Spinal Deformities

Schuermann’s Kyphosis

• Scheuermann's disease, or Scheuermann's kyphosis, is a condition in which the normal roundback in the upper spine (called a kyphosis) is increased. Most people with Scheuermann's disease will have an increased roundback (e.g. a hunch back or hump back) but no pain.The name of this condition comes from Scheuermann, the person who in 1921 described changes in the vertebral endplates and disc space that can occur during development and lead to kyphosis, or roundback deformity of the thoracic spine (upper back).

• The cause of Scheuermann's disease is unknown, but is thought to be due to a growth abnormality of the vertebral body. The growth plate anteriorly (in the front) stops growing but the posterior part of the growth plate continues to grow. This is due to a condition known as osteochondrosis. The wedge-shape of the vertebra creates an increase in the amount of normal kyphosis (front angulation of the thoracic spine) The wedging of vertebrae in Scheuermann’s kyphosis is most common in the thoracic spine (upper back), with the apex of the curve typically between the T7 and T9 levels of the spine. Although less common, Scheuermann’s kyphosis may also occur in the junction between the thoracic and lumbar spine (thoracolumbar spine) or in the lumbar spine (lower back). Scheuermann’s disease does not spread and is not really a “disease” but a condition that can arise during growth. It is more common in males and appears in adolescents usually towards the end of their growth spurt. If the roundback deformity is severe, patients are more likely to have discomfort or pain along with the deformity as they age.

• The normal curvature of the thoracic spine is between 20 and 50 degrees. A curvature of more than 50 degrees, where the spine has three contiguous vertebral bodies that have wedging of 5 degrees or more, constitutes Scheuermann’s disease.Postural roundback in adolescents is most often caused by posture and not by structural changes to the spine. Postural roundback can be easily distinguished from Scheuermann’s kyphosis by the fact that the deformity goes away when the patient lies down. Typically, patients with true Scheuermann’s kyphosis need to sleep on two or three pillows at night to stay comfortable because there deformity remains when they lie down.Most patients with Scheuermann’s also have a mild scoliosis (when the spine curves to the side). These mild scoliosis curves rarely require treatment. As with scoliosis, an X-ray is used to confirm a diagnosis of Scheuermann’s disease.

• Treatment Options for Scheuermann's Disease:Treatment of Scheuermann’s disease is indicated to relieve pain, to correct an unacceptable cosmetic deformity, and to prevent potential progression or worsening of the curve. Treatment will vary depending on the size of the curve, the flexibility of the curve, the patient’s age and the patient’s preferences

• Conservative Treatments for Scheuermann's Disease: For patients with more than one year of growth left, the kyphosis can be partially reversed by wearing a brace (e.g. a Milwaukee brace). The brace can improve the curve during the growing years by restoring height to the front of the vertebral body and sometimes can reduce pain if present. Depending on the severity and progression of the curve, patients may be prescribed a brace for one to two years.For patients who are already skeletally mature, bracing is not an effective treatment.An exercise program, including specific strengthening and hamstring stretching exercises, may be recommended in conjunction with bracing. While exercise won’t correct the deformity, it can be helpful in alleviating back pain and fatigue.

• Surgery for Scheuermann's Disease: Surgery is rarely needed for Scheuermann’s disease. It may be considered for patients with severe deformities (e.g. more than 70 degrees for thoracic kyphosis), if neurological deficits are present, and occasionally if pain is present with the deformity. The goal of the surgery is mostly to reduce the deformity, although some feel it can lessen pain if present .Surgery historically included:A front thoracotomy (approach through the chest) to release the tissues, remove the discs, and place bone graft in the spaces to fuse the thoracic spine, then posterior surgery was done. But today, the spine is approached from the back and instrumentation (such as rods, bars, wires, or screws, which hold the spine straight during the fusion process) is put in place.After surgery, provided the fusion is successful, all of the affected segments will be fused into one continuous bone that will not progress into kyphosis.Because Scheuermann’s disease usually occurs in the thoracic spine, which has almost no motion, a fusion in this area does not affect the normal motion of the spine and typically does not lead to pain later in life. Most of the motion in the spine is in the lumbar spine, and it is usually not necessary to fuse this area. This is important to avoid overstressing the other lumbar spinal segments and causing early breakdown at adjacent levels.

• In general, in a skeletally mature patient, Scheuermann’s kyphosis is not progressive. This is different from adolescent scoliosis, which can continue to progress (if the deformity is more than 50 degrees) going into adulthood. For adults with Scheuermann’s kyphosis, the treatment is usually observation, anti-inflammatory drugs or reconstructive surgery, depending on the severity of the symptoms.

Juvenile Scoliosis

• Juvenile disc disorder, or juvenile discogenic disorder, represents a condition where the endplates of the disc spaces are not strong enough to withstand the pressures generated within the disc spaces. This leads to disc herniations into the vertebral bodies (called Schmorl’s nodes) and causes back pain at an early age.This condition is sometimes referred to as Scheuermann’s disease, or Lumbar Scheuermann’s disease, but the preferred medical terminology for this condition is juvenile disc disorder. Juvenile disc disorder is not as common as Scheuermann’s kyphosis and is not associated with deformity of the spine. Patients with juvenile disc disorder usually have lower back pain that is made worse with bending forward and activity, and feels better with rest. This condition is very much like degenerative disc disease in the adult population, but the degeneration starts at a much earlier age, and usually involves most of the discs of the lumbar spine (as opposed to only one or two discs typically involved in degenerative disc disease).

• Treatments for Juvenile Disc Disorder

• Conservative (non-surgical) treatments for juvenile disc disorder are largely the same as for adult degenerative disc disease, and surgery to fuse a segment is rarely advisable. Conservative treatments may include one or a combination of the following:

• Medications

• Chiropractic or osteopathic manipulations

• Epidural injections

• TENS units

• Physical therapy (exercises, stretching)

• It is important to note that adolescents who have back pain due to juvenile disc disorder do not need to have their activities medically restricted. In fact, physical activity is encouraged as it can help keep the back strong and healthy. In general, adolescents who are inactive have a higher rate of back pain as they become deconditioned and weaker. There is no conclusive evidence that activity accelerates the disc degeneration, so adolescents with this diagnosis should be allowed to participate in athletics as their pain allows. A well-balanced exercise program of daily hamstring stretching, strength training, and aerobic conditioning is best. Because the degeneration typically occurs in multiple discs, any attempt to fuse one or more levels of the lumbar spine will place a lot more pressure on the already weakened other levels. Fusing the whole spine leads to only more pain as the spine is basically meant to move, and attempts at fusing the whole lumbar spine are rarely successful in reducing pain. However, surgery to remove a disc herniation that is compressing a nerve is reasonable, as a decompression surgery (e.g. microdiscectomy) can relieve pain but does not change the natural biomechanics of the spine. Vocationally, patients with a lot of back pain and evidence of juvenile disc disorder on their imaging studies should be counseled to not consider a heavy manual labor job. Even though manual labor may not accelerate the degeneration, if they use their back for a living but are prone to bouts of low back pain, then they may have a lot of difficulty performing their jobs satisfactorily. In general, people are able to perform a more sedentary job whether or not low back pain is present.

Congenital Kyphosis

• Ankylosing spondylitis (AS) is a type of arthritis that primarily affects the spine. The disease is characterized by inflammation and resulting stiffness and pain in the joints along the spine. The knee and shoulder joints may also be affected.

• With ankylosing spondylitis, the inflammation in the joints of the spine will typically result in parts of the vertebrae and joints in the spine fusing together. As parts of the vertebrae grow (or "fuse") together, the spine becomes more rigid and inflexible.The fusion takes place as a reaction to inflammation of ligaments or tendons at the site of attachment to bone. The inflammation causes bone to erode at the site of the attachment, and then as the inflammation subsides, the body's natural healing process causes new bone growths in its place.Because this new bone is stiff, as opposed to the elastic quality of the tissue or ligaments, the normal range of motion of the spine is diminished. Ankylosing spondylitis most commonly is diagnosed in young men between the ages of 15 and 30, although it can affect anyone. Almost everyone with ankylosing spondylitis carries a specific gene called HLA-B27.

• When it is difficult to perform daily tasks or to look forweard because of the defomity caused by Ankylosing spondilitis, a surgical treatment to correct the kyphotic deformity is advised.

• In this surgery, the spine is approached from the back and after exposure, screws are inserted. Then bone cuts are done to the spine to release the fused structures. a bone wedge (sometimes more then 1) is removed and the wedge is closed to correct the kyphosis. finally the screws are connected to a properly bent rod to hold the corrected spine in a stable position.

• The aftercare of an ankylosing spondilitis patient is generally not different form a standard spinal deformity patient. Ambulation is encouraged the next day after surgery and the patients are generally discharged in a week .

• Smoking or the use of a specific groups of drugs like steroids and TNF alpha blockers are strongly discouraged as they interfere with and sometimes totally prevent bone healing.

Posttraumatic Kyphosis

• Scoliosis is abnormal side-to-side curvature of the spine. The spinal curve may develop as a single curve (shaped like the letter C) or as two curves (shaped like the letter S). In children and teens, scoliosis often does not have any noticeable symptoms and may not be noticeable until it has progressed significantly. The two most common forms are degenerative scoliosis and idiopathic scoliosis (adolescent). Three orthopedically approved options exist for combating scoliosis: observation, bracing, or surgery.

• Types of idiopathic scoliosis are categorized by both age at which the curve is detected and by the type and location of the curve. When grouped by age, scoliosis usually is categorized into three age groups:

• Infantile scoliosis: from birth to 3 years old

• Juvenile scoliosis: from 3 to 9 years old

• Adolescent scoliosis: from 10 to 18 years old.This last category of scoliosis, adolescent scoliosis, occurs in children age 10 to 18 years old, and comprises approximately 80% of all cases of idiopathic scoliosis. This age range is when rapid growth typically occurs, which is why the detection of a curve at this stage should be monitored closely for progression as the child’s skeleton develops.

• Terms that describes the location of the curve:

• Thoracic scoliosis is curvature in the middle (thoracic) part of the spine. This is the most common location for spinal curvature.

• Lumbar scoliosis is curvature in the lower (lumbar) portion of the spine.

• Thoracolumbar scoliosis is curvature that includes vertebrae in both the lower thoracic portion and the upper lumbar portion of the spine.

• Scoliosis curves are often described based on the direction and location of the curve. Physicians have several detailed systems to classify specific curves.

• The most commonly known type of scoliosis is idiopathic scoliosis.Other types of scoliosis include:

• Congenital scoliosis, which develops in utero and is present in infancy. A rare condition, affecting one in 10,000, there is no known cause, but in most cases the spinal curve must be corrected surgically.

• Neuromuscular scoliosis, which sometimes develops in individuals who cannot walk due to a neuromuscular condition such as muscular dystrophy or cerebral palsy. This may also be called myopathic scoliosis.

• Degenerative scoliosis (adult scoliosis), which is a common condition that occurs later in life as the joints in the spine degenerate.

• Rarely, scoliosis is caused by spinal lesion or tumor. Patients who are usually younger (age 8 to 11) than typical scoliosis patients will experience symptoms such as pain, numbness and a left-curving thoracic spine (levoscoliosis). A physician who sees any or a combination of these symptoms will order additional diagnostic tests, such as an MRI, to rule out the possibility of spinal tumor or other lesions as a cause of scoliosis.

• In children and teenagers, scoliosis often does not have any noticeable symptoms. The curvature of the spine does not cause pain, and if it is mild, it can go unnoticed.While a healthy spine, when viewed from the side, has natural curvature, when viewed from the back the spine appears as a straight line. A person with scoliosis, however, will appear to have a lateral (side-to-side) curve in their spine when viewed from the back.

Signs of Scoliosis

• Without an X-ray of the spine, there are several common physical symptoms that may indicate scoliosis. One of the most common tests for detecting scoliosis is called the Adam's Forward Bend Test, in which the individual bends from the waist as if touching the toes. The medical professional then observes for one or more of the following signs of scoliosis:

• One shoulder is higher than the other
• One shoulder blade sticks out more than the other
• One side of the rib cage appears higher than the other
• One hip appears higher or more prominent than the other
• The waist appears uneven
• The body tilts to one side
• One leg may appear shorter than the other
• Any type of back pain is not usually considered a scoliosis symptom.

• The risk of curvature progression increases during puberty when the growth rate of the body is the fastest. Scoliosis with significant curvature of the spine is much more prevalent in girls than in boys, and girls are eight times more likely to need treatment for scoliosis because they tend to have curves that have a greater probability of progression. Still, the majority of all cases of scoliosis are mild and do not require treatment.

Pain Needs Further Investigation

• Pain is not a typical symptom of scoliosis. Back pain in a child or teen who has scoliosis may indicate another problem and the child should be evaluated by a pediatrician and/or spine specialist. If a child or teen has back pain and also has scoliosis, it is very important that he or she see a doctor to find out the cause of the pain, as it is probably something other than the scoliosis causing the back pain and may require treatment.

Neurologic Pain and Numbness

• Pain and/or leg numbness that signals a neurologic injury is also a very rare presenting symptom of scoliosis. In this case, spinal curvature is caused by a spinal lesion or tumor. Signs that scoliosis is caused by an injury to the spine are:

• Patient is slightly younger (8-11) than a typical scoliosis patient

• Patient is experiencing pain and numbness that indicates a neural impingement

• Thoracic or thorocolumbar curve that leans to the left (levoscoliosis)

• A patient with any or a combination of the above symptoms should receive diagnostic tests, such as an MRI, to discover whether there is a neurologic injury present; if so, immediate treatment is typically recommended.

• Early detection is essential for scoliosis treatment to be most effective. In general, people with a family history of spinal deformity are at greater risk for developing idiopathic scoliosis.

Early Detection for Scoliosis

• Frequently, a scoliosis curve in the spine is first diagnosed in school exams or during a regular checkup with a pediatrician. Most students are given the Adam's Forward Bend Test routinely in school when they are in fifth and/or sixth grade to determine whether or not they may have scoliosis. The test involves the student bending forward with arms stretched downward toward the floor and knees straight, while being observed by a healthcare professional. This angle most clearly shows any scoliosis symptoms which present as asymmetry in the spine and/or trunk of the adolescent's body.

Further Scoliosis Testing

Because a scoliosis curvature is usually in the thoracic or thoracolumbar spine (upper back or mid back), if a rib hump or asymmetry of the lumbar spine is found, or if the shoulders are different heights, it is possible that the individual has scoliosis. If this is the case, follow-up with a physician for a clinical evaluation and an X-ray is the next step.

Physician's exam: The clinical evaluation with the physician will usually include a physical exam, during which the physician will also test to make sure that there are no neurological deficits. Neurological deficits due to scoliosis are uncommon but necessary to check for because there are rare causes of scoliosis that may have spinal cord involvement. X-ray: The X-ray is ordered to both confirm the scoliosis diagnosis and check on the magnitude of the spinal curvature. The X-ray will also give some indication as to the skeletal maturity of the patient which may influence treatment decisions. In rare instances a physician also may request an MRI scan of the thoracic and/or cervical spine to explore the possibility of an intracanal spinal lesion. Signs of a spinal lesion include:

Neurological deficits, such as leg numbness or weakness, that indicate impingement of the spinal cord (e.g. brisk reflex) A left-sided thoracic curvature, called levoscoliosis (the curves are almost always right sided) If the child is younger (e.g. 8-11 years old) than a typical patient with scoliosis

Formulating a Treatment Plan

Depending on the results of the physician's clinical evaluation and the diagnostic tests, a scoliosis treatment plan will be recommended that may include observation, bracing, or possibly surgery to reduce or correct the spinal curve.

Scoliosis treatment decisions are primarily based on two factors:

The skeletal maturity of the patient (or rather, how much more growth can be expected) The degree of spinal curvature.

