Spine

Anatomy

Please refer to the following pictures to help you understand the normal spinal anatomy.





















Vertebrae

The vertebrae are the bones of the spine. 

The vertebrae line up one on top of another forming the spinal column.  The neck, or the cervical spine, is made of seven bones.  The middle of the back, or the thoracic spine, is made of twelve bones.  The lower back, or lumbar spine, is made of 5 bones.  The sacrum and coccyx make up the very bottom of the spine, or the tailbone.  


The front half of each vertebrae is a solid block of bone called the vertebral body that provides structural support.  The back half of each vertebrae is hollowed out forming the spinal canalwhere the spinal cord and nerves travel.  A nerve exits between each vertebrae on each side at the foramen.  Each nerve supplies specific muscles, sensations, and/or reflexes.  The bones are joined in their front half by large joints, the intervertebral discs, and in the back half by smaller joints, the facet joints.  These joints along with the muscles of the neck and back allow for the normal motion of the spine.




















Intervertebral Discs

The intervertebral discs are the soft, spongy material between each vertebral body. 

The soft disc material is contained between the vertebrae by a firm fibrous band.  Sometimes, due to the repeated stresses and motions of the spine this band can tear and a portion of the soft disc material will bulge or protrude beyond its normal location.  This herniated or bulging disc can then push on either the spinal cord or the nerve roots.  Pressure on the spinal cord causes symptoms of myelopathy and pressure on a nerve root causes symptoms of a radiculopathy.








                                            


Facet Joints

The facet joints are located between two adjacent vertebrae on each side.  They are synovial joints similar to the ones in your wrists and fingers.  Along with the intervertebral discs, these joints allow for the segmental motion of the spinal column.  Over time, the repetitive motion and stresses on these joints can lead to degenerative changes.  This leads to enlargement of the bones that make up the joint and can lead to stenosis.  This can cause arthritis-type pain or directly push on nerves or the spinal cord to cause nerve pain and dysfunction.


Spinal Cord

The spinal cord is a large bundle of nerve tissue that communicates all of the signals to and from your brain to carry out all sensations and movements of the body.  The spinal cord travels down the length of the upper and middle spine in the spinal canal and ends at the top of the lumbar spine.  Nerve roots exit the spinal cord and travel a short distance in the spinal canal to exit between every vertebrae from the neck down to the sacrum.  Normally, the spinal canal is much larger than the spinal cord. Sometimes, overgrowth of the ligaments and joints or disc herniations may decrease the size of the spinal canal and push on the spinal cord.  Pressure on the spinal cord causes signs and symptoms of myelopathy.


Nerve Root

A nerve root is a small bundle of nerve fibers that exits from the spinal cord and then travels to a specific part of the body as a nerve.  Each nerve carries information to and from specific areas of the body. The nerves that exit at the neck (cervical spine) travel to and from the arm.  The nerves that exit at the midback (thoracic spine) travel to and from the torso.  The nerves that exit at the lower back (lumbar spine) travel to and from the legs.  The lowest nerves exit from the sacrum and travel to and from the pelvic area to help control bowel and bladder function.


Diagnosis

Spondylosis

Spondylosis is the normal wear and tear changes on the bones and joints from use and age.  This is a form of arthritis.


These degenerative changes can accelerate in certain individuals more than others.  The vertebrae form outgrowths called osteophytes, or bone spurs, on the vertebral bodies or facet joints that can then put pressure on the spinal cord or nerve roots.  Spondylosis also causes the spongy intervertebral discs to degenerate over time.  They begin to lose strength, height, and elasticity.  They can then bulge or herniate and also cause pressure on the spinal cord or nerve roots.  These degenerative changes are a form of arthritis and may cause or contribute to neck or back pain regardless of pressure on the spinal cord or nerve roots.  Neck and back pain due to spondylosis is best treated nonoperatively with a combination of medications and therapies.  If spondylosis contributes to pressure on the nerves or spinal cord then surgery may be indicated.


Stenosis

Stenosis is the term used for narrowing of the spinal canal.  This is often due to overgrowth of the surrounding bones and ligaments (bone spurs, spondylosis) or intervertebral disc bulging and herniation.  Central stenosis can put pressure on the spinal cord and cause myelopathy.  Stenosis out laterally can put pressure on the exiting nerve roots and cause a radiculopathy.  Stenosis may be purely a radiological finding without causing any symptoms at all.  If stenosis causes symptoms due to pressure on the nerves or spinal cord then surgery may be indicated.

             









           

Spondylolisthesis 

Spondylolisthesis occurs when one vertebrae slips in front of another.  This is often due to bilateral defects, or spondylolysis, in the bone between the adjoining joints.  This slip may increase with flexion or extension of the spine.  As the vertebrae slips forward, it compresses the nerves in the spinal canal as well as at their point of exit from the spine.  This may be a chronic finding that does not warrant any treatment at all.  If it is causing pressure on the nerves or significant back pain then surgery may be warranted.  Surgery often involves decompression of the nerves as well as a fusion to maintain stability.


