Anterior Lumbar Fusion with Cages

A Patient’s Guide to Anterior Lumbar Fusion with Cages

Introduction

Anterior Lumbar Fusion with Cages

Anterior lumbar fusion is an operation done on the front (the anterior region) of the lower spine. Fusion surgery helps two or more bones grow together into one solid bone. Fusion cages are new devices, essentially hollow screws filled with bone graft, that help the bones of the spine heal together firmly. Surgeons use this procedure when patients have symptoms from disc degeneration, disc herniation, or spinal instability.

This guide will help you understand

  • why the procedure becomes necessary
  • what surgeons hope to achieve
  • what to expect during your recovery

Anatomy

Anterior Lumbar Fusion with Cages

What parts of the spine are involved?

Since the surgeon needs to reach the front of the spine, this operation is done through the abdomen. The main structures involved in this procedure are the vertebral bodies and the intervertebral discs.

The vertebral bodies are the large blocks of bone that make up the front section of each vertebra. The intervertebral discs are the cushions between each pair of vertebrae.

Anterior Lumbar Fusion with Cages

The fusion cages help separate the vertebral bodies, taking pressure off the spinal nerves wherethey travel from the spinal canal through openings called the neural foramen.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Rationale

What do surgeons hope to achieve?

In most cases, this procedure is used to stop symptoms from lumbar disc disease. The intervertebral discs in the spine degenerate as a natural part of aging. Daily wear and tear and certain types of vibration can also speed up degeneration in the spine. In addition, strong evidence suggests that smoking speeds up degeneration of the spine. Scientists have also found links among family members, showing that genetics plays a role in how fast these changes occur. When degeneration occurs, a problem disc begins to collapse, and the space decreases between the vertebrae.

Related Document: A Patient’s Guide to Lumbar Degenerative Disc Disease

Anterior Lumbar Fusion with Cages

When this happens, the opening around the spinal nerves (the neural foramen) narrows and may begin to put pressure on the nerves. The long ligaments in the spine slacken. They may even buckle and put pressure on the spinal nerves. The outer rings of the disc, the annulus, weaken and develop small cracks. The nucleus in the center of the disc presses on the weakened annulus and may actually squeeze through the annulus and press on ligaments or nerves. Fragments of the disc that press against the outer annulus and spinal nerves can be a source of pain, numbness, and weakness. Pressure on the spinal nerves can also produce problems with the bowels and bladder, requiring emergency surgery.

View animation of degeneration

A fusion operation can reduce or eliminate the pain caused by a problem disc. If the fusion is successful, the vertebrae that are fused together no longer move against one another. Instead, they move together as one unit. This prevents the disc from causing pain.

Anterior Lumbar Fusion with Cages

Fusion cages are also designed to separate and hold the vertebrae apart. Enlarging the space between two vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through them. Also, the extra space pulls taut the ligaments inside the spinal canal so they don’t buckle into the spinal canal.

View animation of regaining disc height

Fusion cages are most commonly made of metal, graphite, or bone. Many of these cages are shaped like cylinders. A few are rectangular in shape. They are usually threaded like a screw on the outside and hollow on the inside. The main purpose of the cage, regardless of the shape or material, is to hold the two vertebrae apart while the fusion becomes solid.

The surgeon packs the hollow center of the cage with bone. The graft is commonly taken from another part of the body, usually the top of the pelvis bone. Bone taken from another part of your own body is called an autograft. There is a risk of pain, infection, or weakness in the area where the graft is taken.

A new method to avoid this problem is with a bone graft substitute. By using gene therapy, scientists have produced bone graft substitutes called growth factors. These growth factors are natural proteins found in the human body. Genetic engineers have been able to clone proteins known as bone morphogenic proteins (BMPs). These proteins are then made available as powder, small particles, or chips. Hormones that circulate in the bloodstream act on the BMP molecules, causing them to build new bone tissue.

The growth factor that is approved for lumbar fusion with titanium cages is BMP-2. Substituting BMP-2 for an autograft eliminates the complications that go with harvesting autograft material from the patient’s own body. This allows for shorter operation times, less loss of blood during surgery, and quicker recovery times for patients. New research shows that BMP-2 is at least as good as, and maybe even better than, autograft for anterior lumbar fusion with cages.