Although the cause of idiopathic scoliosis is unknown, the way scoliosis curves behave is well understood. In essence:

A small degree of curvature in a patient nearing skeletal maturity is not likely to need treatment; Conversely, a younger patient with a bigger curve is likely to have a curve will continue to advance and will need treatment. There are three main scoliosis treatment options for adolescents:

Observation
Back braces
Scoliosis surgery

No exercises for scoliosis have proved to reduce or prevent curvature. However, exercise is highly recommended for both scoliosis and non-scoliosis patients alike to keep back muscles strong and flexible.

Conservative Treatment Options for Scoliosis

• Observation

• Once scoliosis is detected, observation by a physician is the next step. The physician will measure the curve on a regular schedule and base treatment decisions on the rate of curvature progression.

• Measuring and Tracking Scoliosis Curves

• The orthopedic surgeon may order an X-ray of the spine and use the "Cobb method" - an extremely accurate measuring technique - to calculate the curvature of the spine and its progression.

• Curves that are less than 10 degrees are not considered to represent scoliosis but are considered to be spinal asymmetry. These types of curves are extremely unlikely to progress and generally do not need any treatment, but the child's physician should continue to monitor the curve during regular checkups.

• Curves beyond 20 to 30 degrees in a growing child should be observed at 4 to 6 month intervals by an orthopedic surgeon with expertise in scoliosis.

• In a patient that is still growing, treatment will be needed if the following factors are present:

• The spinal curve progresses more than 5 degrees during a typical period of observation, or;

• The spinal curve has already reached 30 degrees or more.

• If the curve progresses less than 5 degrees during a specified period of observation, the physician may determine that the curve is not worsening rapidly enough to cause deformity, and treatment may not be necessary.

Brace Treatment For Scoliosis

• Back Braces for Scoliosis

• Scoliosis treatment for patients with progressing curves, or curves over 25 degrees in a skeletally immature patient (e.g. girls who are about 11 to 13 years old, and boys who are about 12 to 14 years) is usually centered on use of a back brace.

• Bracing typically is not used for adolescents who are already skeletally mature or almost mature. If an older child has a curve greater than 30 degrees and is almost mature, his or her curvature will be treated with observation only, as there is little growth left and bracing will unlikely do much good.

• Bracing does not straighten the curve that is already present. Instead, the goal of a back brace is to stop the progression of the spinal curve as the child continues to grow. The child will continue to wear the brace until he or she reaches skeletal maturity. Once the individual stops growing, there is little likelihood of progression of a curve.

• Curves that are greater than 50 degrees in angulation can continue to progress after skeletal maturity, so the treatment objective of a back brace is to try to get the child into adulthood with less than a 50-degree curvature.

• Fitting and Wearing a Back Brace

• Working under the direction of an orthopedic surgeon, an orthotist will fit a custom brace to the individual. The braces usually are made of molded plastic and fit tightly around the body and are worn under the clothes every day. Some are worn overnight; some are worn 23 hours a day.

• Although braces for scoliosis are more comfortable than ever before, they still have a low compliance rate for various reasons: children and adolescents feel different from their peers when they have to wear them, and some genuinely cause discomfort and perhaps difficulty breathing.

• Support for children wearing back braces is key to their effectiveness. Studies clearly show that the more closely patients follow their prescribed bracing regimen, the less the scoliosis curve progresses.

• Two Main Types of Back Braces

• There are two types of commonly used scoliosis braces (There are many other brace types including rigid and semirigid types but no evidence of superiority of one over the others):

• The TLSO (thoracolumbar sacral orthosis), which includes a popular model called the Boston Brace, is a custom-molded back brace that applies three-point pressure to the curvature to prevent its progression. It can be worn under loose fitting clothing, and is usually worn 23 hours a day. This type of scoliosis brace can be taken off to swim or to play sports.

• A Charleston bending back brace applies more pressure and bends the child against the curve. This type of scoliosis brace is worn only at night while the child is asleep.

• Unfortunately, even with appropriate bracing, some scoliosis spinal curves will continue to progress. For these cases, especially if the child is very young, bracing may still be continued to allow the child to grow before fusing the spine.

Surgical Treatment in Scoliosis

• Surgery for adolescents with scoliosis is only recommended when their curves are greater than 40 to 45 degrees and continuing to progress, and for most patients with curves that are greater than 50 degrees.

• Unlike back braces, which do not correct spinal curves already present, surgery can correct curvature by about 50%. Furthermore, surgery prevents further progression of the curve.

• There are several approaches to scoliosis surgery, but all use modern instrumentation systems in which hooks and screws are applied to the spine to anchor long rods. The rods are then used to reduce and hold the spine while bone that is added fuses together with existing bone.

• Once the bone fuses, the spine does not move and the curve cannot progress. The rods are used as a temporary splint to hold the spine in place while the bone fuses together, and after the spine is fused, the bone (not the rods) holds the spine in place. However, the rods are generally not removed since this is a large surgery and it is not necessary to remove them. Occasionally a rod can irritate the soft tissue around the spine, and if this happens, the rod can be removed.

• Two Approaches to Scoliosis Surgery

• There are two general approaches to the scoliosis surgery - a posterior approach (from the back of the spine) and an anterior approach (from the front of the spine). Specific surgery is recommended based on the type and location of the curve. Recently, the number of anterior approaches have diminished significantly as our ability to perform the whole surgery from posterior has increased.

Surgical Treatment In Scoliosis-Continued

• 1. Scoliosis Surgery from the Back (Posterior Surgical Approach)

• This approach to scoliosis surgery is done through a long incision on the back of the spine (the incision goes the entire length of the thoracic spine). The muscles are retracted to the sides to expose the spine. The spine is then instrumented (screws are inserted) and the rods are used to reduce the amount of the curvature. Bone is then added (either the patient's own bone, taken from the patient's hip, or cadaver bone), inciting a reaction in which the bones in the spine begin fusing together. The bones continue to fuse after surgery is completed. The fusion process usually takes about 3 to 6 months, and can continue for up to 12 months. For patients who have a severe deformity and/or those who have a very rigid curvature, another procedure may be required prior to this surgery. A surgeon may recommend an anterior release of the disc space (removal of the disc from the front), which involves approaching the front of the spine either through an open incision or with a scope (thoracoscopic technique) and releasing the disc space. After the discs at the appropriate levels of the spine have been removed, bone (either the patient's own bone and/or cadaver bone) is added to the disc space to allow it to fuse together. Removing the discs allows for a better reduction of the spine and also results in a better fusion. These two factors are especially important if the patient is a young child (10 to 12 years old) and has a lot of skeletal growth left. Without the anterior release procedure, the anterior column (the part of the spine facing the front of the body) can continue to grow, eventually twisting around the fused, non-growing posterior spinal column, forming a new scoliosis curve (called "crankshafting"). Fusing the spine anteriorly prevents this process.

• 2. Scoliosis Surgery from the Front (Anterior Surgical Approach)

• For curves that are mainly at the thoracolumbar junction (T12-L1), the scoliosis surgery can be done entirely as an anterior approach. This approach to scoliosis surgery requires an open incision and the removal of a rib (usually on the left side). Through this approach, the diaphragm can be released from the chest wall and spine, and excellent exposure can be obtained for the thoracic and lumbar spinal vertebral bodies. The discs are removed to loosen up the spine.Screws are placed in the vertebral bodies and rods are put in place to reduce the curvature. Bone is added to the disc space (either the patient’s own bone, taken from the patient's hip, or cadaver bone), to allow the spine to begin to fuse together. This fusion process usually takes about 3 to 6 months, and can continue for up to 12 months.If this surgery is applicable because of the type of curvature, the anterior approach to scoliosis surgery has several advantages over the posterior approach. Not as many lumbar vertebral bodies will need to be fused and some additional motion segments can be preserved. Saving motion segments is especially important for lower back curves (lumbar spine), because if the fusion goes below L3 there is a higher risk of later back pain and arthritis. Saving lumbar motion segments also helps prevent loading all the stress on just a few motion segments. This approach can sometimes allow for a better reduction of the curve and a more favorable cosmetic result. The major disadvantage of the anterior approach is that it can only be done for thoracolumbar curves, and most scoliotic curves are in the thoracic spine.

Risks of Scoliosis Surgery

• 1. Paraplegia

• The most concerning risk with scoliosis surgery is paraplegia. It is very rare (about 1 in 1,000 to 1 in 10,000 chance) but is a devastating complication. To help manage this risk, the spinal cord can be monitored during surgery through one of two methods:

• Somatosensory Evoked Potentials (SSEPs). This test involves small electrical impulses that are given in the legs and then read in the brain. If there is the development of slowing of the signals during surgery this can indicate compromise to the spinal cord or its blood supply. Another way to monitor the cord is with Motor Evoked Potentials (MEPs), and often both are used throughout a surgery.

• Stagnara wake up test. This test involves waking the patient during the surgery and asking them to move their feet. The patient does not feel any pain during this procedure and will not remember it afterwards.

• If either of these tests indicates spinal cord compromise, the rods can be cut out and the surgery abandoned. Fortunately, this situation is extremely uncommon, and many procedures can be rescheduled if the patient is found to be neurologically intact after the surgery.

• 2. Excessive Blood Loss

• Another risk with scoliosis surgery is excessive blood loss. There is a lot of muscle stripping and exposed area during the surgery. With proper technique the blood loss can usually be kept to a reasonable amount and blood transfusions are rarely needed. As a precaution, many surgeons will ask the patient to donate his or her own blood prior to surgery (autologous blood donation), which can then be given back to the patient after the surgery. Also, during scoliosis surgery the patient's blood can be collected and transfused back to the patient.

• 3. Other Potential Risks and Complications

• The rods breaking or the hooks or screws dislodging (although with modern instrumentation systems, this type of hardware failure is quite uncommon)

• Infection (less than 1%)

• Cerebrospinal fluid leak (rare)

• Failure of the spine to fuse (about 1%-5%)

• Continued progression of the curve after surgery

Postoperative Care in Scoliosis Patients

• Following scoliosis surgery, patients usually can start to move around about 2 to 3 days after the procedure. The total hospital stay is usually about 4 to 7 days. Patients can return to school about 2 to 4 weeks after surgery, but activity needs to be limited while the bone is fusing.

• It is important to note that the more immobile the spine is kept the better it will fuse. Bending, lifting, and twisting are all discouraged for the first three months after surgery. For this reason, some surgeons will prescribe wearing a back brace for a period following the surgery which helps to restrict movement. Any physical contact or jarring type activities are restricted for about 6 to 12 months after surgery.

• Generally the patient will be monitored with intermittent examinations and X-rays for 1 to 2 years after the surgery. Once the bone is solidly fused no further treatment is required.

• For the most part, patients can resume normal activity levels after a thoracic fusion since fusing the thoracic and upper lumbar spine does not change the biomechanics of the spine all that much. Female patients who have had a scoliosis fusion can still become pregnant and deliver babies vaginally.

Spinal Fractures

• Spinal fractures can vary widely in severity. While some fractures are very serious injuries that require emergency treatment, other fractures can be the result of bones weakened by osteoporosis.

• Most spinal fractures occur in the thoracic (midback) and lumbar spine (lower back) or at the connection of the two (thoracolumbar junction). Treatment depends on the severity of the fracture and whether the patient has other associated injuries.

• Understanding how your spine works will help you to understand spinal fractures. Learn more about your spine: Spine Basics

• Cause:

• Fractures of the thoracic and lumbar spine may result from high-energy trauma, such as a:

• Car or motorcycle crash

• Fall from height

• Sports accident

• Violent act, such as a gunshot wound

• Many times, these patients have additional serious injuries that require rapid treatment. The spinal cord may also be injured, depending on the severity of the fracture.

• Spinal fractures may also be caused by bone insufficiency. For example, people with osteoporosis, tumors, or other underlying conditions that weaken the bone can fracture a vertebra even during low-impact activities--such as reaching or twisting. These fractures may develop unnoticed over a period of time, with no symptoms or discomfort until a bone breaks.

• Description:

• There are different types of spinal fractures. Doctors classify fractures of the thoracic and lumbar spine based upon the specific pattern of the fracture and whether there is a spinal cord injury. Classifying the fracture pattern will help your doctor determine the proper treatment. The three major types of spine fracture patterns are:

Flexion, extension and rotation

• Symptoms

• A fracture of the thoracic or lumbar spine causes moderate to severe back pain that is worsened with movement.

• If the spinal cord is involved, the patient may experience bowel/bladder dysfunction along with numbness, tingling, or weakness in the limbs.

• If the fracture is caused by high-energy trauma, the patient may also have a brain injury and lose consciousness, or "black out." There may also be other injuries— called distracting injuries—that cause pain that overwhelms the back pain. In these cases, it has to be assumed that the patient has a fracture of the spine, especially after a high-energy event such as a motor vehicle crash.

• Emergency Stabilization

• Patients with fractures of the thoracic and lumbar spine that have been caused by trauma need emergency treatment. It may be difficult to assess the extent of their injuries on first evaluation.

• At the accident scene, emergency rescue workers will first check the patient's vital signs, including consciousness, ability to breathe, and heart rate. After the vital signs are stabilized, rescue workers will assess obvious bleeding and limb-deforming injuries.

• Before moving the patient, the emergency team must immobilize the individual in a cervical (neck) collar and backboard. The trauma team will perform a complete and thorough evaluation in the hospital emergency room.

• Physical Examination

• The emergency room doctor will conduct a thorough evaluation, beginning with a head-to-toe physical examination of the patient. This will include an inspection of the head, chest, abdomen, pelvis, limbs, and spine.

• Tests

• Neurological tests. The doctor will also evaluate the patient's neurological status. This includes testing his or her ability to move, feel, and sense the position of all the limbs. In addition, the doctor will test the patient's reflexes to help determine whether there has been an injury to the spinal cord or individual nerves.

• Imaging tests. After the physical examination, a radiologic evaluation is required. Depending on the extent of injuries, this may include x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of multiple areas, including the thoracic and lumbar spine

• Treatment

• Treatment for a fracture of the thoracic or lumbar spine will depend on:

• Other injuries and their treatment

• The particular fracture pattern

• Once the trauma team has stabilized all other life-threatening injuries, the doctor will evaluate the spinal fracture pattern and decide whether spine surgery is needed.

• Nonsurgical treatment.

• Most flexion injuries--including stable burst fractures and osteoporotic compression fractures—can be treated with bracing for 6 to 12 weeks. By gradually increasing physical activity and doing rehabilitation exercises, most patients avoid post-injury problems. Extension fractures that occur only through the vertebral body can typically be treated without surgery. These fractures should be observed closely while the patient wears a brace or cast for 12 weeks.Transverse process fractures are predominantly treated with gradual increase in motion, with or without bracing, based on comfort level.

• Surgical treatment. Surgery is typically required for unstable burst fractures that have:

• Significant comminution (multiple bone fragments)

• Severe loss of vertebral body height

• Excessive forward bending or angulation at the injury site

• Significant nerve injury due to parts of the vertebral body or disk pinching the spinal cord

• Surgery is usually necessary if there is an injury to the posterior (back) ligaments of the spine. In addition, if the fracture falls through the disks of the spine, surgery should be performed to stabilize the fracture.

• Fracture-dislocations of the thoracic and lumbar spine are caused by very high-energy trauma. They can be extremely unstable injuries that often result in serious spinal cord or nerve damage. These injuries require stabilization through surgery. The ideal timing of surgery can often be complicated. Surgery is sometimes delayed because of other serious, life-threatening injuries.