Spondylolysis (Pars Defects)

Spondylolysis is a fracture in the pars interarticularis.  Each vertebrae is connected to the one above and the one below at the facet joints on either side.  The pars is a piece of bone between the joint above and the joint below.  A fracture on both sides at the pars will in effect disconnect the spine above from the spine below and allow abnormal motion.  This type of fracture occurs most commonly at the very bottom of the spine between L5 and S1 or less commonly between L4and L5.  The fracture may be congenital or due to trauma.  Pars defects may even be completely incidental without any symptoms and some studies suggest they may be present in up to 10% of the normal population.  The pars defects may result in abnormal motion of the spine in which the top vertebrae slips in front of the bottom vertebrae (spondylolisthesis).  This can result in compression of the nerves in the spinal canal or at their points of exit from the canal.  If there are symptoms associated with spondylolysis then surgery may be warranted.  Surgery usually involves decompression of the nerves and fusion of the spine to maintain stability.                                        











Disc Herniation

A disc herniation occurs when the soft material within the intervertebral disc protrudes beyond its normal location.  This can occur due to a sudden, severe stress (trauma) or due to chronic, repetitive stress (degenerative).  A small disc herniation is often called a bulging disc.  The disc herniation may cause or contribute to back pain and muscle spasm.  If the disc herniation pushes on the spinal cord or on a nerve then it can also cause symptoms in the arms or legs as well.  If the disc herniation causes symptoms due to spinal cord pressure (myelopathy) or nerve pressure (radiculopathy) then surgery may be indicated.  If the disc herniation is in the neck then it can be treated with either an anterior cervical discectomy and fusion or a posterior foraminotomy and discectomy.


Most disc herniations can resolve on their own without surgery.  Over time, the body breaks down the disc material that herniated out of its normal location.  The symptoms will typically resolve if this happens but sometimes the nerve can be left with permanent injury.  There are essentially two ways to get rid of a disc herniation – the body breaks it down over time or a surgeon removes it.  It is initially best to see if the body can get rid of the disc herniation on its own.  This may take several weeks to months.  While the body does its work, treating and minimizing the symptoms with nonsurgical therapy is the primary goal.                         









Radiculopathy

Radiculopathy is a constellation of signs and symptoms due to impaired function of a nerve root.  Pressure on nerve roots in the neck may cause pain, numbness, or weakness in a specific part of the arm.  There are eight nerves that exit at the neck – one above each vertebrae and one below the seventh cervical vertebrae.  The important nerves to the arm are cervical nerves 4-8 (C4 through C8).

            C4:  sensation to the shoulder and neck area

            C5:  sensation and strength to the shoulder area

            C6:  sensation down the arm to the thumb, biceps strength, biceps reflex

            C7: sensation down the arm to the hand, triceps strength, triceps reflex

            C8: sensation down the arm to the pinky, hand strength


Thoracic nerves in general supply the torso and are rarely symptomatic.


The lumbar nerves and first sacral nerve supply the legs.  Pressure on nerve roots in the lower back may cause pain, numbness, or weakness in a specific part of the leg.  The important nerves to the leg are lumbar nerves 2-5 (L2 through L5) and the first sacral nerve (S1)

            L2  hip and groin sensation and strength

            L3  hip and thigh sensation and strength

            L4  thigh and leg sensation and strength, knee reflex

            L5  leg and foot sensation, foot strength

            S1 leg and foot sensation, foot strength, ankle reflex


The lower sacral nerves (S2-S5) supply the pelvic region and contribute to bowel and bladder function.


Initial treatment for radiculopathy is often nonsurgical therapy.  80-90% of radiculopathies due to an acute disc herniation will resolve without surgery.  Medicines that may be beneficial include a short steroid taper, a mild narcotic, muscle relaxers, and non-steroidal anti-inflammatory medications.  Physical therapy is often beneficial as well.  A steroid injection near the irritated nerve may help alleviate the pain associated with a radiculopathy.  Surgery may be indicated for severe unrelenting pain, significant weakness, persistent numbness, or failure to improve with nonsurgical treatment. 


Myelopathy 

Myelopathy is a constellation of signs and symptoms due to impaired function of the spinal cord.  Pressure on the spinal cord from disc herniations, bone spurs, or trauma may cause myelopathy and often presents with altered strength and sensation.  The process most often builds up slowly and presents over several months to years with progressive clumsiness.  The fingers begin to feel numb and weak and walking becomes unsteady with falling.  A sudden trauma or disc herniation may cause more rapid and dramatic symptoms.  Severe myelopathy, may result in significant loss of strength and bowel or bladder dysfunction.  On exam, this often causes very brisk reflexes and an unsteady gait.  Surgery may be indicated if there are signs or symptoms of myelopathy and imaging studies that demonstrate pressure on the spinal cord.


Neurogenic Claudication

Neurogenic claudication is a constellation of signs and symptoms due to pressure on the nerve roots in the lower spine.  Stenosis of the lumbar spine causes narrowing of the spinal canal and pressure on multiple nerve roots.  This pressure is often increased with standing or walking.  Therefore, symptoms typically include pain, numbness, or weakness in the legs that occurs with standing or walking.  The symptoms typically intensify the longer one stands or the further one walks.  This may be quite severe and cause frequent falls.  Sometimes, one leg is worse than the other.  On rare occasions, this may cause bowel or bladder dysfunction as well.  The symptoms are often relieved by sitting down or leaning forward..  The symptoms typically progress over a prolonged period of time.  Surgery is often indicated if symptoms of neurogenic claudication are significant and there is evidence of spinal stenosis on imaging studies.


