate is then placed over the bone graft and secured to the vertebrae with screws.

Cervical Laminectomy with Fusion

A cervical laminectomy removes the spinous process and lamina from a vertebra to eliminate pressure on the spinal cord. The source of the pressure is often spinal stenosis, a condition in which there is a narrowing of the spinal canal that causes pressure on the spinal cord or nerves. After removing bone, bone grafts can be added to fuse the vertebrae and provide stability to the spine.

What is a cervical laminectomy?
“Laminectomy” means the removal of lamina, or vertebral bone. This removal relieves pressure on the spinal cord or nerves that is often caused by spinal stenosis, which is the narrowing of the spinal canal.

What happens during a cervical laminectomy with fusion?
An incision is made on the back of the neck (cervical spine). The spinous process and lamina are removed from the affected vertebrae. On the sides of the vertebrae, the top layer of the articular processes are removed to prepare for fusion. Finally, bone grafts are placed on the articular processes, eventually fusing to the spine to provide stability.

Lateral Lumbar Interbody Fusion (LLIF)

What is a lateral lumbar interbody fusion?
Lateral fusion is used in cases of herniation, disc degeneration, impingement, and tumors. In this minimally invasive procedure, incisions are made on the side of the body to avoid undue damage to muscles, bones, and blood vessels. An x-ray device called a fluoroscope is used to project images on a screen, helping your surgeon identify and navigate to the correct vertebrae.

What happens during a lateral lumbar interbody fusion?
A probe that monitors your nerves is inserted into the psoas muscle of your back. Then, a series of dilators, increasing in size, are inserted around the probe to make the opening gradually larger. A retractor tool is placed over the area to move aside the muscle, and the dilators are removed. A light and endoscope are then used to view the surgical area.

In cases of disc degeneration, most of the affected disc is removed, and a spacer with bone grafts is inserted to fuse the vertebrae. In cases of herniation and impingement, the spacer relieves pressure on the nerve root.

Anterior Lumbar Interbody Fusion (ALIF)

What is anterior lumbar interbody fusion?
Anterior lumbar interbody fusion (ALIF) involves the removal of degenerated disc material in the lower (lumbar) spine. The procedure makes more room for spinal nerves, relieving pain in the back or the legs.

By approaching the surgical area from the front (anterior) of the body, your surgeon avoids causing damage to the muscles of the lower back.

What happens during an anterior lumbar interbody fusion?
In this procedure, the incision is typically made on the left front (anterior) side of the abdomen. Some or all of the degenerated disc is removed, and a spacer is put in its place. Using a bone graft, the spacer eventually fuses to the vertebrae.

Laminectomy

What is a laminectomy?
“Laminectomy” means the removal of lamina, or vertebral bone. This removal relieves pressure on the spinal cord or nerves.

What happens during a lumbar laminectomy?
In a lumbar laminectomy, an incision is made in the lower (lumbar) back. The spinous processes and lamina in the affected area are removed. The source of the spinal nerve decompression—bone spurs or degenerated discs, for example—is also removed to relieve the pressure exerted on the spinal nerves.

Instrumented Fusion
In a lumbar laminectomy with instrumented fusion, the top layer of the transverse processes of the vertebrae are removed to create a space for the fusion site. Then, instrumentation such as screws and rods are inserted for stabilization of the spine. Finally, a bone graft is used to fuse the spine.

Uninstrumented Fusion
In a lumbar laminectomy with uninstrumented fusion, the fusion is performed without the use of instrumentation.

Lumbar - Minimally Invasive Approach (PLIF)

Step 1: Introduction
A posterior lumbar interbody fusion (PLIF) is performed to remove a degenerating disc that is the source of back or leg pain and fuse spinal vertebrae with bone grafts. It is called a posterior procedure because the spine is approached through an incision on the back. In patients with spinal instability, instrumentation is used to provide space for placing the grafts and to help stabilize the spine. Using a technique known as minimally invasive surgery, this procedure can be done with a much smaller incision than traditional open spinal surgeries and avoids damaging the low back muscles.

Step 2: Incision and Dilation
Two short incisions, approximately 2.5 cm. (1 in.) each, are made on either side of the middle of the lower back. A device that projects live X-ray images onto a screen, called a fluoroscope, is typically used to pinpoint the exact position on the spine where the surgery will be performed. Next, a thin wire or needle is inserted through tissues and muscle to the level of the spine on each side. Special dilators are guided down the wire to separate muscle fibers and provide access to the underlying spine without cutting through the muscles. After the initial dilators are docked on the back of the spine, larger dilators are added, gradually increasing the diameter to allow enough room for the surgical procedure on each side.

Step 3: Retractor and Instrument Set Up
A retractor device that can expand the surgical field and hold back the muscle is placed over the dilators. The dilators are removed and a lighting component is attached to illuminate the surgical field. A hex screwdriver is used to open the retractor blades, holding the soft tissue out of the way. The surgical exposure is now complete. An endoscope or microscope is then added to the edge of the retractor to provide close-up imagery on a screen to help guide the procedure.