• These fractures should be treated surgically with decompression of the spinal canal and stabilization of the fracture. The procedure to decompress the spine is called a laminectomy. In a laminectomy, the doctor removes the bony arch that forms the backside of the spinal canal (lamina), along with any bone or other structures that are pressing on the spinal cord. Laminectomy relieves pressure on the spinal cord by providing extra space for it to drift backward. To perform the laminectomy, your doctor will access your spine with an incision either on your side or on your back. Both approaches allow for safe removal of the structures compressing the spinal cord, while preventing further injury.

• Surgical Procedure

• The ultimate goals of surgery are to:

• Achieve adequate reduction (return the bones into their proper position)

• Relieve pressure on the spinal cord and nerves

• Allow for early movement

• Depending on the fracture pattern, the doctor may perform the procedure through either an anterior (front), lateral (side), or posterior (back) approach—or a combination of all three. There are many types of specialized instruments used in spine surgery. These include metal screws, rods, and cages used to stabilize the spine.

Complications Complications associated with fractures of the thoracic and lumbar spine include:

• Blood clots in the pelvis and legs—these may develop during long periods of bed rest or immobility

• Pulmonary embolism—a blood clot that breaks free and travels to the lungs

• Pneumonia

• Pressure sores

There are also specific complications associated with spinal surgery. These include:

• Bleeding

• Infection

• Spinal fluid leaks

• Instrument failure

• Nonunion

Your doctor will talk with you about these risks and take specific measures to avoid potential complications. These measures may include:

• Early treatment

• Mechanical methods (such as lower leg compression stockings) and medications to protect against blood clots

• Proper surgical technique

• Postoperative programs

Outcomes

Regardless of whether treatment is surgical or nonsurgical, there will be a period of rehabilitation after a fracture has healed. The goals of rehabilitation include:

• Reducing pain

• Restoring mobility

• Returning the patient as closely as possible to his or her preinjury state

Your doctor may recommend both inpatient and outpatient physical therapy to help you achieve these goals. If your fracture was caused by osteoporosis, you are at an increased risk for additional fractures. Your doctor will recommend treatments to address bone density loss during your treatment and recovery. In some cases, there may be issues that delay or complicate rehabilitation and recovery. These issues include inadequate reduction of the fracture, neurologic injury (paralysis), and progressive deformity of the spine.

• As we get older, our bones thin and our bone strength decreases. Osteoporosis is a disease in which bones become very weak and more likely to break. It often develops unnoticed over many years, with no symptoms or discomfort until a bone breaks.

• Fractures caused by osteoporosis most often occur in the spine. These spinal fractures — called vertebral compression fractures — occur in nearly 700,000 patients each year. They are almost twice as common as other fractures typically linked to osteoporosis, such as broken hips and wrists.

• Not all vertebral compression fractures are due to osteoporosis. But when the disease is involved, a vertebral compression fracture is often a patient's first sign of a weakened skeleton from osteoporosis.

• Why Does The Bone Fracture?

• When the small bones of the spine (vertebrae) weaken from osteoporosis, they can narrow or shrink. This can lead to a rounded back, a hump or a "bent forward" look to the spine. Many people with osteoporosis also note that they are getting shorter over time.

• The weakened vertebrae are at a high risk for fracture. A vertebral compression fracture occurs when too much pressure is placed on a weakened vertebra and the front of it cracks and loses height. Vertebral compression fractures are sometimes the result of a fall, although people with osteoporosis can suffer a fracture even when doing everyday things, such as reaching, twisting, coughing, and sneezing.

• Symptoms:

• A vertebral compression fracture causes back pain. The pain typically occurs near the break itself. Vertebral compression fractures most commonly occur near the waistline, as well as slightly above it (mid-chest) or below it (lower back).

• The pain often gets worse with standing or sitting for a period of time, and is often relieved by rest or lying down. Although the pain may move to other areas of the body (for example, into the abdomen or down the legs), this is uncommon.

• Doctor Examination

• Your appointment will begin with a discussion with your doctor about your symptoms and medical history. While you are standing, your doctor will examine the alignment, or straightness, of your spine and your posture. Your doctor will also push on certain places on your back to try and identify whether your pain is from an injury to the muscle or bones. To make sure there is no injury to the spinal nerve roots, your doctor will conduct a neurologic examination. This includes testing your reflexes and muscle strength.

• X-rays

• If your doctor suspects a vertebral compression fracture, he or she will order an x-ray image to confirm the diagnosis. Other problems in the spine may also show up on x-rays. Elderly patients with a vertebral compression fracture may also have narrowing of disk space (degenerative disk disease) and/or scoliosis, which is a sideways curve of the spine.

• Other Imaging Studies

• Other imaging tests may be performed to determine if the vertebral compression fracture is a new (acute) fracture or an older (chronic) fracture.

• Magnetic resonance imaging (MRI) scan. This test will show any damage to the soft tissues around the fracture (nerves and disks) in better detail. Because of how it shows bone, it may help your doctor determine how old the fracture is.

• Bone scan. A bone scan can pick up a wide range of problems in bone, including fractures. It can also show how old a fracture is.

• Computed tomography (CT) scan. Shows soft tissue, as well as bone, and can help your doctor evaluate whether the vertebral compression fracture has extended into the spinal canal, where the spinal cord and nerve roots are located.

• Bone Density Testing

• When you have a vertebral compression fracture, it is important to assess whether you also have osteoporosis, and, if so, how severe the condition is. X-rays will often show thinning of the bone throughout the spine — a condition known as osteopenia. It is a forerunner to osteoporosis, in which the bone becomes much more fragile. The extent of bone loss can be determined with a bone mineral density scan (DEXA). The results of the DEXA help your doctor estimate your risk for additional fractures in the spine and in other parts of your body. The DEXA results provide important information to help your doctor treat any bone density loss with medications.

• Treatment

• Nonsurgical Treatment: Most people who suffer a vertebral compression fracture get better within 6 to 8 weeks without specific treatment to repair the fracture. Simple measures, such as a short period of rest and limited use of pain medications, are often all that is prescribed. In some cases, patients are instructed to wear a brace to restrict movement and allow the vertebral compression fracture to heal. If your doctor has also diagnosed osteoporosis, you are at an increased risk for additional vertebral compression fractures and other fractures, such as to the hip and wrist. Your doctor will address treatments for bone density loss during this time.

• Surgical Treatment:

• If you have severe pain that does not respond to initial treatment measures, then surgery may be considered. In the past, the only surgical options available to patients with a vertebral compression fracture involved extensive procedures. Today, vertebral augmentation procedures offer a minimally invasive alternative.

• The two types of vertebral augmentation methods available are kyphoplasty and vertebroplasty. The best candidates for these procedures are patients who suffer severe pain from recent vertebral compression fractures. If you are a candidate for vertebroplasty or kyphoplasty, your surgeon will discuss which one may be better for you based on the type of vertebral compression fracture you have.

• Kyphoplasty. In a kyphoplasty, a small device called a balloon tamp is inserted into the fractured vertebra. The balloon tamp is inflated from within the vertebra, which restores the height and shape of the vertebral body. When the balloon tamp is removed, it leaves a cavity that is filled with a special bone cement that strengthens the vertebra.. Kyphoplasty can be performed using general anesthesia (which puts you to sleep) or with a local anesthesia (which numbs your body around the fracture). In this procedure, the patient lies face down on the operating table and the surgeon accesses the spine from the back. After surgery, patients can go back to all their normal activities of daily living as soon as possible, with no restrictions.

• Vertebroplasty. Vertebroplasty is a technique similar to kyphoplasty, but a balloon tamp is not used to create a space for the cement. Instead, the cement is injected directly into the narrowed vertebra. Like kyphoplasty, this procedure is performed while the patient is lying face down so that the surgeon can access the fractured vertebra from the back. After this surgery, patients are encouraged to return to their normal, day-to-day activities as soon as possible.

• Surgical Outcomes

• Recently, several reports have been published on the results of vertebral augmentation procedures. These reports have raised questions about how much pain relief can be expected after kyphoplasty or vertebroplasty. Although these few studies have sparked some debate in the medical community, it is important to remember that many studies have also shown very good improvement in back pain for vertebral compression fractures.

• Your surgeon will discuss realistic expectations for recovery if vertebroplasty or kyphoplasty is recommended for you.

Spinal Tumors

• If you have severe back pain, it is natural to wonder whether or not the pain might be a sign of spinal cancer. Tumors in the spinal column may cause back pain from expansion of the bone or from weakening the bone, which in turn can result in spinal fractures, compression (pinching) of the nerves, or spinal instability.

• Symptoms:

• The following general symptoms may be associated with a spinal tumor:

• Pain in the neck or back, followed by neurological problems (such as weakness or numbness of the arms or legs or a change in normal bowel or bladder habits) is most common

• Focal spine pain that is worse in the morning

• Pain that is severe when there is direct manipulation or compression of the affected area of the spine

• Pain that does not diminish with rest, and pain that may be worse at night than during the day

• Back pain along with constitutional symptoms, such as loss of appetite, unplanned weight loss, nausea, vomiting, or fever, chills or shakes.

• Tumors that originate in the spine (primary tumors) are quite rare

• Primary spinal tumors tend to occur in younger adults and most typically are slow growing and benign

• Most spinal tumors have spread (metastasized) from another area of the body

• For patients with cancer elsewhere in the body, any new complaint of spine pain or neurological deficits requires an immediate evaluation to determine if the cancer has spread to the spine.

• There are three common types of spinal tumors that can cause back pain: vertebral column tumors, intradural-extramedullary tumors, and intramedullary tumors.

• 1-Vertebral Column Primary tumors: These tumors occur in the vertebral column, and grow either from the bone or disc elements of the spine. They typically occur in younger adults. Osteogenic sarcoma (osteosarcoma) is the most common malignant bone tumor. Most primary spinal tumors are quite rare and usually grow slowly.

• 2. Intradural-Extramedullary Tumors: Intradural-Extramedullary (inside the dura) tumors grow within the spinal canal (under the membrane that covers the spinal cord) but outside of the nerves. Usually these tumors are benign and slow growing. However, they can cause symptoms of pain and weakness.

• Most of these spinal tumors are:

• Meningiomas that occur in the membranes surrounding the spinal cord and are usually benign but may be malignant. These tumors are more common in middle age and elderly women.

• Nerve sheath tumors (schwannomas and neurofibromas) that arise from the nerve roots that come off the spinal cord. Again, this type of tumor is usually benign and slow growing, and it may be years before any neurological problems occur.

• 3. Intramedullary Tumors: Intramedullary tumors grow from inside the spinal cord or inside the individual nerves and often arise from the cells that provide physical support and insulation for the nervous system (glial cells). These tumors occur most often in the cervical spine (neck). They tend to be benign, but surgery to remove the tumor may be difficult.

• The two most common types of intramedullary tumors are astrocytomas and ependymomas.

• Metastatic tumors: Most often, spinal tumors metastasize (spread) from cancer in another area of the body. These tumors usually produce pain that does not get better with rest, may be worse at night, and is often accompanied by other signs of serious illness (such as weight loss, fever/ chills/shakes, nausea or vomiting).

• In women, spinal tumors most frequently spread from cancer that originates in the breast or lung.

• In men, spinal tumors most frequently spread from cancer that originates in the prostate or lung.

• If any tumor is found in the spine (and there is no other known cancer), a complete examination of all common organs where cancer develops is usually warranted. Evaluation may include:

• Complete medical history

• Complete physical examination

• Complete neurological examination

• Radiographic studies of the spine, chest and GI system to screen for tumors

• MRI and CAT scans to examine the spine.

• Treatments for each common type of spinal tumor is explained in more detail below.

• Treatment of Vertebral Column Tumors

• Because most of these tumors arise from advanced cancer from another organ, the goal of spinal treatment is usually to:

• Control the severe pain that often occurs with these tumors (e.g. by removing pressure on the nerve roots)

• Preserve neurological function (e.g. by removing the pressure on the spinal cord)

• Fix structural instability in the spine (e.g. by reconstructing the unstable spine with a spinal fusion)

• Treating Intradural-Extramedullary and Intramedullary Tumors

• These types of tumors are usually surgically removed. The goal of treatment is usually to:

• Totally remove the tumor

• Preserve neurological function

• The spinal cord and nerves are highly sensitive and avoiding damage to these structures is a critical part of surgery. Monitoring techniques may be used throughout the surgery to determine the function of the spinal cord as the tumors are being removed (e.g. SSEP).

• If the tumor cannot be completely removed (e.g. if it adheres to many spinal nerves), post-operative radiation therapy may improve outcome in some cases. If the tumor is metastatic, chemotherapy may also be helpful.

• Following the surgery, it may take some time for the nerves to fully heal. Usually rehabilitation and time significantly helps improve a patient’s neurological function.

Disc Herniations

• As a disc degenerates, the soft inner gel in the disc can leak back into the spinal canal. This is known as disc herniation, or herniated disc. Once inside the spinal canal, the herniated disc material then puts pressure on the nerve, causing pain to radiate down the nerve leading to sciatica or leg pain (from a lumbar herniated disc) or arm pain (from a cervical herniated disc).

• A cervical herniated disc is diagnosed when the inner core of a disc in the neck herniates, or leaks out of the disc, and presses on an adjacent nerve root. It usually develops in the 30-to-50-year-old age group. While a cervical herniated disc may originate from some sort of trauma or neck injury, the symptoms commonly start spontaneously.

• The arm pain from a cervical herniated disc results because the herniated disc material “pinches” or presses on a cervical nerve, causing pain to radiate along the nerve pathway down the arm. Along with the arm pain, numbness and tingling can be present down the arm and into the fingertips. Muscle weakness may also be present.

• The discs in the cervical spine are not very large; however, there is also not a lot of space available for the nerves. This means that even a small cervical disc herniation may impinge on the nerve and cause significant pain. The arm pain is usually most severe as the nerve first becomes pinched.

• Symptoms of a Cervical Herniated Disc

• A herniated disc in the neck can cause a variety of symptoms in the neck, arm, hand, and fingers, as well as parts of the shoulder. The pain patterns and neurological deficits are largely determined by the location of the herniated disc.

• The cervical spine is constructed around the vertebrae, or the 7 stacked bony building blocks in the spine. They are numbered top to bottom C1 through C7. The nerve that is affected by the cervical disc herniation is the one exiting the spine at that level, so at the C5-C6 level it is the C6 nerve root that is affected.For example:

• C4-C5 (C5 nerve root): A herniation at this level can cause shoulder pain and weakness in the deltoid muscle at the top of the upper arm, and does not usually cause numbness or tingling.

• C5-C6 (C6 nerve root): A C5-C6 disc herniation can cause weakness in the biceps (muscles in the front of the upper arms) and wrist extensor muscles. Numbness and tingling along with pain can radiate to the thumb side of the hand. This is one of the most common levels for a cervical disc herniation to occur.

• C6-C7 (C7 nerve root): A herniated disc in this area can cause weakness in the triceps (muscles in the back of the upper arm and extending to the forearm) and the finger extensor muscles. Numbness and tingling along with pain can radiate down the triceps and into the middle finger. This level is also one of the most common areas for a cervical disc herniation.

• C7-T1 (C8 nerve root): This level is located at the very bottom of the neck, where the cervical spine meets the thoracic, or upper, back. A herniation here can cause weakness with handgrip, along with numbness and tingling and pain that radiates down the arm to the little finger side of hand.

• These are typical pain patterns associated with a cervical disc herniation, but they are not absolute. Some people are simply wired up differently than others, and therefore their arm pain and other symptoms will be different. The pain pattern from a cervical herniated disc is referred to as a cervical radiculopathy.

• Special Diagnostic Tests:,

• After the initial exam, special diagnostic imaging tests may be required to better diagnose a cervical herniated disc.

• MRI Scan to Identify a Cervical Herniated Disc

• The single best test to diagnose a herniated disc is an MRI (Magnetic Resonance Imaging) scan. An MRI scan can image any nerve root pinching caused by a herniated cervical disc.