Cauda Equina Syndrome

Cauda Equina Syndrome is a constellation of symptoms that occur due to pressure on multiple lumbar and sacral nerve roots.  Often due to acute trauma or a very large disc herniation in the lumbar or sacral spine, pressure on multiple nerve roots in the lower spine can result in leg weakness and numbness as well as bowel and bladder dysfunction.  Cauda Equina means "horses tail" in Latin which refers to the collection of lower nerve roots as they descend in the lumbar and sacral spine.  This is often a surgical emergency that warrants prompt decompression of the nerves to give the best chance at recovery of function. 


Spinal Trauma

Trauma to the spine can result in significant pain and neurological injury.  The types of fractures that occur in the neck are a little different than the ones in the lower spine.  Spinal trauma can cause neurological injury by direct pressure on the nerves from a fractured fragment of bone, by instability and abnormal motion of the vertebrae that can then narrow the spinal canal, or by bleeding within the spinal canal.


Cervical Fractures (neck)

Jefferson Fracture: This is a fracture of the C1 vertebral body.  The fracture fragments typically spread away from the spinal canal so there typically is not neurological injury.  This is usually treated with rigid cervical immobilization by wearing a hard neck brace.


Odontoid Fracture: This is a fracture of the C2 vertebral body.  The C2 vertebral body has a peg of bone called the odontoid process that extends upwards and articulates with the C1 vertebral body.  Traumatic flexion of the neck can cause this peg of bone to fracture.  The spinal canal is quite large at this level so neurological injury is not common.  Depending on the severity of the fracture this may require surgical intervention as it is often an unstable fracture.


Hangman's Fracture:  This is a fracture of the C2 vertebral body.  This is a fracture of the pars interarticularis, a portion of the bone between the facet joints.  This often leads to instability at the C2-C3 junction.  Neurological injury is not common.  This is most often treated either with a rigid cervical collar or with more rigid nonsurgical immobilization.  In severe cases, neurological injury may occur and surgery may be required.


Clay Shoveler's Fracture: This is a fracture of the C6 or C7 spinous process.  This is a fracture at the tip of the bone that points posteriorly in the back of the neck.  This is a stable fracture that does not cause neurological injury.  There is no treatment required for this fracture but it is often associated with other more serious fractures.


Facet Fracture: This is a fracture of the joint between two adjacent vertebrae.  If this occurs on one side only this is typically a stable injury often treated with a cervical brace.  If this occurs on two sides at a given level this may be unstable and require further intervention.  No neurological injury occurs unless this is associated with a severe dislocation and a slip of one vertebrae in front of the other.


Facet Dislocation: The facet joint is made of a shelf of bone from two adjacent vertebrae.  The pieces of bone that make up the joint overlap each other like shingles on a roof.  If the "shingle" from the bone above moves in front of the "shingle" from the bone below then this is a joint dislocation.  This is an unstable injury and requires reduction of the dislocation back to its normal anatomical alignment.  A dislocation on one side typically does not cause neurological injury but bilateral dislocations often do.  This can be fixed with traction on the neck or with surgery.


Lumbar-Thoracic Fractures (back)

Compression Fracture:  This is a fracture that results in a collapse of the front half of the vertebral body.  This is typically a stable fracture.  Common causes for compression fractures include trauma, osteoporosis, or sometimes cancer to the bone.  Neurological injury typically does not occur.  This is often treated with pain medication and a brace.  Sometimes, if pain is severe then it may be treated with a minor surgical procedure called kyphoplasty in which cement is injected into the vertebral body to help provide support to the fractured vertebral body.

                                          













Burst Fracture:  This is a fracture that results in a collapse of the front and back half of the vertebral body.  This is typically an unstable fracture and most often due to a severe trauma.  Neurological injury may occur if a piece of bone pushes back into the spinal cord or nerves.  Depending on the severity of the fracture and neurological injury, this may be treated with bracing or with surgical stabilization.

                                          












Transverse Process Fracture:  This is a fracture of a piece of bone on the sides of the vertebral body that only functions as an attachment for the surrounding muscles.  This is a stable fracture and does not cause neurological injury.  There is no specific treatment required for this kind of fracture other than pain medication.


Treatment

Medication

The most bothersome symptom is most often pain and there are a number of medications that may help provide relief.  Patients are often started on a mild narcotic (percocet/oxycodone, lortab/hydrocodone), a nonsteroidal anti-inflammatory drug (motrin, advil, aleve), and a muscle relaxer (flexeril, skelaxin, robaxin).  These medicines will not help with numbness or weakness but can certainly benefit pain and muscle spasm.  A steroid (methylprednisolone, prednisone) is often prescribed at a tapering dose over the course of a week as well.  This can decrease the inflammation of the injured nerve and may benefit any of the symptoms.


Physical Therapy

Physical therapy involves mild strength training, stretching, and massage.  It is often a first line treatment.  This can help improve muscle loss, relax muscle tension/spasm, and minimize postures and activities that may aggravate the symptoms.  Here is a list of area Physical Therapy Facilities that provide these services.


Cervical Traction

Cervical traction involves stretching the neck with a gentle distraction device.  This may be used to gently spread the vertebrae apart giving the exiting nerves more room and temporary relief of the pressure.