Step 4: Excision
Cutting instruments are used to remove portions of the lamina (laminectomy), and portions of facet joints (facetectomy) from the back of the vertebrae on each side. Removing bone here allows the surgeon to see the degenerating disc. A grasping instrument is used to remove most of the intervertebral disc by entering through the incisions on either side. Removing the abnormal disc relieves the pressure.

Step 5: Instrumentation
Next, the vertebrae are prepared for instrumentation. A sharp awl is used to make holes in the pedicles for insertion of pedicle screws. Screws are placed through a metal plate and then into the pedicle holes, ending with the screw tips in the middle of the vertebral body. Screws and plates are placed on both sides of the spine. Two more pedicle screws are then placed through the metal plate and screwed into the lower vertebral body pedicles.

Step 6: Distraction and Graft Placement
To prepare for bone graft insertion, the disc space is spread apart (distracted) by moving the vertebral bodies or applying pressure on the pedicle screws. The screws are tightened to hold the disc space in this open position. Two bone grafts are then placed between the vertebral bodies. The bone grafts allow for eventual fusion as bone grows between the vertebral bodies. In variations of this procedure, spacers, cages packed with graft material, or ground bone graft material may also be packed into the disc space to aid with the fusion.

Step 7: Compression
To provide stability to the spine while the fusion occurs, the lower screws are loosened and the vertebral bodies are squeezed together (compressed). The screws are tightened in the compressed position, which allows for a tight fit of the grafts in between the vertebral bodies. Small screws called blockers are placed on the pedicle screws to lock the screws to the metal plate.

Step 8: Summary
The Minimally Invasive Surgery (MIS) approach can be safely performed with less trauma to the surrounding muscles. MIS procedures can result in less postoperative pain, shorter hospitalizations and quicker patient recovery than traditional open surgical methods.

Lumbar - Minimally Invasive Approach (TLIF)

Step 1: Introduction
A transforaminal lumbar interbody fusion (TLIF) is performed to remove a portion of a disc that is the source of back or leg pain and fuse the spine. Like the PLIF (posterior lumbar interbody fusion) procedure, bone graft is used to fuse the spinal vertebrae after the disc is removed. However, the TLIF procedure places a single bone graft between the vertebrae from the side, rather than two bone grafts from the rear as in the PLIF procedure. In patients with spinal instability, instrumentation is used to help stabilize the spine during the bone graft fusion. Using a technique known as minimally invasive surgery, this procedure can be done with a much smaller incision than traditional open spinal surgeries and decreases damage to the low back muscles.

Step 2: Accessing the Spine
A short incision, approximately 2.5 cm. (1 in.), is made to the side of the middle of the lower back. A device that projects live X-ray images onto a screen, called a fluoroscope is typically used to pinpoint the exact position on the spine where the surgery will be performed. Next, a thin wire or needle is inserted through tissues and muscle to the level of the spine. Special dilators are guided down the wire to separate muscle fibers and provide access to the underlying spine without cutting through the muscles. After the initial dilator is docked on the back of the spine, larger dilators are added, gradually increasing the diameter to allow enough room for the surgical procedure.

Step 3: Retractor and Instrument Set Up
A retractor device that can expand the surgical field and hold back the muscle is placed over the dilators. The dilators are removed and a lighting component is attached to illuminate the surgical field. A hex screwdriver is used to open the retractor blades, holding the soft tissue out of the way. The surgical exposure is now complete. An endoscope or microscope is then added to the edge of the retractor to provide close-up imagery on a screen to help guide the procedure.

Step 4: Accessing the Disc
Through the opening in the retractor, the surgeon is now able to remove the entire facet joint in order to allow access to the disc. Removing bone here allows the surgeon to access the disc.

Step 5: Excision
A grasping instrument is used to remove most of the intervertebral disc. Removing the facet joints and disc relieves pressure on the spinal nerves.

Step 6: Graft Placement
A single bone graft is placed in the disc space from the lateral (side) aspect through the area exposed where the facet joint was removed. The bone graft will provide stability to the spine when it fuses with the vertebrae above and below it. In variations of this procedure, spacers, cages packed with graft material, or ground bone graft material may also be packed into the disc space to aid with the fusion.

Step 7: Instrumentation
Next, the vertebrae are prepared for instrumentation. A sharp awl is used to make holes in the pedicles for insertion of pedicle screws. A guide wire is positioned in the holes and screws are placed over the guide wire and screwed into the pedicle. After the screws have been placed, the guide wire is removed. Next, a rod is positioned between the screws and fastened in place. The rod and screw instrumentation provides stability to the spine and prevents the vertebrae from moving while the bone graft fusion takes place.

Step 8: Summary
The Minimally Invasive Surgery (MIS) approach to the TLIF procedure can be safely performed with little trauma to the surrounding low back muscles. MIS procedures may result in less postoperative pain, shorter hospitalizations, and quicker patient recovery than traditional open surgical methods.

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