• CT Scan with Myelogram

• An MRI is the best first test, although occasionally a CT scan with a myelogram may also be ordered, as it is more sensitive and can diagnose even subtle cases of nerve root pinching.

• While a CT scan with myelogram is more sensitive it is also a slightly invasive test, as the myelogram dye must be injected into the spinal canal as part of the procedure. Because of the injection, a CT scan with myelogram is not usually the first test ordered.

• Plain CT scans (without myelogram) are for the most part not useful for the diagnosis of a herniated cervical disc.

• EMG to Identify Other Conditions Causing Pain

• Occasionally, an EMG (electromyography) may also be requested. An EMG is an electrical test that is done by stimulating specific nerves and inserting needles into various muscles in the arms or legs that may be affected from a pinched nerve. If the muscles have lost their normal innervation, there will be spontaneous electrical activity.

• An EMG can also help rule out other nerve entrapment syndromes that can give one arm pain, such as carpal tunnel syndrome, brachial plexitis, ulnar nerve entrapment, thoracic outlet syndrome, among other conditions.

• Conservative Treatment for Cervical Disc Herniation

• The majority of the time, the arm pain from a cervical herniated disc can be controlled with medication, and non-surgical (also called conservative) treatments alone are enough to resolve the symptoms.

• Once the arm pain starts to improve it is unlikely to return. If the arm pain gets better it is acceptable to continue with nonsurgical treatment, as there really is no literature that supports the theory that surgery for cervical disc herniation helps the nerve root heal quicker.

• All treatments for a cervical herniated disc are essentially designed to help resolve the arm pain, and usually the weakness and numbness/tingling will resolve with time.

• Medications

• When the initial pain from a cervical herniated disc hits, anti-inflammatory medications (NSAIDs) such as ibuprofen (e.g., Advil, Nuprin, Motrin) or COX-2 inhibitors (e.g. Celebrex) can help reduce the pain.

• The pain caused by a cervical herniated disc is caused by a combination of two processes:

• Pinching of the nerve root

• Inflammation associated with the disc material itself

• Therefore, taking anti-inflammatory medications to remove some of the inflammation can reduce this component of the pain while the pressure component (pinching of the nerve root) resolves.

• For patients with severe pain from a herniated disc, oral steroids (such as Prednisone or a Medrol Dose Pak) may give even better pain relief. However, these medications can only be used for a short period of time (one week).

• Nonsurgical Treatments

• In addition to anti-inflammatory medications mentioned above, there are a number of non-surgical treatment options that can help alleviate the pain from a cervical herniated disc, such as:

• Physical therapy and exercise. Just as in the lumbar spine, Mckenzie exercises can be used to help reduce the pain in the arm. In the initial period a physical therapist may also opt to use modalities, such as heat/ice or ultrasound, to help reduce muscle spasm.

• Cervical traction. Traction on the head can help reduce pressure over the nerve root. It does not work for everyone but is easy to do, and if effective the patient can use a home traction device.

• Chiropractic manipulation. Gentle manual manipulation can help reduce the joint dysfunction that may be an added component of the pain. This type of low-velocity manipulation is referred to as mobilization. Any high velocity manipulation, often referred to as an adjustment, should be avoided as they can make the pain worse, or worsen any neurological damage.

• Osteopathic medicine. Gentle osteopathic manipulation manipulation and special techniques to restore normal joint motion can be helpful in reducing pain from a cervical herniated disc.

• Activity modification. Some types of activities may tend to exacerbate the herniated disc pain and it is reasonable to avoid these activities to keep from irritating the nerve root. Such activities may include heavy lifting (e.g. over 50 pounds), activities that can cause increased vibration and compression to the cervical spine (boating, snowmobile riding, running, etc.), and overhead activities that require prolonged neck extension and/or rotation.

• Bracing. In some instances a cervical collar or brace may be recommended to help provide some rest for the cervical spine.

• Medications. In addition to the anti-inflammatory medications mentioned above, narcotic agents (painkillers, or opioids) might be used on a temporary basis to help reduce the pain and discomfort from a cervical herniated disc. Also, muscle relaxants or certain anti-depressants may help reduce the nerve-type pain (neuropathic pain) and help restore normal sleep patterns.

• Injections. Cervical Epidural steroid injections or selective nerve root blocks can be helpful to reduce inflammation in cases of severe pain from a cervical herniated disc, and can be very effective if accompanied by a comprehensive rehabilitation program that may involve a number of the above treatments.

• Physicians who provide the above treatments for a cervical herniated disc may include family practitioners, physiatrists (physical medicine and rehabilitation physicians), osteopathic physicians, neurologists, and orthopedic spine surgeons.

• Cervical Disc Herniation- Surgical Treatment

• Most episodes of arm pain due to a cervical herniated disc will resolve over a period of weeks to a couple of months. However, if the pain lasts longer than 6 to 12 weeks, or if the pain and disability are severe, spine surgery may be a reasonable option.

• Spine surgery for a cervical herniated disc is generally reliable. The success rate is about 95 to 98% in terms of providing relief of arm pain.

• With an experienced spine surgeon, the surgery should carry a low risk of failure or complication, and can be done with a minimal amount of postoperative pain and morbidity (unwanted aftereffects).

• The surgery for a cervical herniated disc can be done a number of different ways:

• Anterior cervical discectomy and spine fusion (ACDF): This is the most common method among spine surgeons for most cervical herniated discs. In this surgery, the disc is removed through a small one-inch incision in the front of the neck. After removing the disc, the disc space itself is fused. A plate can be added in front of the graft for added stability and possibly a better fusion rate.

• Posterior cervical discectomy: This is similar to a posterior (from the back) lumbar discectomy, and for discs that occur laterally out in the neural foramen (the “tunnel” that the nerve travels through to exit the spinal canal) it may be a reasonable approach. However, it is technically more difficult than an anterior approach because there are a lot of veins in this area that can result in a lot of bleeding, and the bleeding limits visualization during the surgery. This approach also necessitates more manipulation to the spinal cord.

• Cervical artificial disc replacement: Like an ACDF, an artificial disc surgery involves removing the affected disc through a small incision in the front of the neck. However, instead of a fusion in the disc space, an artificial disc is placed in the disc space. The goal of the artificial disc is to mimic the form and function of the original disc.

• Although any major surgery has possible risks and complications, with an experienced spine surgeon serious complications from cervical disc surgery should be rare. The two most common surgeries, ACDF and artificial disc, are both considered reliable surgeries with favorable outcomes in terms of reducing the patients pain.

• Postoperative Care for Cervical Herniated Disc Surgery

• For anterior surgery, such as an ACDF and artificial disc, there usually is not a great deal of postoperative pain. The surgery is done through a small incision in the front of the neck, and the spine can be accessed in between tissue planes that do not require cutting. This type of surgery usually can be done either outpatient (going home the same day as surgery) or with one overnight stay in the hospital.

• The pain in the arm usually goes away fairly quickly, although it may take weeks to months for the arm weakness and numbness to subside. It is not uncommon to have some neck pain for a while.

• Postoperatively, most spine surgeons prescribe a neck brace, although the type of brace and length of usage is variable. Also, most spine surgeons will ask their patients to limit their activities postoperatively, although the amount of restrictions and the length of time tend to vary. Ask your spine surgeon before the surgery what his or her usual protocol is regarding postoperative care.

• A herniated disc in the upper back can occur when the inner gelatinous material of an intervertebral disc leaks out of the inside of the disc. A thoracic herniated disc can cause upper back pain and other symptoms, such as radiating pain or numbness.

• Specific symptoms of a thoracic herniated disc are usually different depending on where the disc herniates, as the herniated disc material in the upper back can either impinge on an exiting nerve root or on the spinal cord itself.

• Thoracic Degenerative Disc Disease

• Thoracic disc disease is conceptually similar to disc disorders in the cervical and lumbar spine, but symptomatic lesions (anatomical problems related to the symptoms) are far less common.

• The most common location for thoracic disc disorders is at the thoracolumbar (the thoracic and lumbar parts of the spinal column) junction (T8-T12) in the mid back. The true incidence is unknown because many thoracic disc disorders do not cause thoracic back pain or other symptoms, and they comprise only a very small percent of all herniated disc treatment surgeries.

• In one study, 90 asymptomatic patients (with no pain or other symptoms) were evaluated with thoracic MRI scans. These were the findings:

• 73% of patients were found to have disc abnormalities in the upper back, such as a thoracic herniated disc or thoracic degenerative disc disease

• 37% specifically had a thoracic herniated disc

• 29% had radiographic evidence of spinal cord impingement identified on the MRI.

• These patients were followed for 26 months and none of them developed thoracic back pain from their thoracic disc disorders.

• The fact that so many people had thoracic herniated discs but no pain or symptoms is important to mention, as it shows that people may have both upper back pain and a thoracic herniated disc, but that the disc disorder may not be the cause of the thoracic back pain – it may just be an incidental finding.

• In fact, there are many causes of upper back pain that are much more common than a herniated disc, and a correct diagnosis of the cause of the patient’s pain is more important than whether or not an MRI scan shows a thoracic disc herniation.

• Doctors typically classify thoracic herniated discs as being caused by either one of two sources:

• Degenerative disc disease. Many thoracic herniated discs occur from gradual wear and tear on the disc, which leads to settling of the vertebral bodies and calcification about the disc space.

• Trauma to the upper back. Traumatic herniated discs are defined as those associated with a significant traumatic event that caused the abrupt onset of symptoms.

• Thoracic Disc Herniation From Degenerative Disc Disease:

• When symptomatic of degenerative disc disease, the symptoms of a thoracic herniated disk most commonly occur between the 4th and 6th decades of life and usually develop very gradually.

• With degenerative disc disease, the patient’s thoracic back pain and other symptoms are often present for a longer period of time prior to consultation with a physician.

• Thoracic Disc Herniation Because of Trauma:

• Any injury that causes a high degree of sudden force on the discs in the upper spine could lead to a thoracic herniated disc. Examples of a traumatic event that may lead to a thoracic herniated disc include a fall or sports injury that places sudden force on the upper back.

• Thoracic herniated discs tend to occur in younger patients prior to significant degenerative disc changes. While in most cases some history of mild trauma has led to an exacerbation of the patient’s symptoms, a mild trauma (such as reaching up while twisting) will usually just worsen symptoms from a degenerated disc.

• Regardless of the cause of the thoracic back pain, getting a correct diagnosis is critical because it will guide treatment of the thoracic herniated disc.

• Thoracic Disc Herniation Symptomatology:

• Pain is the most common symptom of a thoracic herniated disc and may be isolated to the upper back or radiate in a dermatomal (single nerve root) pattern. Thoracic back pain may be exacerbated when coughing or sneezing.

• Radiating pain may be perceived to be in the chest or belly, and this leads to a quite different diagnosis that will need to include an assessment of heart, lung, kidney and gastrointestinal disorders as well as other non-spine musculoskeletal causes.

• Within the spine itself there are also many other disorders that can have similar presenting symptoms of upper back pain and/or radiating pain, such as a spine fracture (e.g. from osteoporosis), infection, tumor, and certain metabolic disorders

• If the disc herniates into the spinal cord area, the thoracic herniated disk may also present with myelopathy (spinal cord dysfunction). This may be evident by sensory disturbances (such as numbness) below the level of compression, difficulty with balance and walking, lower extremity weakness, or bowel or bladder dysfunction.

• Thoracic Disc Herniation Diagnosis:

• The first step in diagnosing a thoracic herniated disc always includes a good patient medical history and physical examination. The spine physician will begin by getting a better understanding of the patient’s symptoms, including the:

• Location of the pain

• Severity of the pain

• Type of pain (numbness, weakness, burning, etc.).

• The physician will often follow up by learning if any injuries occurred prior to the thoracic back pain or if any other problems (weight loss, fevers, illnesses, difficulty urinating) were recently present before the upper back pain. The physician will then perform a physical examination.

• This combination of the patient’s description of how the pain feels, where it occurs, when it occurs, etc., as well as the spine physician’s physical examination, should yield clues to help localize the lesion to the thoracic spine.

• Diagnostic Tests:

• If a thoracic herniated disc is suspected as the underlying cause of the pain, there are several diagnostic tests that can confirm the diagnosis and provide additional information, including:

• X-rays – While plain x-rays will not show a thoracic herniated disc, they may be used to help localize injuries in cases of trauma as well as aid in identifying spinal instability.

• Magnetic Resonance Imaging (MRI) – An MRI utilizes a powerful magnet attached to a computer to produce images of the spine. A painless and often accurate test, an MRI scan is the most useful imaging tool to identify disc pathology.In some cases, a physician may seek even more detailed information beyond an MRI and order the following tests:

• Computer Topography (CT) – A CT scan involves the use of a computer that constructs a cross-dimensional, three-dimensional image of the spine after processing data from an X-ray beam rotated around the spine.

• Myelogram – A myelogram involves the injection of a special dye into the spinal column, with an X-ray taken to examine any pressure on the spine and any problems with the discs or vertebrae.

• In cases where an MRI scan is contraindicated, a post-myelogram CT can help identify an area of external compression, but it will not yield information about injury within the substance of the cord (myelomalacia).

• Thoracic Disc Herniation Treatment:

• The vast majority of thoracic herniated disc symptoms can be treated without thoracic surgery. There are a variety of nonsurgical treatment options that can be tried, and often patients will need to try several, or a combination of different treatments, to find what works best for them.

• Non-Surgical Treatments for Thoracic Herniated Discs

• Non-surgical treatment options for symptoms of a thoracic herniated disc will typically include one or a combination of the following:

• A short period of rest (e.g. one or two days) and activity modification (eliminating the activities and positions that worsen or cause the thoracic back pain). After a short period or rest, the patient should return to activity as tolerated. Gentle exercise, such as walking, is a good way to return to activity.

• Narcotic and non-narcotic analgesic medications to help reduce the thoracic back pain. Narcotic pain medication is usually only prescribed to treat severe upper back pain for a short period of time. For mild or moderate thoracic back pain, an overthe- counter pain reliever such as acetaminophen (e.g. Tylenol) is commonly recommended for thoracic herniated discs. • Anti-inflammatory agents, to help reduce inflammation around the herniated disc in the upper back, including:

• Medications (NSAIDs - such as ibuprofen or a COX-2 inhibitor, or oral steroids)

• Anti-inflammatory injections (such as an epidural steroid injection)

• Ice packs (applied to the painful area for 15–20 minutes at a time, as often as necessary)

• Manual manipulation (usually performed by a chiropractor or an osteopathic doctor)

• Strengthening exercises (such as core stabilization exercises)

• The patient’s activity levels should be progressed gradually over a 6 to 12 week period as symptoms improve. In the vast majority of cases, the natural history of thoracic disc herniation is one of improvement with one or a combination of the above conservative (non-operative) treatments.

• Thoracic Disc Herniation Surgery

• Thoracic herniated disc surgery is indicated in only rare instances when a herniated disc leads to myelopathy (spinal cord dysfunction), progressive neurologic deficits, or intolerable pain.

• Typically, these symptoms occur following an acute traumatic herniated disc with myelopathy. The thoracic surgery to address these symptoms, called a decompression, is designed to take the pressure off the spinal cord or nerve root.

• Different Approaches to Thoracic Surgery

• Historically, the surgical approach for a decompression was performed in a laminectomy approached from the posterior (behind). Outcomes were poor in large part because retraction on the spinal cord is not well tolerated and most thoracic herniated discs have a central component that cannot be reached without spinal cord retraction.

• More recently, one of the following surgical approaches will be used:

• For central and centro-lateral herniations, an open thoracotomy may be performed from an anterior trans-thoracic approach (a front approach that crosses the thoracic spine). This involves approaching the spine through the chest cavity (instead of through the back). In some centers, the procedure may be done as a minimally invasive VATS (Video Assisted Thoracic Surgery) procedure, which involves the use of several small incisions, small scopes and a video screen.