Epidural Steroid Injection

A steroid can be injected in the space around the nerve that is being pressed.  The nerve that is being pressed is typically swollen and inflamed due to the pressure.  Injecting a steroid near the nerve will decrease that swelling and may temporarily relieve some of the symptoms.  If there is a lot of neck pain, other types of injections may be of benefit as well since the neck pain is most often due to the arthritis in the neck and not the pressure on the nerve.  A facet injection puts steroid directly in the joint and a pressure point injection puts it in the muscles that are hurting.


Surgery

Surgery is often reserved for symptoms that persist over time despite conservative therapy or for severe, acute symptoms.   Reasons for early surgery include severe pain that limits function and cannot be controlled adequately or severe or progressive loss of strength.  If there is significant weakness in the muscle supplied by an injured nerve then relieving pressure on that nerve in a timely fashion will give it the best chance at recovery.  There are several surgical options to relieve problems in the cervical spine. 


Anterior Cervical Discectomy and Fusion (ACDF)

An ACDF is performed to relieve pressure on the spinal cord and/or nerve roots in the neck.  Pressure on the spinal cord may cause symptoms such as numbness, weakness, clumsiness, or difficulty walking (myelopathy).  Pressure on a nerve root may cause pain,  numbness, or weakness in the shoulder, arm, or hand (radiculopathy).  An ACDF may be indicated when nonsurgical options have failed to relieve symptoms or when the symptoms are progressive and severe.


An ACDF involves making an incision in the front of your neck to expose and remove herniated disc and bone spur that are pressing on the spinal cord and/or nerve roots.  The removed disc is replaced with a bone graft that ultimately fuses with the vertebrae above and below.  A titanium plate is permanently secured with screws to the involved vertebrae to add stability until the fusion is complete.  Patients are admitted for surgery on the same day as the procedure and typically spend 1-3 days in the hospital.  The primary goal is to relieve the pressure on the spinal cord and/or nerve roots in order to relieve symptoms and prevent further injury. 

                           











Alternatives: Depending on the diagnosis, there may be alternative surgical or non-surgical therapies for the management of your symptoms.  Non-surgical therapy is often recommended before pursuing surgical options.  Treatment may include:     

  • Medication such as narcotic or non-narcotic pain medicine, steroids, anti-inflammatory medicines, and muscle relaxers
  • Physical therapy
  • Cervical traction
  • Injection therapy
  • Cervical Disc Replacement
  • Posterior Cervical Hemilaminotomy and Discectomy (PHLD)


Goals: Based on the diagnosis and symptoms, surgery may be recommended.  The goals of surgery are:

  • To remove pressure on the spinal cord and/or nerve roots
  • To remove the disc and fuse the involved vertebral bodies
  • To maintain normal stability of the neck


Benefits: The benefits include:

  • Immediate relief of the underlying problem
  • Improvement or stabilization of symptoms
  • Improved ability to walk and take care of oneself
  • Return to work and other activities


Risks: Surgery is a big decision and not recommended lightly.  In general, surgery is recommended when the benefits far exceed the expected risks of the procedure.  The possible risks may include:

  • Adverse reaction to anesthesia
  • Myocardial infarct (heart attack)
  • Stroke
  • Deep venous thrombus or pulmonary embolus
  • Nerve root injury causing weakness or numbness
  • Spinal cord injury causing weakness, numbness, bowel/bladder dysfunction
  • Swallowing difficulty
  • Hoarseness
  • Infection
  • Bleeding
  • Failure to relieve symptoms
  • Failed fusion or failure of the hardware
  • Need for further surgery

Outcomes: No guarantees can be made regarding the outcome following any surgery.  However, patients tend to do very well following an ACDF.  Success rates are quoted as high as 90% overall.  An ACDF is very good at relieving arm and leg symptoms related to pressure on the nerve roots or spinal cord.  Improvement in neck pain is more variable.  Major complications are very rare.  Most patients experience some degree of sore throat or difficulty swallowing for a few days to few weeks following surgery.  Most patients spend 1-3 days in the hospital.  Improvement may continue to occur for 3-6 months following the surgery.  Light activity is recommended for at least six weeks following surgery. 


    Cervical Disc Replacement 

A cervical disc replacement, or cervical arthroplasty, is performed to relieve pressure on the spinal cord and/or nerve roots in the neck.  Pressure on the spinal cord may cause symptoms such as numbness, weakness, clumsiness, or difficulty walking (myelopathy).  Pressure on a nerve root may cause pain,  numbness, or weakness in the shoulder, arm, or hand (radiculopathy).  A cervical disc replacement may be indicated when nonsurgical options have failed to relieve symptoms or when the symptoms are progressive and severe.


A cervical disc replacement involves making an incision in the front of your neck to expose and remove herniated disc and bone spur that are pressing on the spinal cord and/or nerve roots.  The removed disc is replaced with an artificial disc that functions similarly to the original intervertebral disc.  Patients are admitted for surgery on the same day as the procedure and typically spend 1-3 days in the hospital.  The primary goal is to relieve the pressure on the spinal cord and/or nerve roots in order to relieve symptoms and prevent further injury.  By avoiding a fusion at this level, this procedure may diminish the stresses on adjacent levels.


