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Spine


x-ray

Cervical spine surgery

The cervical spine is comprised of seven vertebrae and begins at the base of the skull and extend down to the thoracic spine. Vertebrae are stacked on top of each other with a cervical disc in between them. Spinal cord runs down behind vertebrae in the spinal canal. The spinal cord sends messages from the brain to control all aspects of the body. Separate nerve roots split off spinal cord at each vertebrae level. Nerve roots and spinal cord can be compressed by damaged cervical disc or by build-up bone and soft tissue.

Overall cervical spine surgery is primarily done to treat severe arm pain caused by pinched nerve root. If cervical spinal cord is compressed it can lead to condition called myelopathy and you may notice symptoms like heavy feeling in the legs, inability to walk at a brisk pace, deterioration in fine motor skills (such as handwriting or buttoning a shirt), intermittent shooting pains into the arms and legs (like an electrical shock), arm pain.

Surgeries encompass range of procedures but vast majority of surgeries are done from the front and it involves removal of the whole disc with overgrown bone. Removed disc is than replaced with an artificial cage and bone like material and sometimes reinforced with plate and screws. This will cause bone fusion between affected vertebrae. In certain circumstances cervical disc can be replaced by artificial disc that maintains flexibility of the cervical spine segment. This may prevent further cervical spine degeneration and possibly need for more surgery in the future. There are also surgeries done from the back of the spine called laminectomy or foraminotomy and they all have a role in certain conditions to free up spinal cord or nerve roots.

Any risks or complications will be discussed in advance of your treatment with your consultant.


spinal-cord

Back pain/Lumbar spine surgery

Back pain is a common problem that affects most people at some point in their life.

Lower back pain can be caused by a problems with any parts of the lumbar spine as spinal muscles, nerves, bones, discs or tendons. It is often accompanied by pain and changes in power and sensation in legs.

The most common type of issues are:

Disc bulge/herniation, degenerative disc disease, radiculopathy, sciatica, microdiscectomy

Degenerative disc disease is a process of intervertebral disc ageing characterized by wear and tear changes. These changes can be accelerated by injury, lifestyle and type of occupation. Disc herniation occurs when the core of the disc extends beyond disc boundary. If we imagine your disc as a pillow, than putting pressure on one side causes bulging on the other hence disc bulge. When the core of the pillow rips the cover and actually comes through that is what we think of as disc herniation. When part of the pillow core completely separates from the disc that is what we call free disc fragment. Disc bulge, herniation or disc fragment can exert pressure on nerve roots and cause irritation, swelling and inflammation. This can cause pain, weakness and sensory changes in the part of the body supplied by the affected nerve root and that is what we refer to as radiculopathy. In severe cases it can also cause bowel and bladder symptoms. Any pain shooting down the leg is usually referred to as sciatica however it is a very non-specific term. Most of the people do not require any intervention and pain resolves with medication, rest and physiotherapy.

Other alternative treatments are:

Nerve root injection, Facet Joint injection, Epidural injection – please see pain procedures below

Lumbar microdiscectomy

Lumbar microdiscectomy is a procedure that refers to the removal of part of the lumbar spinal disc that compresses the nerve roots. In some cases the whole disc needs to be removed. Typically this is done using a surgical microscope. Surgery requires a small incision on your or the back (2-4cm), and is carried out under a general anaesthetic and usually involves a 1-2 stay in hospital.

Spinal stenosis/ pseudoclaudication/, spondylolisthesis

Spinal stenosis refers to narrowing of the spinal canal. This may affect the Cervical (neck) or Lumbar spine. The spinal canal is the main corridor for spinal the spinal cord and spinal nerves. Narrowing of the spinal canal is usually caused by overgrown bone and soft tissue of the spine. Prolonged compression of nerve tissue causes insufficient blood supply and also direct damage which manifests as pain, weakness and sensory changes. In cases of lumbar spinal stenosis, it usually causes general pain and fatique in legs when walking or standing. This is called pseudoclaudication. Stopping, bending over or sitting alleviates pain. Pain can be predominant in one leg and can have a sharp pain component in cases of nerve roots being trapped.

Spondylolisthesis is a condition when vertebral bodies do not maintain proper alignment and there is a visible slip on imaging. In many cases it causes no symptoms but over time it can produce back pain, leg pain, numbness, weakness or combination thereof. It is often combined with spinal stenosis.