• Lateral herniated discs can be reached through a posterolateral approach (from behind and the side) known as a costotransversectomy, which involves removal of rib and transverse process (a small bone attached to the spine) to allow access to the disc space.

• Thoracic herniated disc surgery is reserved for cases of myelopathy, progressive lower extremity weakness, and intolerable radicular pain that does not get better with non-surgical treatments.

• Thoracic Herniated Disc Surgery Outcomes

• In cases where thoracic surgery was indicated, two researchers evaluated 19 patients treated with either costotransversectomy or trans-thoracic decompression of a thoracic disc herniation.

• The following was reported:

• 16 patients with good or excellent outcomes

• 3 patients with fair or poor results

• 2 of the poor outcomes were in the costotransversectomy group.

• With these results in mind, the researchers opined that the trans-thoracic approach should be the preferred approach.

• In a separate study, other researchers reported 76% satisfactory results in 29 patients who underwent a Video Assisted Thoracic Surgery procedure, the minimally invasive trans-thoracic approach to the thoracic disc space.

• As a disc degenerates and breaks down, the inner core can leak out through the outer portion of the disc, and this condition is known as a disc herniation or a herniated disc. The weak spot in the outer core of the intervertebral disc is directly under the spinal nerve root, so a herniation in this area puts direct pressure on the nerve.

• The nerve runs through the leg, and any type of pinched nerve in the lower spine can cause pain to radiate along the path of the nerve through the buttock and down the leg. This type of pain is also called sciatica or a radiculopathy.

• Lumbar Herniated Disc Symptoms:

• General symptoms typically include one or a combination of the following:

• Leg pain (sciatica), which may occur with or without lower back pain. Typically the leg pain is worse than the lower back pain.

• Numbness, weakness and/or tingling in the leg

• Lower back pain and/or pain in the buttock

• Loss of bladder or bowel control (rare), which may be an indication of a serious medical condition called cauda equina syndrome.

• L4-L5 and L5-S1 Disc Herniation Symptoms

• The vast majority of disc herniations will occur toward the bottom of the spine at L4- L5 or L5- S1 levels. In addition to typical sciatica symptoms, nerve impingement at these levels can lead to:

• L5 nerve impingement (at the L4 – L5 level) from a herniated disc can cause weakness in extending the big toe and potentially in the ankle (foot drop). Numbness and pain can be felt on top of the foot, and the pain may also radiate into the buttock.

• S1 nerve impingement (at the L5 – S1 level) from a herniated disc may cause loss of the ankle reflex and/or weakness in ankle push off (patients cannot do toe rises). Numbness and pain can radiate down to the sole or outside of the foot.

• Lumbar Disc Herniation Treatment

• In most cases, if a patient’s pain is going to get better it will start to do so within about six weeks.

• While waiting to see if the symptoms will abate on their own, several non-surgical treatments can help alleviate the pain and facilitate long term healing. The most common herniated disc nonsurgical treatments include:

• Physical therapy

• Osteopathic/chiropractic manipulation (manual manipulation)

• Heat and/or ice therapy

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Oral steroids (e.g. prednisone or methyprednisolone)

• An epidural (cortisone) injection

• If the pain and other symptoms continue after six weeks, and if the pain is severe, it is reasonable to consider microdiscectomy surgery as an option.

• Lumbar Herniated Disc Surgery

• A microdiscectomy is designed to take the pressure off the nerve root and to provide the nerve with a better healing environment. Usually, only the small portion of the disc that is pushing against the nerve root needs to be removed, and the majority of the intervertebral disc remains intact.

• Using microsurgical techniques and a small incision, a microdiscectomy can usually be done on an outpatient basis or with one overnight stay in the hospital, and most patients can return to work full duty in one to three weeks. With an experienced surgeon, the success rate of this surgery should be about 95%.

• Recurrent Disc Herniation

• Unfortunately, approximately 10% of patients will experience another disc herniation at the same location. This recurrence is most likely to happen early in the postoperative period (within the first three months), although it can happen years later. Usually a recurrence can be handled with another microdiscectomy..

• If it recurs multiple times, a lumbar fusion surgery to stop the motion at the disc level and remove all of the disc material may be considered.

Degenerative Spinal Disorders

• Degenerative spinal disorders are a group of conditions that involve a loss of normal structure and function in the spine. These common disorders are associated with the normal effects of aging, but also may be caused by infection, tumors, muscle strains, or arthritis.

• Pressure on the spinal cord and nerve roots associated with spinal degeneration may be caused by disc displacement or herniation; spinal stenosis, a narrowing of the spinal canal; or osteoarthritis, cartilage breakdown at spinal joints.

• Causes

• The discs between the bones of the spine are made up of cartilage, fibrous tissue, and water. With age these discs can weaken and may flatten, bulge, break down, or herniate. Disc herniation, a common cause of pain associated spinal degeneration, occurs when the fibrous portion of a disc weakens and the disc nucleus pushes through and puts pressure on nearby nerves. In addition, a degenerating disc also may cause bony growths that can place additional pressure on the spinal cord.

• Spinal stenosis, or narrowing of the spinal canal, is a condition potentially more serious than degenerative disc disease. As the spinal canal tightens, the spine and nerves may be significantly compressed and irritated, causing both back pain and pain that radiates to other parts of the body, depending on the location of the pressure on the nerves.

• Symptoms

• The primary symptoms of degenerative spinal disorders are sharp and/or chronic pain in the back and legs, weakness, limited motion, and sensory loss. If spinal degeneration leads to compression or injury of the spinal cord, weakness and limited motion may increase significantly. Loss of bladder and bowel function and problems with sexual function also may occur as the problem worsens. The specific symptoms often depend on the location of the structural problem in the spine.

• Diagnosis

• Diagnosis often begins with a spinal x-ray, which does not show the discs but can show other bony changes in the spine. Magnetic resonance imaging (MRI) scans are the primary means of diagnosis because they can show the disc in detail and allow physicians to see the nerves and spinal canal space and how they are affected by the disease. Computed tomography (CT) scans also may be used. However, the diagnosis of back problems, even with MRI, can be difficult by the presence of findings that do not correlate well with a patients symptoms.

• Treatment

• Treatment for degenerative spinal disorders depends on the severity of the condition. In most cases, the problem is not severe. The first line of treatment is activity modification, oral pain medication, and physical therapy to strengthen the muscles of the back and improve flexibility and range of motion. In addition, epidural injections of steroids or pain medication, may be used to isolate the source of pain and provide temporary pain relief making physical therapy more productive in patients with severe pain. Noninvasive and minimally invasive procedures will provide pain relief for the vast majority of patients.

• Surgery may eventually be necessary as a condition progresses. Surgery is indicated in patients with chronic severe pain, nerve deficits, and loss of bladder and bowel control. Also, surgery may be considered in patients who have not responded to less invasive treatment and in patients who have an identifiable structural abnormality that can be effectively corrected. Surgical procedures used vary depending on the type of condition and its severity. In some patients, a herniated disc can be surgically repaired to restore the normal anatomic structure. In other patients the disc that is causing pain or the bone placing pressure on the spinal cord must be removed. In patients with spinal stenosis for example, only surgery to alleviate the pressure on the spinal cord can provide relief of notable duration. The vertebrae may also need to be stabilized through a process called spinal fusion. Metallic devices are used to stabilize the spine, and then bone taken from another part of the body or from a bone bank is implanted to encourage bone to grow across the span. Bone growth may be encouraged with bone morphogenetic protein, a biologic product that stimulates the creation of new bone. The results of surgery usually are excellent and most patients return to normal function in a matter of weeks.

Spinal Stenosis

• In the medical field, stenosis means the abnormal narrowing of a body channel. When combined with the word spinal, it defines a narrowing of the bone channel occupied by the spinal nerves or the spinal cord.

• Cervical Spinal Stenosis : Cervical spinal stenosis is rarer and more dangerous than lumbar spinal stenosis.

• Some people are born with a congenital form, but most develop spinal stenosis as part of the degenerative cascade. A few do not feel any effects of the narrowing, but as part of the aging process, most people will eventually notice radiating pain, weakness, and/or numbness secondary to the compression of the nerves or spinal cord.

• While the narrowing may occur at different parts of the spine, the symptoms of nerve compression are often similar. That is why specialists often will perform testing to determine the cause and location of the narrowing.

• Lumbar vs. Cervical Stenosis

• The lower back develops lumbar stenosis, while the neck develops cervical stenosis.

• Lumbar Spinal Stenosis

• In lumbar stenosis, the spinal nerve roots in the lower back become compressed and this can produce symptoms of sciatica— tingling, weakness or numbness that radiates from the low back and into the buttocks and legs—especially with activity.

• Lumbar spinal stenosis often mimics symptoms of vascular insufficiency. Both conditions can cause claudication, which means leg pain with walking. If vascular studies identify normal blood flow, and there is confirmation of spinal stenosis on diagnostic testing, the symptoms are then called neurogenic claudication. In the classic description, people with spinal stenosis will describe an onset of leg pain, or weakness with walking, but with relief of symptoms with sitting. Many will also describe increased tolerance to walking when flexed forward, such as when walking while leaning forward on a shopping cart.

• While lumbar spinal stenosis most often occurs at the L4-L5 and L3-L4 levels, it can occur any level in the spine. The degenerative cascade may eventually effect most of the vertebral segments of the lumbar spine.

• Cervical Stenosis

• Spinal stenosis pain in the neck is called cervical spinal stenosis. This condition means that there is potential compression of the spinal cord. Unfortunately, the spinal cord compression can lead to serious problems such as extreme weakness, or even paralysis. With cervical stenosis, anyone who develops signs of spinal cord compression (myelopathy) may need more invasive treatment, such as surgery.Thoracic stenosis can also occur, but is less common. The thoracic part of the spine is the middle/ upper portion of the spine, and mainly consists of the vertebrae that are attached to the rib cage. This stable and strong part of the spine allows for minimal movement, which is why degenerative conditions such as spinal stenosis are less likely to develop.

• Spinal Stenosis and the Aging Spine

• Spinal stenosis is related to degeneration in the spine and usually will become significant in the 5th decade of life and extend throughout every subsequent age group. As it is a gradual process and rarely causes immediate symptoms, the subtle changes of spinal stenosis often result in a gradual decrease in physical activity, and a development of a more kyphotic or forward flexed posture.

• This gradual accommodation may be evident when looking at a series of oneself in pictures - over the course of several years— after around age 50. It is typical to start stooping forward more and become less active as effects of spinal stenosis increase.

• Common Spinal Stenosis Symptoms

• Overall, spinal stenosis symptoms are often characterized as:

• Developing slowly over time, or slow onset

• Coming and going, as opposed to continuous pain

• Occurring during certain activities (such as walking for lumbar stenosis, or biking while holding the head upright) and/or positions (such as standing upright for lumbar stenosis)

• Feeling relieved by rest (sitting or lying down) and/or any flexed forward position.

• Lumbar Stenosis Symptoms

• When stenosis has developed in the lower back (lumbar spine), leg pain with walking may develop. Leg pain with walking is medically known as claudication, and it can be caused by either arterial circulatory insufficiency (vascular claudication) or from spinal stenosis (neurogenic or pseudo-claudication). Leg pain from either condition will go away with rest, but with spinal stenosis the patient usually has to sit down for a few minutes to ease the leg and often low back pain, whereas leg pain from vascular claudication will go away if the patient simply stops walking.

• For lumbar stenosis, flexing forward or sitting will open up the spinal canal by stretching the ligamentum flavum and will relieve the leg pain and other symptoms, but the symptoms will recur if the patient gets back into an upright posture. Numbness and tingling can accompany the pain, but true weakness is a rare symptom of spinal stenosis.

• Spinal Stenosis Diagnosis

• Diagnostic imaging studies for patients with any type of spinal stenosis include either an MRI scan or a CT scan with myelogram (using an X-ray dye in the spinal sac fluid), and sometimes both. Plain CT scans can better identify bony causes of spinal stenosis, but cannot give the same detail for soft tissue causes of stenosis such as disc bulges, disc herniations, and ligament hypertrophy. Due to this changing compression, spinal stenosis symptoms vary from time to time and the physical examination generally will not show any neurological deficits or motor weakness. Certain activities and body position may trigger the symptoms.

• In some medical centers, upright MRIs, flexion extension MRIs, and spine load-bearing MRIs have been used to identify the dynamic changes on the spine, and the canal dimensions. The efficacy of these tests are still being studied, but there may be additional information provided by such tests.

• Cervical foraminal stenosis can be pinpointed not only by the CT and MRI scans, but by injecting the suspicious nerve with a small volume of local anesthetic. This procedure is called a selective nerve root block.

• After the injection a remission of the patient's symptoms along with true temporary weakness of the limb is clinically diagnostic and can help the surgeon determine the source of symptoms, and potentially reduce the size and complexity of the surgery.

• Rarely, a surgeon will use electrodiagnostic studies to determine the type of surgery. Those studies can be helpful in trying to determine if a symptom is caused by a neuropathy, rather than a radiculopathy. But few surgeons are confident of the specificity provided by these studies. The results will not help plan a surgical procedure, but may help decide to cancel one—for example, if it is a global neuropathic problem, surgery may not be beneficial.

• Spinal Stenosis Treatment

• There is a wide range of nonoperative treatments for spinal stenosis. The more common options include:

• Exercises: A suitable program of physical therapy and exercise is a component of almost every spinal stenosis treatment program. While the spinal stenosis exercises are not a cure, it is important for patients to remain active as tolerated and not become additionally debilitated from inactivity.

• The treating physician may prescribe a supervised physical therapy program. After a period of physical therapy instruction, most people can then start their own exercise program. The key is to start slowly, and build strength and tolerance over time.

• Activity modification: Patients are usually told to avoid activities that worsen their spinal stenosis symptoms. For lumbar stenosis, patients are typically more comfortable while flexed forward. For example, recommended activity modification might include walking while bent over and leaning on a walker or shopping cart instead of walking upright; stationary biking (leaning forward on the handlebars) instead of walking for exercise; sitting in a recliner instead of on a straight-back chair.

• Epidural injections: An injection of cortisone into the space outside the dura (the epidural space) can temporarily relieve symptoms of spinal stenosis. Some recent studies have questioned the long term efficacy of these injections, and there are some concerns about the use of corticosteroid injections for patients at risk for osteoporosis related fractures. While it is still a mainstream option offered by many physicians, as with most treatments there are both risks and benefits.

• Medication: Anti-inflammatory medication (such as aspirin or ibuprofen) may be helpful in alleviating spinal stenosis symptoms. With careful use, a short term course of narcotic medication use may be helpful for severe episodes of nerve related pain. Some physicians will also prescribe muscle relaxers and nerve desensitizing medications such as gabapentin. In some instances, anti-depressant medications can also provide pain relief.

• Side effects from medications are always a concern. As a precaution, it is essential the patients make sure their physician and pharmacist are aware of all their medications and medication allergies.

• Fortunately, many people successfully manage the symptoms of spinal stenosis with the non-surgical therapies. For others, symptoms may become disabling and surgery may be considered.

• Surgical Treatment in Spinal Stenosis

• In most cases of advanced claudication (spinal or vascular), a decompression surgery is required to treat the symptoms of spinal stenosis.

• Current surgical techniques try to minimize exposure or violation of nearby tissues. Most surgeons try to preserve the spine ligaments and facet capsules in an attempt to reduce the chance of developing next-level or adjacent-level degeneration or stenosis in the future.

• Medical care overall has improved, but medical risks such as prior heart disease, diabetes, and osteoporosis must also be weighed when making the decision for surgery. Sometimes, the prudent decision may be to not operate, considering the medical risks, and the otherwise chance of a successful outcome.