The surgeon packs the hollow center of the fusion cages with bone graft, either in the form of an autograft or bone graft substitute. Two cages are placed side by side within the disc. The cages spread the vertebrae apart, and the threads bind the vertebrae to keep them from moving. After implanting the cages, most surgeons attach metal hardware on the vertebrae to rigidly lock them in place. This helps the bone graft heal, fusing the vertebrae together.

Once the bones fuse, they are prevented from moving against one another. This helps relieve the mechanical pain, which occurs in the moving parts of the back. Fusion also prevents additional wear and tear on the structures inside the section that was fused. By fusing the bones together, surgeons hope to reduce future problems at the spinal segment.

Preparations

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Anterior Lumbar Fusion with Cages

Traditionally, this operation requires a sizeable abdominal incision. Recently, however, surgeons have begun using a laparoscope in this operation. A laparoscope is a small television camera that lets the surgeon see inside the abdominal cavity to perform the operation. Several much smaller abdominal incisions are needed in the laparoscopic method. The smaller incisions allow patients to begin moving sooner and healing faster. However, performing anterior lumbar fusion with a laparoscope is difficult. It isn’t the right choice for all fusion surgeries.

Patients are positioned on their backs with a pad placed under the low back. They are given general anesthesia to put them to sleep. As they sleep, their breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

In the traditional method, an incision is made through one side of the abdomen. Organs and blood vessels are gently moved aside to expose the front of the lumbar spine.

Anterior Lumbar Fusion with Cages

The problem disc is located with a fluoroscope, a special X-ray that shows images on a TV screen. The surgeon drills two large holes horizontally through the front of the disc. The fusion cages are sized to fit into the newly drilled holes. Bone graft may be taken from the top of the pelvis. The other option is for the surgeon to use a bone graft substitute. The bone graft material is packed into the hollow cages. Then the surgeon screws the cages into the holes in the disc. The threads of the cages clinch the vertebrae above and below, holding them rigidly in place. The fluoroscope is used to check the position and fit of the cages.

As mentioned earlier, the surgeon may also fix the vertebrae in place using metal screws or plates. One option is screwing a strap of metal across the front of the spine. A second method involves additional surgery through the low back. This may be done on the same day or during a later surgery. Metal plates or screws applied through the back of the spine lock the two vertebrae and prevent them from moving. This protects the graft so it can heal better and faster.

Related Document: A Patient’s Guide to Posterior Lumbar Fusion

Anterior Lumbar Fusion with Cages

A drainage tube may be placed in the wound. The muscles and soft tissues are put back in place, and the skin is stitched together. The surgeon may place the patient in a rigid brace.

The threaded cages rigidly connect the vertebrae above and below. Small openings in the surface of the cages allow the bone graft inside to contact the surfaces of both vertebrae. As the new bone inside the cages heals to the nearby vertebrae, the two vertebrae become rigidly fused into one solid bone.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following anterior lumbar fusion with cages include

  • problems with anesthesia
  • thrombophlebitis
  • infection
  • nerve damage
  • blood vessel damage
  • problems with the graft or hardware
  • nonunion
  • ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

  • pressure stockings to keep the blood in the legs moving
  • medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Anterior Lumbar Fusion with Cages

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to the spinal cord or spinal nerves can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Blood Vessel Damage

The abdominal aorta (the largest artery in the body) and the large veins that accompany it run in front of the spine as they split to run to each leg. These vessels must be moved aside to perform the anterior cage procedure. Because of this, the vessels may be injured, causing bleeding. When the procedure is performed using the laparoscope, too much bleeding may require opening the abdomen with a larger incision to repair the injured vessels.

Problems with the Graft or Hardware

Fusion surgery with cages requires bone grafting. The graft is commonly taken from the top rim of the pelvis (autograft). As mentioned earlier, there is a risk of pain, infection, or weakness in the area where the graft is taken. These risks are avoided when a bone graft substitute, such as BMP-2, is used in place of an autograft.