          










Alternatives: Depending on the diagnosis, there may be alternative surgical or non-surgical therapies for the management of your symptoms.  Non-surgical therapy is often recommended before pursuing surgical options.  Treatment may include:     

  • Medication such as narcotic or non-narcotic pain medicine, steroids, anti-inflammatory medicines,and muscle relaxers
  • Physical therapy
  • Cervical traction
  • Injection therapy
  • Anterior Cervical Discectomy and Fusion (ACDF)
  • Posterior Cervical Hemilaminotomy and Discectomy (PHLD)

Goals: Based on the diagnosis and symptoms, surgery may be recommended.  The goals of surgery are:

  • To remove pressure on the spinal cord and/or nerve roots
  • To remove the disc and maintain normal physiological function at the treated level
  • To maintain normal stability of the neck

Benefits: The benefits include:

  • Immediate relief of the underlying problem
  • Maintenance of normal motion at the treated level
  • Improvement or stabilization of symptoms
  • Improved ability to walk and take care of oneself
  • Return to work and other activities

Risks: Surgery is a big decision and not recommended lightly.  In general, surgery is recommended when the benefits far exceed the expected risks of the procedure.  The possible risks may include:

  • Adverse reaction to anesthesia
  • Myocardial infarct (heart attack)
  • Stroke
  • Deep venous thrombus or pulmonary embolus
  • Nerve root injury causing weakness or numbness
  • Spinal cord injury causing weakness, numbness, bowel/bladder dysfunction
  • Swallowing difficulty
  • Hoarseness
  • Infection
  • Bleeding
  • Failure to relieve symptoms
  • Failure of the hardware/prosthesis
  • Need for further surgery

Outcomes: No guarantees can be made regarding the outcome following any surgery.  However, patients tend to do very well following a cervical disc replacement.  This procedure is very good at relieving arm and leg symptoms related to pressure on the nerve roots or spinal cord.  Improvement in neck pain is more variable.  Major complications are very rare.  Most patients experience some degree of sore throat or difficulty swallowing for a few days to few weeks following surgery.  Most patients spend overnight in the hospital.  Improvement may continue to occur for 3-6 months following the surgery.  Light activity is recommended for at least six weeks following surgery. 


Posterior Cervical Hemilaminotomy and Discectomy (PHLD) 

A PHLD is performed to relieve pressure on a nerve root in the neck.  Pressure on a nerve root may cause pain,  numbness, or weakness in the shoulder, arm, or hand (radiculopathy) and may be caused by either a bone spur or disc herniation.  A PHLD may be indicated when nonsurgical options have failed to relieve symptoms or when the symptoms are progressive and severe.


A PHLD involves making an incision in the back of your neck to expose and remove herniated disc and bone spur that are pressing on the nerve root.  The nerve root is often squeezed by disc material in front and by bone spurs in back.  The bone is removed from behind first to expose and relieve pressure on the nerve root.  The herniated disc is then identified and removed.  Sometimes the herniated disc is too firm to be removed from this approach and the decompression is achieved by removal of bone alone.  Patients are admitted for surgery on the same day as the procedure and typically stay overnight in the hospital and go home the next day.  The primary goal is to relieve the pressure on the nerve root in order to relieve symptoms and prevent further injury. 


Alternatives: Depending on the diagnosis, there may be alternative surgical or non-surgical therapies for the management of your symptoms.  Non-surgical therapy is often recommended before pursuing surgical options.  Treatment may include: 

  • Medication such as narcotic or non-narcotic pain medicine, a steroid taper, anti-inflammatory medicines,  and muscle relaxers.
  • Physical therapy
  • Cervical traction
  • Injection therapy
  • Anterior Cervical Discectomy and Fusion (ACDF)
  • Cervical Disc Replacement


Goals: Based on the diagnosis and symptoms, surgery may be recommended.  The goals of surgery are:

  • To remove pressure on the nerve root
  • To remove the disc and/or bone spur
  • To maintain normal stability and motion of the neck


Benefits: The benefits include:

  • Immediate relief of the underlying problem
  • Improvement or stabilization of symptoms
  • Improved ability to walk and take care of oneself
  • Return to work and other activities


Risks: Surgery is a big decision and not recommended lightly.  In general, surgery is recommended when the benefits far exceed the expected risks of the procedure.  The possible risks may include:

  • Adverse reaction to anesthesia
  • Myocardial infarct (heart attack)
  • Stroke
  • Deep venous thrombus or pulmonary embolus
  • Nerve root injury causing weakness or numbness
  • Spinal cord injury causing weakness, numbness, bowel/bladder dysfunction
  • Infection
  • Bleeding
  • Failure to relieve symptoms
  • Need for further surgery


Outcomes: No guarantees can be made regarding the outcome following any surgery.  However, patients tend to do very well following a PHLD.  A PHLD is very good at relieving arm symptoms related to pressure on the nerve root.  Improvement in neck pain is more variable.  Major complications are very rare.  Most patients experience some degree of neck pain for a few days to few weeks following surgery.  Most patients spend 1-3 days in the hospital.  Improvement may continue to occur for 3-6 months following the surgery.  Light activity is recommended for at least six weeks following surgery.   