• Fortunately, spinal stenosis surgery outcomes for decompression can be among the most rewarding surgical methods used on the spine. Generally patients do well after decompression surgery and are able to increase their activity following recovery from spinal stenosis surgery. Many patients have a better walking tolerance following back surgery for spinal stenosis.

• There are several opinions and techniques used in spinal stenosis surgery, but there are key components common to all such approaches, as explained in more detail below.

• The gold standard of surgery to treat spinal stenosis is a laminectomy. Modern techniques may use smaller access incisions to the narrowed bones, but the goals are the same. The area of bony compression is removed, and soft tissues such as hypertrophic ligamentum flavum are peeled off the thecal sac and out the neuroforamen. This technique can be used in the lumbar or cervical area.

• In the cervical spine, sometimes much of the compression is located from the front of the spine, or, if there is a more forward bend to the neck (kyphosis), anterior decompression of the spine via anterior cervical discectomy/corpectomy with fusion (ACDF) may be the preferred surgery.

• For patients with spinal instability as well as stenosis, or for patients that require such a decompression that they will become unstable after the decompression, the standard is to perform both a laminectomy decompression procedure as well as a fusion, which involves stabilizing the vertebrae so they will come together as one bone.

• More recently, a few new surgical approaches have also been introduced. For example:

• Interspinous process devices. This procedure has had some success for central canal stenosis patients, but the procedure has not benefited all spinal stenosis patients. In addition, it has no use in patients with more than two levels of central stenosis, and depending on the imaging studies, the various devices may not accommodate certain anatomies.

• Facet replacement or total element replacement. This is a newer class of devices and remains experimental. Several of the devices studies have had discontinuation of the research. While there may have been some merit in the concept, the devices are no longer available for more patients.

• The bottom line is that surgical treatment for spinal stenosis can be effective for the right patient, with the right diagnosis, right imaging studies, and the right procedure. The goals will always be the same: Remove the narrowing on the nerves without creating other longer term issues for the spine. If there is an instability pattern (spondylolisthesis) along with the narrowing, fusion is likely necessary to achieve an acceptable surgical outcome.

Spondylolisthesis

• Spondylolisthesis is a condition in which one vertebra slips forward over the one below it. Spondylolisthesis is a fairly common cause of lower back pain and leg pain in younger adults (age 30 to 50), and degenerative spondylolisthesis is a fairly common cause of pain in older adults (age 50 and up). The most common symptoms are lower back pain and/or leg pain that limits activity level.

• Degenerative Spondylolisthesis

• Degenerative spondylolisthesis is Latin for "slipped vertebral body," and it is diagnosed when one vertebra slips forward over the one below it. This condition occurs as a consequence of the general aging process in which the bones, joints, and ligaments in the spine become weak and less able to hold the spinal column in alignment.

• Degenerative spondylolisthesis is more common in people over age 50, and far more common in individuals older than 65. It is also more common in females than males by a 3:1 margin.

• A degenerative spondylolisthesis typically occurs at one of two levels of the lumbar spine:

• The L4-L5 level of the lower spine (most common location)

• The L3-L4 level.

• Degenerative spondylolisthesis is relatively rare at other levels of the spine, but may occur at two levels or even three levels simultaneously. While not as common as lumbar spondylolisthesis, cervical spondylolisthesis (in the neck) can occur. When degenerative spondylolisthesis does occur in the neck, it is usually a secondary issue to arthritis in the facet joints.

• Degenerative Spondylolisthesis Causes

• Every level of the spine is composed of a disc in the front and paired facet joints in the back. The disc acts as a shock absorber in between the vertebrae, whereas the paired facet joints restrain motion. They allow the spine to bend forwards (flexion) and backwards (extension) but do not allow for a lot of rotation.

• As the facet joints age, they can become incompetent and allow too much flexion, allowing one vertebral body to slip forward on the other.

• Degenerative spondylolisthesis is diagnosed by a spine specialist through a 3-step process:

• Medical History – primarily a review of the patient’s symptoms and what makes the symptoms better or worse.

• Physical Examination – the patient is examined for physical symptoms, such as range of motion, flexibility, any muscle weakness or neurological symptoms.

• Diagnostic Tests – if a spondylolisthesis is suspected after the medical history and physical exam, an X-ray may be done to confirm the diagnosis and/or rule out other possible causes of the patient’s symptoms. Based on the results of the X-ray, further tests may be ordered, such as an MRI scan, to gain additional insights.

• Unlike isthmic spondylolisthesis, the degree of the slip of a degenerative spondylolisthesis is typically not graded as it is almost always a grade 1 or 2.

• In cases of degenerative spondylolisthesis, the degenerated facet joints tend to increase in size, and enlarged facet joints then encroach upon the spinal canal that runs down the middle of the spinal column, causing lumbar spinal stenosis.

• Degenerative Spondylolisthesis Symptoms

• As the facet joints in the spine degenerate they often get larger, which can encroach upon the spinal canal that runs down the middle of the spinal column, resulting in spinal stenosis. The symptoms of a degenerative spondylolisthesis are very commonly the same as that of spinal stenosis.

• The main symptoms of degenerative spondylolisthesis include:

• Lower back pain and/or leg pain are the most typical symptoms of degenerative spondylolisthesis. Some patients do not have any back pain with degenerative spondylolisthesis and others have primarily back pain and no leg pain.

• Patients often complain of sciatic pain, an aching in one or both legs, or a tired feeling down the legs when they stand for a prolonged period of time or try to walk any distance (called pseudoclaudication).

• Generally, patients do not have a lot of pain while sitting, because in the sitting position the spinal canal is more open. In the upright position, the spinal canal gets smaller, accentuating the stenosis and pinching the nerve roots in the canal.

• Patients typically have tight hamstring muscles (the muscles in the back of the thigh) decreased flexibility in the lower back, and difficulty or pain with extension (arching the back backwards).

• The nerve root pinching can lead to weakness in the legs, but true nerve root damage is rare.

• There is no spinal cord in the lumbar spine, so even for patients with severe pain, there is no danger of spinal cord damage. If the spinal stenosis becomes very severe, or if the patient also has a disc herniation, they can develop cauda equina syndrome where there is progressive nerve root damage and loss of bladder/bowel control. This clinical syndrome is very rare, but if it does occur it is a medical emergency.

• Degenerative Spondylolisthesis Treatment

• While there is a wide range of non-surgical treatment options (such as pain medications, ice or heat application) that may help with some of the pain of a degenerative spondylolisthesis, there are essentially four categories of treatment options a patient will ultimately have to choose from.

• Activity Modification: Patients can modify their activities so they spend more time sitting and less time standing or walking. Activity modification generally includes:

• A short period of rest (e.g. one to two days of bedrest or resting in a reclining chair)

• Avoiding standing or walking for long periods

• Avoiding active exercise

• Avoiding activities that require bending backwards.

• If activity modification substantially reduces the patient’s pain and symptoms, this is an acceptable way to manage the condition long term. Simple self care can assist in this approach, such as application of cold packs and or heating pads and/or taking appropriate over-the-counter pain relievers, such as ibuprofen and/or acetaminophen, after walking or any strenuous activity.

• For patients who want to be more active, stationary biking is a reasonable option, as activity in the sitting position should be tolerable. Another option is pool therapy – physical therapy done while in a warm swimming pool – as the water provides support and buoyancy and the patient is allowed to exercise in a flexed forward position.

• Many patients also benefit from controlled, gradual exercise and stretching as part of a physical therapy program to maintain and/or increase range of motion and flexibility, which in turn tends to alleviate pain as well as help the patient maintain their ability to function in everyday activities.

• Manual Manipulation: Chiropractic manipulation provided by chiropractors, or manual manipulation provided by osteopathic physicians, physiatrists or other appropriately trained health professionals, can help reduce pain by mobilizing painful joint dysfunction.

• Epidural Injections: For patients with severe pain, especially leg pain, epidural steroid injections may be a reasonable treatment option. The injections are effective in helping to curb pain and increase a patient’s function in up to 50% of cases. If an epidural steroid injection does work to relieve the patient’s pain, it can be done up to three times per year. The length of time that the lumbar epidural injection can be effective is variable, as the pain relief can last one week or a year.

• Surgery: Surgery for degenerative spondylolisthesis is rarely needed, and most patients can manage their symptoms with the above nonsurgical options. Surgery may be considered if the patient’s pain is disabling and they would likely be able to function better and be more active with less pain. Surgery is also indicated if the patient is experiencing progressive neurologic deterioration.The goals of surgery are to realign the affected segment of the spine to alleviate pressure on the nerve and provide stability to the area.

• Surgery for Degenerative Spondylolisthesis

• Surgery for a degenerative spondylolisthesis usually includes two parts, done together in one operation:

• A decompression (also called a laminectomy)

• A spine fusion with pedicle screw instrumentation

• Decompression surgery (e.g. a laminectomy) alone is usually not advisable as the instability is still present and a subsequent fusion will be needed in up to 60% of patients. A 1991 randomized controlled study of fusion with and without pedicle screw instrumentation and found the fusion rates were much higher in the patients with instrumentation, but the clinical results were about the same. However, when these same patients were followed up on 10 years later, the patients with a solid fusion ultimately fared significantly better than those that had not fused.

• It is a difficult surgery to recover from as there is a lot of dissection. The hospital stay typically ranges from one to four days. It can take up to a year to fully recover. Usually, most patients can start most of their activities after the fusion has had three months to heal. Once the bone is fused, then the more active the patient is, the stronger the bone will become.

• Potential Benefits of the Surgery

• Spinal fusion surgery for a degenerative spondylolisthesis is generally quite successful, with upwards of 90% of patients improving their function and enjoying a substantial decrease in their pain.

• Potential Risks and Complications

• There are numerous risks and possible complications with surgery for degenerative spondylolisthesis and they are basically the same as for any fusion surgery. There are risks of non union (nonfusion, or arthrodesis), hardware failure, continued pain, adjacent segment degeneration, infection, bleeding, dural leak, nerve root damage and all the possible general anesthetic risks (e.g. blood clots, pulmonary emboli, pneumonia, heart attack or stroke). Most of these complications are rare, but increased risks can be seen in certain situations. Conditions that increase the risk of surgery include smoking (or any nicotine intake), obesity, multilevel fusions, osteoporosis (thinning of the bones), diabetes, rheumatoid arthritis, or prior failed back surgery.

• Since degenerative spondylolisthesis is a condition that disproportionately affects individuals over age 60 or 65, the surgery does present some additional risk. Surgical risk is more directly related to the overall health of a patient and not his or her absolute age.

• Particularly in patients who have multiple medical problems, surgery can be very risky. For some patients, even if non-surgical treatments have failed to alleviate their symptoms, surgery may present too much risk, and intermittent epidural injections combined with activity modification may be their best option.

• After a fusion procedure, degeneration of the spinal segment adjacent to the fusion is possible. In an attempt to alleviate transferring extra stress to the next segment, there are many different devices currently being studied that hold the promise of being able to replace the function of the facet joint without having to include a fusion procedure. It is too early to determine whether or not the results of these newer technologies are better or worse than the standard fusion procedure.

Sacroiliac Joint Disorders

• The sacroiliac (SI) joints are formed by the connection of the sacrum and the right and left iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. The sacrum is made up of five vertebrae that are fused together and do not move. The iliac bones are the two large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis. The sacrum and the iliac bones (ileum) are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of translation at these joints. Most of the motion in the area of the pelvis occurs either at the hips or the lumbar spine. These joints do need to support the entire weight of the upper body when we are erect, which places a large amount of stress across them. This can lead to wearing of the cartilage of the SI joints and arthritis.

• What is sacroiliac joint dysfunction?

• There are many different terms for sacroiliac joint problems, including SI joint dysfunction, SI joint syndrome, SI joint strain, and SI joint inflammation. Each of these terms refers to a condition that causes pain in the SI joints from a specific cause.

• What are the causes of sacroiliac joint dysfunction?

• As with most other joints in the body, the SI joints have a cartilage layer covering the bone. The cartilage allows for some movement and acts as a shock absorber between the bones. When this cartilage is damaged or worn away, the bones begin to rub on each other, and degenerative arthritis (osteoarthritis) occurs. This is the most common cause of SI joint dysfunction. Degenerative arthritis occurs commonly in the SI joints, just like other weight-bearing joints of the body.

• Another common cause of SI joint dysfunction is pregnancy. During pregnancy, hormones are released in the woman's body that allows ligaments to relax. This prepares the body for childbirth. Relaxation of the ligaments holding the SI joints together allows for increased motion in the joints and can lead to increased stresses and abnormal wear. The additional weight and walking pattern (altered gait) associated with pregnancy also places additional stress on the SI joints.

• Any condition that alters the normal walking pattern places increased stress on the SI joints. This could include a leg length discrepancy (one leg longer than the other), or pain in the hip, knee, ankle, or foot. Patients with severe pain in the lower extremity often develop problems with either the lower back (lumbar spine) or SI joints. Usually, if the underlying problem is treated, the associated lumbar spine or SI joint dysfunction will also improve.

• There are many disorders that affect the joints of the body that can also cause inflammation in the SI joints. These include gout, rheumatoid arthritis, psoriatic arthritis, reactive arthritis, and ankylosing spondylitis. These are all various forms of arthritis that can affect all joints. Ankylosing spondylitis is an inflammatory arthritis that always affects the SI joints. It can lead to stiffness and severe pain in the SI joints, due to inflammation in the sacroiliac joints (sacroiliitis). As the disease process continues, the SI joints can fuse together and have no range of motion. Once this occurs, there is no further pain associated with the SI joints. Rarely, bacterial infection can involve the sacroiliac joints.

• What are sacroiliac joint dysfunction symptoms?

• The most common symptom of SI joint dysfunction is sacroiliac joint pain. Patients often experience pain in the lower back or the back of the hips. Pain may also be present in the groin and thighs. In many cases, it can be difficult to determine the exact source of the pain. Your physician can perform specific tests to help isolate the source of the pain. The pain is typically worse with standing and walking and improved when lying down. Inflammation and arthritis in the SI joint can also cause stiffness and a burning sensation in the pelvis.

• How is sacroiliac joint dysfunction diagnosed?

• The first step in diagnosis is typically a thorough history and physical examination by a physician. Certain signs can also help differentiate pain coming from the SI joints, lumbar spine, or hips. There are various tests a physician can perform during the physical examination that can help isolate the source of the pain. By placing the patient's hips and legs in certain positions and applying pressure, the SI joints can be moved or compressed to identify them as a source of pain. Other portions of the examination are to exclude certain possibilities that could mimic sacroiliac disease.

• The next step in diagnosis is often plain radiographs (X-rays). The patient may have X-rays of the pelvis, hips, or lumbar spine depending on what the physician finds on the history and physical examination. A computed tomography (CAT or CT) scan may also help in the diagnosis. A CT scan gives a more detailed look at the joint and bones. Both X-rays and CT scans can help identify sacroiliitis. This can appear as sclerosis in the joints. More severe wear in the joints can appear as erosion of the bone around the SI joints. These tests can also look for fusion of the SI joints. A magnetic resonance imaging (MRI) scan can also be helpful. This provides a better evaluation of the soft tissues, including muscles and ligaments. It can also identify subtle fractures that may not be visible on an X-ray. The MRI can identify inflammation in the SI joint by the presence of excessive fluid in the joint. A bone scan can be obtained to help isolate the source of the pain and can be used to identify bony abnormalities. The bone scan can identify areas of increased activity in the bone. This is a nonspecific test and can be positive in cases of arthritis, infection, fracture, or tumors of bone.

