• 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.

• 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 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 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.

• 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.