Posterior Cervical Laminectomy with or without Fusion 

A posterior cervical laminectomy is performed to relieve pressure on the spinal cord and nerve roots in the neck.  Pressure on the spinal cord may cause symptoms such as numbness, weakness, clumsiness, or difficulty walking (myelopathy). Pressure on a nerve root may cause pain,  numbness, or weakness in the shoulder, arm, or hand (radiculopathy).  A posterior cervical laminectomy is often recommended for progressive myelopathy that is caused by cervical stenosis at multiple levels in the neck.  If there is also an abnormal curve in the spine or concern for instability then a fusion may be recommended as well.  A posterior cervical laminectomy with or without fusion may be indicated when nonsurgical options have failed to relieve symptoms or when the symptoms are progressive and severe.


A posterior cervical laminectomy involves making an incision in the back of your neck to expose and remove the laminae, or portion of bone that forms the roof of the spinal canal.  The spinal cord and nerve roots are often squeezed by disc material in front and by bone and ligament in back.  The bone and ligament is removed from behind to relieve pressure on the spinal cord and nerve roots.  If there are herniated discs contributing to the pressure these can not be removed from this approach.  However, successful decompression is usually achieved by removal of bone and ligament alone.  If a fusion is required then this is performed through the exact same incision.  Small titanium screws are placed into the vertebrae on each side.  A rod is then placed on each side and secured to the screws.  The joint spaces are drilled open and bone chips mixed with bone stimulating factors are placed along the vertebrae to augment the fusion.  Patients are admitted for surgery on the same day as the procedure and typically stay a few days in the hospital.  The primary goal is to relieve the pressure on the spinal cord and nerve roots in order to relieve symptoms and prevent further injury. 













                                                                                                    

Alternatives: Depending on the diagnosis, there may be alternative surgical or non-surgical therapies for the management of your symptoms.  Non-surgical therapy is often recommended before pursuing surgical options.  Treatment may include:

  • Medication such as narcotic or non-narcotic pain medicine, a steroid taper, anti-inflammatory medicines, and muscle relaxers,
  • Physical therapy
  • Injection therapy
  • Anterior Cervical Discectomy and Fusion (ACDF)


Goals: Based on the diagnosis and symptoms, surgery may be recommended.  The goals of surgery are:

  • To remove pressure on the spinal cord and nerve roots
  • To remove bone and ligament pushing on the spinal cord and nerve roots
  • To maintain normal stability of the neck


Benefits: The benefits include:

  • Immediate relief of the underlying problem
  • Improvement or stabilization of symptoms
  • Improved ability to walk and take care of oneself
  • Return to work and other activities


Risks: Surgery is a big decision and not recommended lightly.  In general, surgery is recommended when the benefits far exceed the expected risks of the procedure.  The possible risks may include:

  • Adverse reaction to anesthesia
  • Myocardial infarct (heart attack)
  • Stroke
  • Deep venous thrombus or pulmonary embolus
  • Nerve root injury causing weakness or numbness
  • Spinal cord injury causing weakness, numbness, bowel/bladder dysfunction
  • Infection
  • Bleeding
  • Failure to relieve symptoms
  • Failure of the rods or screws or failure of the fusion to take place
  • Need for further surgery


Outcomes: No guarantees can be made regarding the outcome following any surgery.  However, patients tend to do very well following a posterior cervical laminectomy with or without fusion.  This procedure is very good at relieving arm or leg symptoms related to pressure on the spinal cord or nerve roots.  Improvement in neck pain is more variable.  Major complications are very rare.  Most patients experience some degree of neck pain for a few days to few weeks following surgery.  Most patients spend 1-3 days in the hospital.  Improvement may continue to occur for 3-6 months following the surgery.  Light activity is recommended for at least six weeks following surgery.  X-rays will be taken at specific intervals to evaluate for spinal stability and for fusion.  


Lumbar Discectomy 

A lumbar discectomy is sometimes performed when a disc herniation pushes on a nerve root and causes signs and symptoms of a radiculopathy.  Pressure on a nerve root may cause pain, numbness, or weakness in a specific pattern down the leg or into the foot.  Rarely, a large disc herniation may push on multiple nerves and affect both legs or bowel and bladder function (cauda equina syndrome).  A lumbar discectomy may be indicated when non-surgical methods fail to improve symptoms or if there is significant pain or weakness on initial presentation.


A lumbar discectomy involves making a small incision in the middle of the back.  A small piece of bone is removed from the vertebrae in order to expose the nerve root and disc.  The herniated disc material is removed and part of the normal disc that comes out easily is also removed.  The majority of the normal disc stays in place.  The nerve root is directly visualized and pressure caused by the herniated disc and any bone spurs is relieved.  Patients are admitted for surgery on the same day as the procedure and typically stay overnight in the hospital.  The primary goal is to relieve the pressure on the nerve root in order to relieve symptoms and prevent further injury. 