• A helpful method of diagnosing SI joint dysfunction is by performing an injection that can numb the irritated area, thereby helping to pinpoint the pain source. An anesthetic material (for example, lidocaine [Xylocaine]) can be injected along with a steroid (cortisone) directly into the SI joint. This is usually performed with the aid of an X-ray machine to verify the injection is in the SI joint. The anesthetic and steroid can help relieve the pain from inflammation that is common with SI joint dysfunction. The duration of pain relief is variable, but this is very useful to determine that the SI joint is the source of the pain.

• What is the treatment for sacroiliac joint dysfunction?

• As stated above, injections into the SI joint can provide both diagnosis and treatment. The duration of pain relief from injection can last from one day to much more long term. The injections can be repeated each month up to three each year. Oral antiinflammatory medications (NSAIDs, ibuprofen [Motrin], naproxen [Naprosyn]) are often effective in pain relief as well. These can be taken long term if the patient does not have any other medical problems that prevent them from taking these medications. Oral steroids (prednisone) are used as well for short periods of time occasionally to treat the inflammation.

• Physical therapy can be very helpful. Pain in the SI joint is often related to either too much motion or not enough motion in the joint. A physical therapist can teach various stretching or stabilizing exercises that can help reduce the pain. A sacroiliac belt is a device that wraps around the hips to help stabilize the SI joints, which can also help the SI joint pain. Other options to stabilize the SI joints include yoga, manual therapy, and Pilates.

• If other treatments fail and pain continues to interfere with normal activities, surgery might be an option. Surgery for SI dysfunction typically involves a fusion of the SI joints. In this surgery, the cartilage covering the surfaces of the SI joints is removed and the bones are held together with plates and screws until they grow together (fuse). This eliminates all motion at the SI joints and typically relieves the pain. This should be considered only if other less invasive treatments have not been successful.

• What is the prognosis of sacroiliac joint dysfunction?

• The prognosis of sacroiliac joint dysfunction varies depending on the cause of the dysfunction. When the problem is caused by pregnancy, the prognosis is excellent, as the condition usually improves after pregnancy during the postpartum period. Conditions affecting the sacroiliac joints such as ankylosing spondylitis and psoriatic arthritis are chronic, but excellent treatments are available. These treatments can minimize the SI joint pain and prevent destruction of the joints. Degenerative arthritis affecting the SI joint is also a chronic condition and cannot be reversed, but treatments are generally very effective in improving symptoms.

• Is it possible to prevent sacroiliac joint dysfunction

• Unfortunately, SI joint dysfunction is not preventable in some people. For many, it is an unfortunate part of the normal aging process. However, the severity can be reduced through treatment with medication, injections, or physical therapy. Maintaining a healthy body weight and good conditioning can reduce the chances of developing SI joint dysfunction and other forms of arthritis. By reducing the loads on the joints, there is less chance for cartilage damage and subsequent arthritis.

Failed Back Surgery

• Failed back surgery syndrome (also called FBSS, or failed back syndrome) is a misnomer, as it is not actually a syndrome - it is a very generalized term that is often used to describe the condition of patients who have not had a successful result with back surgery or spine surgery and have experienced continued pain after surgery. There are many reasons that a back surgery may or may not work, and even with the best surgeon and for the best indications, spine surgery is no more than 95% predictive of a successful result.

• Reasons for Failed Back Surgery and Pain after Surgery

• Spine surgery is basically able to accomplish only two things:

• Decompress a nerve root that is pinched, or

• Stabilize a painful joint.

• Unfortunately, back surgery or spine surgery cannot literally cut out a patient’s pain. It is only able to change anatomy, and an anatomical lesion (injury) that is a probable cause of back pain must be identified prior to rather than after back surgery or spine surgery.

• By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the lesion that was operated on is not in fact the cause of the patient’s pain.

• Predictability of Pain after Surgery

• Some types of back surgery are far more predictable in terms of alleviating a patient’s symptoms than others. For instance,

• A discectomy (or microdiscectomy) for a lumbar disc herniation that is causing leg pain is a very predictable operation. However, a discectomy for a lumbar disc herniation that is causing lower back pain is far less likely to be successful.

• A spine fusion for spinal instability (e.g. spondylolisthesis) is a relatively predictable operation. However, a fusion surgery for multi-level lumbar degenerative disc disease is far less likely to be successful in reducing a patient’s pain after surgery.

• Therefore, the best way to avoid a spine surgery that leads to an unsuccessful result is to stick to operations that have a high degree of success and to make sure that an anatomic lesion that is amenable to surgical correction is identified preoperatively.

• Other Causes of FBSS and Continued Pain after Surgery

• In addition to the above-mentioned cause of failed back surgery syndrome, there are several other potential causes of a failed surgery, or continued pain after surgery:

• Fusion surgery considerations (such as failure to fuse and/or implant failure, or a transfer lesion to another level after a spine fusion, when the next level degenerates and becomes a pain generator)

• Lumbar decompression back surgery considerations (such as recurrent spinal stenosis or disc herniation, inadequate decompression of a nerve root, preoperative nerve damage that does not heal after a decompressive surgery, or nerve damage that occurs during the surgery)

• Scar tissue considerations (such as epidural fibrosis, which refers to a formation of scar tissue around the nerve root)

• Postoperative rehabilitation (continued pain from a secondary pain generator).

• Failed Spinal Fusion Surgery

• In addition to the primary reasons for failed back surgery syndrome (FBSS) discussed on the prior page, there are several reasons why a spinal fusion might fail to alleviate a patient’s back pain after surgery, including fusion and implant failures, and transfer lesions.

• Failure of Solid Fusion After Spine Surgery

• When the fusion is for back pain and/or spinal instability, there is a correlation (although weak) between obtaining a solid fusion and having a better result of the spine surgery. If a solid fusion is not obtained through the spine surgery, but the hardware is intact and there is still good stability to the spine, the patient may still achieve effective back pain relief with the spine surgery. In many cases, achieving spinal stability alone is more important than obtaining a solid fusion from the spine surgery.

• On postoperative imaging studies it is often very difficult to tell if a patient’s spine has fused, and it can be even harder to determine if a further fusion surgery is necessary. In general, it takes at least three months to get a solid fusion, and it can take up to a year after the spine surgery. For this reason, most surgeons will not consider further spine surgery if the healing time has been less than one year. Only in cases where there has been breakage of the hardware and there is obvious failure of the spinal construct would back surgery be considered sooner.

• Implant Failure in Spine Surgery

• An instrumented fusion can fail if there is not enough support to hold the spine while it is fusing. Therefore, spinal hardware (e.g. pedicle screws) may be used as an internal splint to hold the spine while it fuses after spine surgery. However, like any other metal it can fatigue and break (sort of like when one bends a paper clip repeatedly). In very unstable spines, it is therefore a race between the spine fusing (and the patient’s bone then providing support for the spine), and the metal failing.

• Metal failure (also called hardware failure, implant failure), especially early in the postoperative course after back surgery, is an indicator of continued gross spinal instability. The larger a patient is and the more segments that are fused, the higher the likelihood of implant failure. Implant failure following spine surgery should be very uncommon in normal sized individuals with a one level fusion.

• Transfer Lesion to Another Level after a Spine Fusion

• A patient may experience recurrent pain many years after a spine fusion surgery. This can happen because the level above or below a segment that has been successfully fused can break down and become a pain generator.

• This degeneration is most likely to happen after a two-level fusion (e.g. a fusion for L4-L5 and L5-S1 levels) and in a young patient (in the 30-50 year old age range).

• It is much less likely to happen if only the L5-S1 level is fused, as this segment typically does not have much motion and fusing this level does not change the mechanics in the spine all that much.

• Most of the motion in the spine is at the L4-L5 level, and to a lesser extent at L3-L4. When the L4-L5 level is included in the spine fusion it transfers a lot of stress to L3-L4. This does not present as much of a problem for elderly patients, since they tend to not be as active nor do they have the fusion for as many years.

• Transfer lesions are far more common in degenerative osteoarthritis conditions ( e.g. degenerative spondylolisthesis) and far less common in disc degeneration problems (e.g. degenerative disc disease or isthmic spondylolisthesis).

• Lumbar Decompression Back Surgery Considerations

• The nerve root can take a long time to heal from a lumbar decompression (such as a discectomy, microdiscectomy or laminectomy), making it difficult to gauge the outcome of the surgery.

• In general, if a patient is getting better within three months of the surgery, he or she should continue to get better.

• If there has not been any improvement in the pain approximately three months after the decompression, then the back surgery can be assumed to be unsuccessful, and further work up would be reasonable.

• During the first three months, the success of the back surgery really cannot be judged, and it is often too early to describe the procedure as either a successful or failed back surgery.Decompression of the lumbar spine will usually relieve the patient’s leg pain directly after the back surgery. However, for 10-20% of patients, the pain will continue until the nerve starts to heal. In some cases, the pain may even be worse for a while after the back surgery because operating around the nerve root creates some increased swelling and this leads to pain.

• It usually takes far longer for symptoms of numbness/tingling or weakness to resolve, and sometimes it can take up to a year for these symptoms to subside. If these symptoms persist after a year, they probably represent permanent nerve damage and are unlikely to resolve.

• Recurrent Stenosis or Herniation after Decompression

• Years after decompression (lumbar laminectomy), lumbar stenosis can come back (the bone can grow back) at the same level, or a new level can become stenotic and cause back pain or leg pain. Pain that is relieved right after surgery but then returns abruptly is often due to a recurrent lumbar disc herniation. Recurrent lumbar disc herniations happen to about 5% to 10% of patients, and they are most likely to occur during the first three months after back surgery.

• Technical Problems after Lumbar Decompression Surgery

• Three potential technical problems that cause the pain after surgery to continue include:

• Missed fragment (of the disc or bone) is still pinching the nerve

• The back surgery operation was done at the wrong level of the spine

• Dissection of the nerve root may cause further trauma.

• Nerve damage during a discectomy or a lumbar decompression is very uncommon, but has been reported in about 1 in 1,000 cases. When it does occur during back surgeries, a permanent neurological deficit with new weakness in a muscle group is possible, and a postoperative EMG (electromyography) can be helpful to see if there has been nerve damage and if there is any reinnervation (nerve healing) after the back surgery.

• At times, decompressing a nerve root through back surgery will cause it to become more inflamed and lead to more pain temporarily until the inflammation subsides.

• Inadequate Decompression of a Nerve Root after Surgery

• Decompressing a nerve root with back surgery is not always successful, and if a portion of the nerve root is still pinched after the back surgery there can be continued pain. If this is the case, there will usually be no initial pain relief following the back surgery, and subsequent postoperative imaging studies may show continued spinal stenosis in a portion of the lumbar spine.

• Scar Tissue and Continued Pain After Back Surgery

• Scar tissue formation is part of the normal healing process after back surgery. While scar tissue can be a cause of pain, actual scar tissue pain is very rare since the tissue contains no nerve endings.

• Rather, the principal mechanism of pain is thought to be the binding of the lumbar nerve root by fibrous adhesions, called epidural fibrosis. Postoperative stretching exercises can help decrease the effects of postoperative scarring around the nerve root.

• Scar Tissue Formation after Back Surgery

• All patients will heal with scar tissue after back surgeries as this is the only way to heal. The reality is that although scar tissue is often clinically the reason given for continued pain after surgery, it is probably rarely the cause of postoperative pain. Particularly in patients that have similar pain postoperatively to what they had before surgery, it is unlikely that the addition of scar tissue has any clinical relevance.

• However, clinicians often use the explanation of scar tissue as the cause of continued pain, whether or not there is any evidence that this is in fact the patient's pain generator. Often, a better explanation for continued pain after surgery is that either the patient has a secondary problem that needs to be addressed, or that the lesion operated on was not in fact the source of the patient's pain. These are far more likely scenarios than actual scar tissue pain.

• A Possible Exception for Scar Tissue Pain

• The one time that scar tissue (epidural fibrosis) may be symptomatic is for a patient who initially does well after a lumbar discectomy or a decompression, only to have recurrent pain come on slowly between 6 to 12 weeks after surgery.

• This is the time period that scar tissue takes to form, and as it forms it can cause the nerve root to become adherent within the spinal canal. Keeping the nerve moving through stretching exercises can help prevent this scenario.

• Pain that starts years after surgery, or pain that continues after surgery and is never relieved, is not from scar tissue.

• Rehabilitation After Spine Surgery

• After an incorrect preoperative diagnosis and subsequent spine surgery, improper and/or inadequate postoperative rehabilitation is probably the second most common cause of continued back pain after surgery.

• It often takes months to a year to heal after many of these back surgeries, and a postoperative rehabilitation program that includes stretching, strengthening and conditioning is an important part of any successful spine surgery.

• In general, the bigger the back surgery and the longer a patient has had their preoperative symptoms, the longer and harder the postoperative rehabilitation will be. It is often far more reasonable to continue with rehabilitation after spine surgery than to consider further surgery (with some exceptions, such as if there has been a recurrent disc herniation).

• Secondary Problems after Spine Surgery

• Often, there are other secondary problems that must be worked out after back surgery. For example, a patient with a pinched L5 nerve root from a disc herniation may still need physical therapy afterward because they may have a secondary piriformis syndrome. Unpinching the L5 nerve root may relieve the radiculopathy (sciatica) but the patient still has pain in the buttocks from continued muscle spasm in the piriformis. Until this is worked out, the patient will not feel like the back surgery is successful.

• Many times, spine surgery is necessary to provide enough back pain relief for the patient to start a rehabilitation program, but it should only be one component of the patient’s healing process. Unfortunately, some patients feel that if they have had back surgery they have been “fixed” and no further treatment is necessary. However, this is rarely true, and continued therapies and rehabilitation are usually necessary for a successful outcome.

• Rehabilitation Considerations after Back Surgery

• After spine surgery, careful follow-up and rehabilitation is very important. If there is continued pain after surgery despite adequate time to heal and rehabilitate, then further workup may be warranted to find if there is a new lesion or a different type of problem that could contribute to the patient’s pain. • Failed back surgery syndrome is really not a syndrome, and there are no typical scenarios. Every patient is different, and a patient’s continued treatment and workup need to be individualized to his or her particular problem and situation.

Spina Bifida

Spina bifida is part of a group of birth defects called neural tube defects. The neural tube is the embryonic structure that eventually develops into the baby's brain and spinal cord and the tissues that enclose them.

Normally, the neural tube forms early in the pregnancy and closes by the 28th day after conception. In babies with spina bifida, a portion of the neural tube fails to develop or close properly, causing defects in the spinal cord and in the bones of the spine.

Spina bifida occurs in various forms of severity. When treatment for spina bifida is necessary, it's done surgically, although such treatment doesn't always completely resolve the problem.

Doctors aren't certain what causes spina bifida. As with many other problems, it appears to result from a combination of genetic and environmental risk factors, such as a family history of neural tube defects and folic acid deficiency.

•Although doctors and researchers don't know for sure why spina bifida occurs, they have identified a few risk factors:

• Race. Spina bifida is more common among whites and Hispanics.

• Sex. Girls are affected more often.

• Family history of neural tube defects. Couples who've had one child with a neural tube defect have a slightly higher chance of having another baby with the same defect. That risk increases if two previous children have been affected by the condition.

• In addition, a woman who was born with a neural tube defect, or who has a close relative with one, has a greater chance of giving birth to a child with spina bifida. However, most babies with spina bifida are born to parents with no known family history of the condition.

• Folate deficiency. Folate (vitamin B-9) is important to the healthy development of a baby. Folate is the natural form of vitamin B-9. The synthetic form, found in supplements and fortified foods, is called folic acid. A folate deficiency increases the risk of spina bifida and other neural tube defects.

• Some medications. Anti-seizure medications, such as valproic acid (Depakene), seem to cause neural tube defects when taken during pregnancy, perhaps because they interfere with the body's ability to use folate and folic acid.

• Diabetes. Women with diabetes who don't control their blood sugar well have a higher risk of having a baby with spina bifida.