After the cages are in place, the surgeon checks their position before completing the surgery. However, the cages may shift slightly soon after surgery to the point that they are no longer able to hold the spine stable. Abnormal or excessive loads on the spine, for example from heavy lifting or carrying or from the impact of jumping from a high surface, can cause the cages to collapse. This shifting or collapsing of the cages can cause injury to the nearby tissues. If this happens, a second surgery may be needed to replace the cages and to apply additional instrumentation to lock the spine firmly in place.

Hardware can also cause problems. Screws or pins may loosen and irritate the nearby soft tissues. Also, the metal plates can sometimes break. If this happens, the surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem.

Nonunion

Anterior Lumbar Fusion with Cages

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (The term pseudarthrosis means false joint.) When more than one level of the spine is fused at one time, there is a greater chance that nonunion will occur. Fusion of more than one level means two or more consecutive discs are removed and replaced with bone graft. If the joint motion from a nonunion causes pain, you may need a second operation.

In the second procedure, the surgeon may have to replace the cages. Metal plates and screws may also be added to rigidly secure the bones so they will fuse.

Ongoing Pain

Anterior lumbar fusion with cages is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are sometimes placed in a rigid body brace after surgery. This brace may not be needed if the surgeon attached metal hardware to the spine during the surgery.

Patients usually stay in the hospital after surgery for up to one week. During this time, a physical therapist helps patients learn safe ways to move, dress, and do activities without putting extra strain on the back. Patients may be instructed to use a walker for the first day or two. Before going home, patients are shown how to control pain and avoid problems.

Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. Patients are cautioned against bending forward, lifting, twisting, driving, and prolonged sitting for up to six weeks. Activities and exercises that cause the spine to bend back place hazardous stress on the cages and should be avoided for at least six months. Outpatient physical therapy usually begins a minimum of six weeks after the date of surgery.

Rehabilitation

What should I expect as I recover?

Rehabilitation after anterior lumbar fusion with cages can be a slow process. Many surgeons prescribe outpatient physical therapy beginning a minimum of six weeks after surgery. This delay is needed to make sure the fusion is taking. You will probably need to attend therapy sessions for two to three months, and you should expect full recovery to take up to eight months. However, therapy can usually progress faster for patients who had fusion with instrumentation.

At first, treatments help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Your therapist may also use massage and other hands-on techniques to ease muscle spasm and pain.

Active treatments are slowly added. These include exercises for improving heart and lung function. Short, slow walks are generally safe to start with. Swimming and use of a stairclimbing machine are helpful in the later phases of treatment. Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back.

Your therapist also works with you on how to move and do activities. This form of treatment, called body mechanics, helps you develop new movement habits. This training helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. You’ll also work on safe body mechanics with lifting, carrying, pushing, and pulling.

As your condition improves, the therapist tailors your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job or to do alternate forms of work. You’ll learn to do these tasks in new ways that keep your back safe and free of strain.

Before your therapy sessions end, your therapist will teach you ways to avoid future problems.

Lumbar Disc Herniation

A Patient’s Guide to Lumbar Disc Herniation

Introduction

Lumbar Disc Herniation

Although people often refer to a disc herniation as a slipped disc, the disc doesn’t actually slip out of place. Rather, the term herniation means that the material at the center of the disc has squeezed out of its normal space. This condition mainly affects people between 30 and 40 years old.

This guide will help you understand

  • how the problem develops
  • how doctors diagnose the condition
  • what treatment options are available

Lumbar Disc Herniation

Anatomy

What parts of the spine are involved?

The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is known as the lumbar spine.

Lumbar Disc Herniation

The lumbar spine is made up of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back a slight inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Some people have an extra, or sixth, lumbar vertebra. This condition doesn’t usually cause any particular problems.

Intervertebral discs separate the vertebrae. The discs are made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. These fibers help the disc withstand tension and pressure.

Lumbar Disc Herniation

A disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones.

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity. They also protect it during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Lumbar Disc Herniation

Causes

Why do I have this problem?