Alternatives: Depending on the diagnosis, there may be alternative surgical or non-surgical therapies for the management of your symptoms.  Non-surgical therapy is often recommended before pursuing surgical options.  Treatment may include:

  • Medication such as narcotic or non-narcotic pain medicine, a steroid taper, anti-inflammatory medicines, and muscle relaxers
  • Physical therapy
  • Injection therapy


Goals: Based on the diagnosis and symptoms, surgery may be recommended.  The goals of surgery are:

  • To remove pressure on the nerve roots
  • To remove the herniated disc
  • To maintain normal stability of the lower spine


Benefits: The benefits include:

  • Immediate relief of the underlying problem
  • Improvement or stabilization of symptoms
  • Improved ability to walk and take care of oneself
  • Return to work and other activities


Risks: Surgery is a big decision and not recommended lightly.  In general, surgery is recommended when the benefits far exceed the expected risks of the procedure.  The possible risks may include:

  • Adverse reaction to anesthesia
  • Myocardial infarct (heart attack)
  • Stroke
  • Deep venous thrombus or pulmonary embolus
  • Nerve root injury causing weakness, numbness, bowel or bladder dysfunction
  • Infection
  • Bleeding
  • Failure to relieve symptoms
  • Spinal fluid leak and headache
  • Need for further surgery


Outcomes: No guarantees can be made regarding the outcome following any surgery.  However, patients tend to do very well following a lumbar discectomy.  Success rates are quoted as high as 80-90% overall.  A discectomy is very good at relieving leg symptoms related to pressure on the nerve root.  Improvement in back pain is more variable.  Major complications are very rare.  Most patients experience some degree of back pain for a few days to few weeks following surgery.  Most patients stay overnight in the hospital and go home the next day.  Improvement may continue to occur for 3-6 months following the surgery.  Light activity is recommended for at least six weeks following surgery. 


Lumbar Laminectomy

A lumbar laminectomy is most often performed when there is spinal stenosis causing signs and symptoms ofneurogenic claudication or radiculopathy.  Pressure on the lower nerve roots may cause pain, numbness, or weakness in a specific pattern down the legs or into the feet.  A lumbar laminectomy may be indicated when non-surgical methods fail to improve symptoms or if there is significant pain or weakness on initial presentation.


A lumbar laminectomy involves making an incision in the middle of the lower back in order  to expose and remove the laminae, or portion of bone that forms the roof of the spinal canal.  The nerve roots are often squeezed by disc material in front and by bone and ligament in back.  The bone and ligament is removed from behind to relieve pressure on the nerve roots.  If there are herniated discs contributing to the pressure these can also be removed from this approach.  However, successful decompression is usually achieved by removal of bone and ligament alone. The nerve roots are directly visualized and pressure is relieved.  Patients are admitted for surgery on the same day as the procedure and typically stay overnight or just a few days in the hospital.  The primary goal is to relieve the pressure on the nerve roots in order to relieve symptoms and prevent further injury. 


Alternatives: Depending on the diagnosis, there may be alternative surgical or non-surgical therapies for the management of your symptoms.  Non-surgical therapy is often recommended before pursuing surgical options.  Treatment may include:

  • Medication such as narcotic or non-narcotic pain medicine, a steroid taper, anti-inflammatory medicines, and muscle relaxers
  • Physical therapy
  • Injection therapy
  • Lumbar Interbody Fusion


Goals: Based on the diagnosis and symptoms, surgery may be recommended.  The goals of surgery are:

  • To remove pressure on the nerve roots
  • To maintain normal stability of the lower spine


Benefits: The benefits include:

  • Immediate relief of the underlying problem
  • Improvement or stabilization of symptoms
  • Improved ability to walk and take care of oneself
  • Return to work and other activities


Risks: Surgery is a big decision and not recommended lightly.  In general, surgery is recommended when the benefits far exceed the expected risks of the procedure.  The possible risks may include:

  • Adverse reaction to anesthesia
  • Myocardial infarct (heart attack)
  • Stroke
  • Deep venous thrombus or pulmonary embolus
  • Nerve root injury causing weakness, numbness, bowel or bladder dysfunction
  • Infection
  • Bleeding
  • Failure to relieve symptoms
  • Spinal fluid leak and headache
  • Need for further surgery


Outcomes: No guarantees can be made regarding the outcome following any surgery.  However, patients tend to do very well following a lumbar discectomy.  A lumbar laminectomy is very good at relieving leg symptoms related to pressure on the nerve roots.  Improvement in back pain is more variable.  Major complications are very rare.  Most patients experience some degree of back pain for a few days to few weeks following surgery.  Most patients stay overnight in the hospital and go home the next day.  Improvement may continue to occur for 3-6 months following the surgery.  Light activity is recommended for at least six weeks following surgery. 


Lumbar Fusions 

A lumbar fusion is performed when there is unstable or abnormal motion of the spinal column.  This may occur with chronic degenerative processes, with acute trauma, or after surgical intervention without fusion.   Abnormal motion may result in back pain or increased pressure on the nerves resulting in radiculopathy.  A fusion may be done alone or in combination with a spinal decompression.  The primary benefit of a spinal fusion is to prevent abnormal motion in the spine which may be contributing to symptoms.  The primary risks include increased time for surgery, nerve root injury, malposition or breakage of the hardware, or failure of the bone to fuse together.


Depending on the primary problem and anatomy, a lumbar fusion may be performed a number of different ways.  There are five general ways to perform the fusion.  These are Posterolateral Lumbar Fusion (PLF). Posterior Lumbar Interbody Fusion (PLIF), Transforaminal Lumbar Interbody Fusion (TLIF), Extreme Lateral Interbody Fusion (XLIF), and Anterior Lumbar Interbody Fusion (ALIF).