• Obesity. Pre-pregnancy obesity is associated with an increased risk of neural tube birth defects, including spina bifida.

• Increased body temperature. Some evidence suggests that increased body temperature (hyperthermia) in the early weeks of pregnancy may increase the risk of spina bifida. Elevating your core body temperature, due to fever or the use of saunas or hot tubs, has been associated with increased risk of spina bifida.

• If you have known risk factors for spina bifida, talk with your doctor to determine if you need a larger dose or prescription dose of folic acid, even before a pregnancy begins.

• If you take medications, tell your doctor. Some medications can be adjusted to diminish the potential risk of spina bifida, if plans are made ahead of time.

• Spina bifida may cause no symptoms or only minor physical disabilities. Frequently, it leads to severe physical and mental disabilities.

• Factors that affect severity

• The severity of the condition is affected by:

• The size and location of the neural tube defect

• Whether skin covers the affected area

• Which spinal nerves come out of the affected area of the spinal cord

• Range of complications

• Complications may include:

• Physical and neurological problems. This may include lack of normal bowel and bladder control and partial or complete paralysis of the legs. Children and adults with this form of spina bifida might need crutches, braces or wheelchairs to help them get around, depending on the size of the opening in the spine and the care received after birth.

• Accumulation of fluid in the brain (hydrocephalus). Babies born with myelomeningocele also commonly experience accumulation of fluid in the brain, a condition known as hydrocephalus.

• Most babies with myelomeningocele will need a ventricular shunt — a surgically placed tube that allows fluid in the brain to drain as needed into the abdomen. This tube might be placed just after birth, during the surgery to close the sac on the lower back, or later as fluid accumulates.

• Infection in the tissues surrounding the brain (meningitis). Some babies with myelomeningocele may develop meningitis, an infection in the tissues surrounding the brain, which may cause brain injury and can be life-threatening.

• Other complications. Additional problems may arise as children with spina bifida get older. Children with myelomeningocele may develop learning disabilities, including difficulty paying attention, problems with language and reading comprehension, and trouble learning math.

• Children with spina bifida may also experience latex allergies, skin problems, urinary tract infections, gastrointestinal disorders and depression.

• Spina bifida treatment depends on the severity of the condition. Spina bifida occulta often doesn't require treatment at all, but other types of spina bifida do.

• Surgery

• Meningocele involves surgery to put the meninges back in place and close the opening in the vertebrae. Myelomeningocele also requires surgery, usually within 24 to 48 hours after birth.

• Performing the surgery early can help minimize risk of infection that's associated with the exposed nerves and may also help protect the spinal cord from additional trauma.

• During the procedure, a neurosurgeon places the spinal cord and exposed tissue inside the baby's body and covers them with muscle and skin. Sometimes a shunt to control hydrocephalus in the baby's brain is placed during the operation on the spinal cord.

• Prenatal surgery

• In this procedure — which takes place before the 26th week of pregnancy — surgeons expose a pregnant mother's uterus surgically, open the uterus and repair the baby's spinal cord.

• Proponents of fetal surgery believe that nerve function in babies with spina bifida seems to worsen rapidly after birth, so it may be better to repair spina bifida defects while you're still pregnant and the baby is still in your uterus (in utero).

• So far, children who received the fetal surgery need fewer shunts and are less likely to need crutches or other walking devices. But the operation poses risks to the mother and greatly increases the risk of premature delivery.

• Discuss with your doctor whether this procedure may be right for you.

• Ongoing care

• Treatment doesn't end with the initial surgery, though. In babies with myelomeningocele, irreparable nerve damage has already occurred and ongoing care from a multidisciplinary team of surgeons, physicians and therapists is usually needed. Babies with myelomeningocele may need further operations for a variety of complications.

• Paralysis and bladder and bowel problems often remain, and treatment for these conditions typically begins soon after birth. Babies with myelomeningocele may also start exercises that will prepare their legs for walking with braces or crutches when they're older.

• Many have a tethered spinal cord — a condition in which the spinal cord is bound to the scar of the closure and is less able to properly grow in length as the child grows. This progressive "tethering" can cause loss of muscle function to the legs, bowel or bladder. Surgery can limit the degree of disability and may also restore some function.

• Cesarean birth

• Cesarean birth may be part of the treatment for spina bifida. Many babies with myelomeningocele tend to be in a feet-first (breech) position. If your baby is in this position or if your doctor has detected a large cyst, cesarean birth may be a safer way to deliver your baby.

Coccyx pain - Coccygodynia

• Coccygodynia (also referred to as coccydynia, coccalgia, coccygalgia, or coccygeal pain) is a painful syndrome affecting the tailbone (coccygeal) region. The word coccyx comes from the Greek word for cuckoo (kokkyx), on the basis of this structure’s resemblance to the shape of a cuckoo’s beak (see the image below).

• The pain in coccygodynia is typically triggered by or occurs while sitting on hard surfaces. The pain often varies and sometimes is aggravated by arising from the sitting position.

• For most patients with coccygodynia, conservative therapy (eg, massage, injection, and ganglion impar block) appears to play a vital role in management. For those with intractable pain that does not respond to conservative therapy, coccygectomy is typically effective. However, optimal specific therapy for each specific type of coccyx in coccygodynia is still a matter of debate, and no final consensus has yet been reached.

• Frequency

• Coccygodynia accounts for fewer than 1% of all back pain conditions. It is five times more prevalent in women than in men,presumably because the bone is more prominent in women than in men. Although coccygodynia can occur over a wide age range, the mean age of onset is around 40 years.

• Etiology

• Several possible causes of coccygodynia have been described. The most common of these is a single axial trauma, such as occurs with a fall directly onto the coccyx or during childbirth. However, Maigne et al have suggested that only a traumatic event that occurs within 1 month of onset is significant in increasing the risk of instability and subsequent coccygodynia.

• Obesity is another possible cause of coccygodynia. A body mass index (BMI) greater than 27.4 in women or 29.4 in men is a risk factor for the development of both idiopathic and posttraumatic coccygodynia. As high-BMI individuals attempt to sit down, the coccyx tends to jut out posteriorly as a result of inadequate sagittal pelvic rotation. This results in increased exposure to the intrapelvic pressure that occurs with sitting, ultimately causing subluxation of the coccyx.

• The coccygeal configuration (see Pathophysiology) also appears to influence the cause of pain. Types II, III, and IV are more painful than type I.

• Coccygodynia may also occur in individuals with a normal coccyx. In such cases, the pain may derive from secondary causes, such as tumor, infection, bursitis, or posttraumatic arthritis.Postacchini and Massobrio have classified coccygeal configurations into four types (see the image below).

• Type I: Coccyx is curved slightly forward, with its apex directed downward and caudally. Type II: Forward curvature is more marked, and apex extends straight forward. Type III: Coccyx most sharply angulates forward. Type IV: Coccyx is subluxated at sacrococcygeal joint or at intercoccygeal joint.

• The majority of cases of coccygodynia occur in conjunction with either a subluxated or a hypermobile coccyx (often referred to as a culprit lesion). It has been proposed that the pathologic instability may give rise to chronic inflammatory changes and pain. However, the study by Postacchini and Massobrio showed that there was no statistical difference between asymptomatic patients and those with coccygodynia in terms of the numbers of coccygeal segments or the incidence of fusions between the segments.

• Presentation

• Coccygodynia is a rare condition but can be highly unpleasant when it does occur. Patients' chief complaint is pain.

• History and physical examination

• Most patients give a history of a fall or an antecedent childbirth. In 1950, Schapiro described this disorder as "television disease" because most of the patients had followed poor postural adaptation while watching television, [10] and this poor adaptation was thought to be an important predisposing factor for coccygodynia. Prolonged sitting while using a computer likewise can be a harbinger of coccygodynia.

• Patients usually complain of pain that is aggravated by sitting on hard surfaces. Some patients may complain of pain during defecation and sexual intercourse or while riding a bicycle or a motorbike.

• From the 1930s through the late 1960s, George Thiele published several articles relating to coccyx pain,[3] as a consequence of which coccygodynia is still sometimes referred to as Thiele syndrome. Thiele's description of the clinical features continues to hold true today. The main symptoms include pain in the lower sacrum or coccyx or in the adjacent muscles or soft tissues. The patient usually points to the coccyx as the site of pain.[1] The severity of pain depends on the amount of time spent sitting.

• There is tenderness over the localized region. In fact, absence of local tenderness over the coccyx should lead the examiner to consider other diagnoses, such as lumbar disk disease or herniated disk. A rectal and pelvic examination also should be performed to check for any masses (tumors).

• Differential diagnosis

• The differential diagnosis can be broadly divided into the the following three major categories: Nociceptive, Neuropathic, Visceral

• The nociceptive aspect of the differential diagnosis includes conditions involving pain arising from the os coccygis, such as the following:

• Levator ani syndrome, where the mobilization of the os coccygis is not painful

• Osteomyelitis

• Intraossal lipoma

• Intraossal chondroma

• Avascular necrosis

• Precoccygeal cysts

• Degenerative disease

• The neuropathic aspect includes conditions in which the pain arises from the spine,[12] such as the following:

• Lumbar disc herniation, where the symptoms are not related to provocation by sitting

• Neural tumors (eg, schwannoma, neurinoma, chordoma, arachnoid cysts of the cauda equina, sacrococcygeal meningeal cysts, and paragangliomas of the caudal end of the os coccygis) • Visceral pain is the result of pain referred from the visceral structures[13] and may arise from the following:

• Infections and tumors of rectum, sigmoid colon. and urogenital system

• Metastases

• Laboratory Studies

• The diagnosis of coccygodynia is predominantly based on clinical examination. Laboratory investigations show no particular abnormality, except in the presence of infection or tumor.[1]

• Imaging Studies

• Radiologic investigations are helpful in diagnosis. However, because coccygodynia is a dynamic disorder, it can only be appreciated on dynamic radiographic imaging.

• Dynamic radiography: Dynamic films taken in both a sitting and a standing position allow measurement of sagittal pelvic rotation and the coccygeal angle of incidence. The coccyx can move as much as 22° when a person sits or shifts from standing to sitting. Subtle posterior coccygeal subluxations can be found only when a sitting lateral film of the coccyx is compared to a standing film to check the amount of translation. Sitting and standing films will show radiographic abnormalities in as many as 70% symptomatic cases of coccygodynia.[5] (See the image below.) In dynamic radiographic imaging, hypermobility of the coccyx is defined as more than 25° of flexion on the lateral view; subluxation is defined as more than 25% translation of the coccyx from the standing view to the sitting view. Measurement of the intercoccygeal angle (ie, the angle formed between the first coccygeal segment and the last coccygeal segment) can provide an objective measurement of the forward inclination of the coccyx.

• Computed tomography: Computed tomography (CT) plays no role in diagnosing idiopathic coccygodynia, except in cases of traumatic etiology with an obvious fracture or in cases involving infections or tumors. Contrast films may be helpful in differentiating infection and tumors.

• Magnetic resonance imaging and bone scanning: Magnetic resonance imaging (MRI) and technetium-99m bone scanning may demonstrate inflammation of the sacrococcygeal area indicative of coccygeal hypermobility.[5] However, these advanced imaging techniques may not be as accurate as dynamic radiography.[9] MRI can be helpful for ruling out possible tumor.

• Provocative discography: Provocative discography is a promising investigation in the assessment of coccygodynia. In a study by Maigne et al,[14] coccygeal discography was technically successful in 44 of 51 cases and yielded positive results in all cases of subluxation and hypermobility; 50% of the patients had normal dynamic films but positive discograms.

• Fluoroscopy and injection: Pressing the region of tenderness with a blunt needle to elicit pain and subsequent relief of pain with injection of local anesthetic under fluoroscopic guidance may be helpful in confirming the diagnosis and may be therapeutic as well.

• Conservative Management

• A wide variety of therapeutic methods have been proposed for the treatment of coccygodynia. However, conservative management continues to be the mainstay of treatment.

• Pharmacologic therapy

• Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to decrease the pain associated with inflammation, and laxatives may be given as stool softeners to reduce the pressure on the coccyx during defecation. These are helpful in the short term but must be combined with precautions such as using soft seats and avoiding hard seats; ring-shaped cushions may be helpful.

• Injection of a local anesthetic at the site of maximum tenderness can be helpful helps both diagnostically (in confirming the diagnosis) and therapeutically (in relieving pain). This can be followed by injection of asteroid at the same site through the same needle left in situ.

• In a study evaluating the results of dextrose prolotherapy for recalcitrant coccygodynia, Khan et al reported it to be an effective treatment option in patients with chronic nonresponding coccygodynia and advised using it in these patients before they undergo any major surgical procedure (eg, coccygectomy).

• Although injection is popular in practice, there is no clear consensus in the literature regarding its appropriate use; response rates vary, as does the duration of relief.

• Other nonsurgical therapies

• Ergonomic adaptation includes strapping of the buttocks, postural training, and the use of a rubber ring or a firm corset. A sitz bath over a tub of warm water may be helpful in relieving pain.

• Thiele massage is a particular method of massaging the posterior pelvic floor muscles, including the coccygeus. It is a massage of the levator muscles along the long direction of the muscle fibers on both sides.

• Although Thiele massage was found to be helpful in treating pain due to muscle spasm, it remained unhelpful in patients with pain due to coccygeal mobility. In the technique described by Mennell, the coccyx is grasped between the thumb and the index finger inserted into the anal canal, then manipulated. In addition, Maigne et al advised keeping the coccyx in a hyperextended position with the help of an index finger applied over its anterior aspect and counterpressure applied by the other hand over the posterior aspect of the sacrum.

• A newer type of manipulation has also been proposed in which the coccygeus, the levator ani, and the external sphincter are stretched by keeping the coccyx still with one finger internally and one externally. This particular technique is helpful in patients with restricted sacrococcygeal extension.

• Radiofrequency (RF) ganglion impar block for pericoccygeal pain due to carcinoma, has been adopted for alleviation of pain in patients with severe coccygodynia. Although extracorporeal shock wave therapy (ECSWT) has been widely used in different musculoskeletal conditions, its use in patients with coccygodynia is a comparatively recent development.

• Surgical Intervention

• Surgical treatment is reserved for patients who do not respond to conservative managment and involves the removal of the coccyx (ie, coccygectomy). Two main techniques of coccygectomy have been described in the literature, as follows:

• Powers technique

• Gardner technique

• Powers technique

• The patient is positioned prone, with the buttocks firmly strapped laterally for ease of exposure. A midline incision is developed down to the bone, and the sacrococcygeal joint is exposed proximally up to the tip of the coccyx distally. A subperiosteal plane is developed along the anterior surface of the coccyx, and the coccyx is lifted up. Amputation is carried out just proximal to the sacrococcygeal joint.

• Gardner technique

• A 7.5 cm incision is made, extending from just proximal to the sacrococcygeal joint up to the buttock crease. This incision is brought down to the fascia and the insertion of the gluteus maximus directly over the bone.

• Coccygeal vessels are ligated, and the tip of the coccyx is elevated by means of blunt dissection. The tip of the coccyx is separated from the external sphincter ani by means of sharp dissection. The coccyx is then elevated from the underlying rectum and the dense fascia that separates the two. With the help of a moist sponge, the fascia and the rectum are mobilized up to the sacrococcygeal joint, and the coccyx is excised by means of sharp dissection at the sacrococcygeal joint.

• Complications

• The most common complication with coccygectomy is wound infection due to the presence of the abundant perineal skin flora as contaminants. Delayed wound healing is almost the rule, and pain relief may not occur for many months, even after surgical treatment. Other complications include the risk of injury to the rectum and the sphincter ani.

Schuermann’s Kyphosis

Congenital Kyphosis

Juvenile Scoliosis

Posttraumatic Kyphosis