Herniation occurs when the nucleus in the center of the disc pushes out of its normal space. The nucleus presses against the annulus, causing the disc to bulge outward. Sometimes the nucleus herniates completely through the annulus and squeezes out of the disc.

Lumbar Disc Herniation

Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand this pressure. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as degeneration. Over time, the annulus weakens, and the nucleus may begin to herniate (squeeze) through the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may herniate completely through the outer ring of the disc.

Related Document: A Patient’s Guide to Lumbar Degenerative Disc Disease

Vigorous, repetitive bending, twisting, and lifting can place abnormal pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus, leading to herniation.

A lumbar disc can also become herniated during an acute (sudden) injury. Lifting with the trunk bent forward and twisted can cause a disc herniation. A disc can also herniate from a heavy impact on the spine, such as falling from a ladder and landing in a sitting position.

Lumbar Disc Herniation

Herniation causes pain from a variety of sources. It can cause mechanical pain. This is pain that comes from the parts of the spine that move during activity, such as the discs and ligaments. Pain from inflammation occurs when the nucleus squeezes through the annulus. The nucleus normally does not come in contact with the body’s blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain. A disc herniation may also put pressure against a spinal nerve. Pressure on an irritated or damaged nerve can produce pain that radiates along the nerve. This is called neurogenic pain.

Symptoms

What does the condition feel like?

Many cases of lumbar disc herniation result from degenerative changes in the spine. The changes that eventually lead to a disc herniation produce symptoms gradually. At first, complaints may only be dull pain centered in the low back, pain that comes and goes over a period of a few years. Doctors think this is mainly from small tears in the annulus. Larger cracks in the annulus may spread pain into the buttocks or lower limbs.

When the disc herniates completely through the annulus, it generally causes immediate symptoms, with sharp pain that starts in one hip and shoots down part or all of the leg. Commonly, patients no longer feel their usual back pain, only leg pain. This is likely because painful tension on the annulus releases when the nucleus pushes completely through.

Disc herniations produce inflammation when the nucleus comes in contact with the body’s blood supply (mentioned earlier). The inflammation can be a source of throbbing pain in the low back and may spread into one or both hips and buttocks.

Lumbar Disc Herniation

A herniated disc can press against a spinal nerve, producing symptoms of nerve compression. Nerve pain follows known patterns in the lower limbs. It can be felt on the side of the upper thigh, in the calf, or even in the foot and toes.

Lumbar Disc Herniation

Pressure on the nerve can also cause sensations of pins, needles, and numbness where the nerve travels down the lower limbs. If this happens, a person’s reflexes slow. The muscles controlled by the nerve weaken, and sensation in the skin where the nerve goes is impaired.

Rarely, symptoms involve changes in bowel and bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder.

Lumbar Disc Herniation

The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. These will include questions about where you feel pain and whether you have numbness or weakness in your legs. Your doctor will also want to know what positions or activities make your symptoms worse or better. Doctors rely on your report of pain to get an idea which disc is causing problems and if a nerve is being squeezed.

Then the doctor examines you to determine which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Lumbar Disc Herniation

X-rays are of minor help in diagnosing disc herniations. The discs don’t actually show up on X-rays. However, doctors can tell if the space between the vertebrae is smaller than normal. This can be an indication that wear and tear on one or more discs is causing problems. However, many peoples’ X-rays show degeneration of the discs. This is because degeneration in the discs is part of aging, like skin that wrinkles with time.

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body’s tissue. The image can show if a herniated disc is putting pressure on a spinal nerve.

Doctors may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal, called the the subarachnoid space. When the CT scan is performed, the dye highlights the spinal cord and nerves. The dye can improve the accuracy of a standard CT scan for diagnosing a herniated disc.

Lumbar Disc Herniation

When more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It gives a clear picture of the discs and whether a herniation is present. Like the CT scan, this machine creates pictures that look like slices of the area your doctor is interested in. The test does not require special dye or a needle.

Doctors sometimes order a specialized X-ray test called discography. In this test, dye is injected into one or more discs. The dye is seen on X-ray and can give some information about the health of one or more discs. This test may be used when surgery is being considered to determine which disc is causing problems.