Posterolateral Lumbar Fusion (PLF)

A PLF typically involves making an incision in the back and fusing along the lamina and facet joints on the back surface of the spine.  This can be noninstrumented in which bone chips and bone stimulating materials are placed directly on top of the normal bone or this can be supplemented with instrumentation in which screws and rods are also placed.


Pedicle Screws:  The screws are passed through a portion of bone called the pedicle and end within the vertebral body.  A rod is then passed through the pedicle screws on each side to provide stability between adjacent vertebrae.  Pedicle screws may be placed following trauma, following a simple decompression, or to augment any of the other types of lumbar fusions.  They can be placed with an open incision or through minimally-invasive percutaneous techniques.

                                        




















Facet Screws:  The screw is passed directly through the facet joint and compressed in order to provide stability between adjacent vertebrae.  Unlike pedicle screws, however, a single screw is placed through the joint instead of two separate screws above and below the joint and no rods are used.  This can be performed on one or both sides depending on the requirements of the case.  They can be placed through an open incision or through a minimally-invasive percutaneous approach.  Facet screws may be placed following trauma, following a simple decompression, or to augment any of the other types of lumbar fusions.

                                                                  














Posterior Lumbar Interbody Fusion (PLIF) and Transforaminal Lumbar Interbody Fusion (TLIF)

A PLIF is an anterior fusion of the vertebral bodies that is performed through a posterior incision.  An incision is made in the back and a decompression is performed if necessary.  The facet joints are partially or completely removed.  The entire intervertebral disc is removed.  Bone chips, bone stimulating material, and a structural cage are then placed within the cleaned out disc space and will ultimately fuse the adjacent vertebrae together.  Pedicle screws are often placed to supplement the stability of the spine.  A TLIF is very similar except that the surgery is performed on one side only.  Unlike a posterolateral fusion alone, a PLIF or TLIF will allow for increased decompression of the nerve roots by removing the facet joint and propping open the disc space.  Common indications for either a PLIF or TLIF include recurrent disc herniationsspondylolisthesis, and severe foraminal stenosis with radiculopathy.

                                                               













Extreme Lateral Interbody Fusion (XLIF)

An XLIF is a minimally invasive fusion of the vertebral bodies performed through an incision on the side or flank.  Using fluoroscopic x-ray guidance, a small incision is made in the flank and the entire intervertebral disc is removed.  Bone chips, bone stimulating material, and a structural cage are then placed within the cleaned out disc space and will ultimately fuse the adjacent vertebrae together.  Laterally placed screws or pedicle screws are sometimes placed to supplement the stability of the spine at the surgical level.  An XLIF props open the disc space and allows for indirect decompression of the nerve roots.  Common indications for an XLIF include mild scoliosis,spondylolisthesis, or severe foraminal stenosis with radiculopathy.


Anterior Lumbar Interbody Fusion (ALIF)

An ALIF is a fusion of the vertebral bodies performed through an incision in the abdomen.  Due to the location of major arteries and veins, this procedure is limited to the two lowest levels in the lumbar spine.  A general surgeon is often involved to perform the exposure of the disc space behind the abdominal contents.  Bone chips, bone stimulating material, and a structural cage are then placed within the cleaned out disc space and will ultimately fuse the adjacent vertebrae together.  Sometimes a plate and screws are placed in front of the vertebral bodies and sometimes pedicle screws are placed through a separate incision in the back.  An ALIF props open the disc space and allows for indirect decompression of the nerve roots.  Common indications for an ALIF include spondylolisthesis and severe foraminal stenosis with radiculopathy.


Kyphoplasty 

Kyphoplasty is a minimally invasive procedure performed for compression fractures of the spine.  This procedure is indicated within three months of the fracture occurring for ongoing pain or progressive collapse of the vertebral body.  Once the bone heals, this procedure does not work.  Using fluoroscopic x-ray guidance, a needle is passed through a small incision in the back and into the fractured bone.  A balloon is then passed into the vertebral body through the needle and inflated.  The balloon creates a space within the vertebral body and may elevate the fracture back to a more normal position.  The balloon is then deflated and the bone is filled with cement to provide structural support. 

















Kyphoplasty is a minimally invasive spinal procedure.  Treatment time is typically less than 30 minutes per level treated.  Most patients with spend over night in the hospital but this can be performed on an outpatient basis as well.  This is generally a safe procedure and most patients note improvement in pain symptoms shortly after the procedure is completed.  Risks are very rare and include infection, bleeding, or failure to relieve symptoms.  Some patients may require further surgical treatment.  There is a small risk of developing another fracture at a level above or below the treated level.  There is a small risk of injury to the spinal cord or nerve root if cement leaks out from within the vertebral body - image guidance is performed during the procedure to prevent this from happening. 

                                                                     

Overall, this is a very well-tolerated procedure for stabilization and relief of pain symptoms following an acute compression fracture of the spine.  Light activity is generally recommended for 6 weeks following the procedure.  Although the collapsed vertebrae does not typically regain its normal configuration, the cement provides structural support to prevent further collapse and ongoing pain symptoms.


*some of the graphics on this page are provided by Depuy Spine

For further ARTICLES on spine anatomy, diagnoses, and treatments please visit www.allaboutbackandneckpain.com.

For further ANIMATIONS on spine anatomy, diagnoses, and treatments please visit www.spine-health.com.

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The Lumbar Spine (Posterior View)

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