Spinal decompression/ fusion

Spinal decompression surgery refers to the removal of parts of the spine that cause compression such as bone, bonny spurs, overgrown ligaments, cysts etc. Terms such as laminectomy, hemilaminectomy, partial hemilaminectomy are often used and refer to the removal of part of the vertebrae called lamina from an incision on your back. This can be performed on any part of the spine but more commonly on the lumbar spine. In some cases fusion is also necessary in the lumbar spine mostly if there is instability due to spondylolisthesis. Lumbar fusion is major surgery that can last for a few hours. There are different methods of spinal fusion but generally insertion of metal screws into vertebrae connecting them with metal rods is required. It is important to have detailed discussion with your consultant about the benefits and risks. The surgery has serious risks and although this type of surgery is common, there is no guarantee it will work to relieve your pain.

http://www.nhs.uk/Conditions/Lumbardecompressivesurgery/Pages/Whatisitpage.aspx
http://www.webmd.com/back-pain/spinal-fusion-arthrodesis

Any risks or complications will be discussed in advance of your treatment with your consultant.

 


Pain procedures

Mainstay of back pain is conservative treatment that involves medication, intensive physiotherapy and weight loss. Often it is combined with interventions such as spinal injections to provide temporary pain relief. Only about 10% of patients seen by neurosurgeon will need surgery.

Nerve root injection

A nerve root injection is an injection of local anaesthetic and steroid (anti-inflammatory) medication around a nerve in the lower back as it leaves the spine under X-ray guidance. Your specialist thinks that the symptoms in your lower back and/or leg are due to irritation of a nerve by a damaged disc or bony spur. The aim of the injection is to establish if this nerve is the source of your symptoms and to relieve those symptoms by reducing inflammation around the nerve. The procedure is performed under X-ray or CT guidance by a specialist consultant.

Facet Joint injection

A facet joint injection may be done to help diagnose the facet joints as the source of the patient’s pain, as well as to provide pain relief.

Facet joints are pairs of small joints in between the vertebrae in the back of the spine. These joints have opposing surfaces of cartilage, which limits friction between the bones. The joint is surrounded by a capsule filled with a small amount of synovial fluid. The synovial fluid acts as an additional lubricant to reduce friction between bones that rub together.

Healthy facet joints support the spine while also allowing a wide range of twisting and bending motion. These joints may become inflamed and painful due to a variety of conditions, such as osteoarthritis, degenerated discs, spinal stenosis, or from a trauma such as a car accident. A lumbar facet joint injection is an injection of local anaesthetic and steroid (anti-inflammatory) medication inside or around a facet joint in the lower back under X-ray or CT guidance. The aim of the injection is to establish if this facet joint is the source of your symptoms and to relieve those symptoms by reducing inflammation around the joint.

Epidural injection

Epidural steroid injection is a treatment option for many forms of low back pain and leg pain. It is an option of the non-surgical management of sciatica and low back pain. The goal of the injection is pain relief but generally an epidural steroid injection is used in combination with a physiotherapy program to provide additional benefit. A needle is inserted into the skin and directed toward the epidural space, which is space within the spinal canal (formed by the surrounding vertebrae) lying outside the dura mater (leathery tissue covering spinal nerve roots and spinal cord). The epidural steroid solution is then injected.

Spinal cord stimulation for intractable back and leg pain

Spinal cord stimulation (SCS) is a well-established pain treatment. Usually it is reserved for patients with chronic back and leg pain who failed other traditional treatment options.

It delivers electrical pulses to the spinal cord to mask or interrupt the transmission of abnormal pain signals to the brain. The pulses are sent by small electrodes placed near the spinal cord that connect to a compact battery-powered generator, which is implanted under the skin.

A common side effect of most SCS therapies is a tingling or buzzing sensation, known as paresthesia. For many patients, this tingling masks their pain, but it is always present.

Recently new type of SCS has been proven to provide more patients more relief in both back pain and leg pain compared with traditional SCS. Unlike traditional SCS, new therapy relieves pain without tingling or buzzing and it won’t give you an unexpected shock when you bend, twist, or engage in other daily activities.

http://www.nevro.com/English/Patients/Chronic-Pain-and-Treatments/default.aspx

Any risks or complications will be discussed in advance of your treatment with your consultant.