Doctors may also order electrical tests to locate more precisely which spinal nerve is being squeezed. Several tests are available to see how well the nerves are functioning, including the electromyography (EMG) test. This test measures how long it takes a muscle to work once a nerve signals it to move. The time it takes will be slower if a herniated disc has put pressure on a spinal nerve. Another test is the somatosensory evoked potential (SSEP) test. The SSEP is used to measure nerve sensations. These sensory impulses travel up the nerve, informing the body about sensations such as pain, temperature, and touch. The function of a nerve is recorded by an electrode placed over the skin in the area where the nerve travels. Doctors will often run these tests before performing surgery for a lumbar disc herniation.

Treatment

What treatment options are available?

Nonsurgical Treatment

Unless your condition is causing significant problems or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may want your low back immobilized. Keeping the back still for a short time can calm inflammation and pain. This might include one or two days of bed rest. Lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients to do ordinary activities using pain to gauge how much is too much. In rare cases in which bed rest is prescribed, it is usually used for a maximum of two days.

A back support belt is sometimes used for patients with lumbar disc herniation. The belt can help lower pressure inside the problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, their trunk muscles begin to rely on the belt and start to atrophy (shrink).

Doctors prescribe certain types of medication for patients with lumbar disc herniation. At first, you may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Severe symptoms that don’t go away may be treated with narcotic drugs, such as codeine or morphine. But narcotics should only be used for the first few days or weeks because they are addictive when used too much or improperly. Muscle relaxants may be prescribed if the low back muscles are in spasm. Pain that spreads down the leg is sometimes relieved with oral steroids taken in tapering dosages.

You may work with a physical therapist. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a program to help you prevent future problems.

Lumbar Disc Herniation

Some patients who continue to have symptoms are given an epidural steroid injection (ESI). Steroids are powerful anti-inflammatories. In an ESI, medication is injected into the space around the lumbar spinal nerves where they branch off of the spinal cord. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren’t working. But ESIs are not always successful in relieving pain. If they do work, they often provide only temporary relief.

Most people with a herniated lumbar disc get better without surgery. As a result, doctors usually have their patients try nonoperative treatments for at least six weeks before considering surgery. But when patients simply aren’t getting better, or if the problem is becoming more severe, surgery may be suggested.

Surgery

If the symptoms you feel are mild and there is no danger they’ll get worse, surgery is not usually recommended. However, if signs appear that pressure is building on the spinal nerves, surgery may be required, sometimes right away. The signs doctors watch for when reaching this decision include weakening in the leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Surgical treatment for lumbar disc herniation includes

  • laminotomy and discectomy
  • microdiscectomy
  • posterior lumbar fusion

Lumbar Disc Herniation

Laminotomy and Discectomy

The lamina forms a roof-like structure over the back of the spinal canal. In this procedure, a thumbnail-sized piece of the lamina is removed (laminotomy) so the surgeon can more easily take out the problem disc (discectomy). This procedure is mainly used when the herniated disc is putting pressure on a nerve and causing pain to spread down one leg.

Related Document: A Patient’s Guide to Lumbar Discectomy

Microdiscectomy

Microdiscectomy is becoming the standard surgery for lumbar disc herniation. The procedure is used when a herniated disc is putting pressure on a nerve root. It involves carefully taking out part of the problem disc (discectomy). By performing the operation with a surgical microscope, the surgeon only needs to make a very small incision in the low back. Categorized as minimally invasive surgery, this surgery is thought to be less taxing on patients. Advocates also believe that this type of surgery is easier to perform, that it prevents scarring around the nerves and joints, and that it helps patients recover more quickly.

Posterior Lumbar Fusion

Lumbar disc herniation causes mechanical pain, the type of pain caused by wear and tear in the parts of the lumbar spine. Fusion surgery is mainly used to stop movement of the painful area by joining two or more vertebrae into one solid bone. This keeps the bones and joints from moving, easing mechanical pain.

Lumbar Disc Herniation

In posterior lumbar fusion, the surgeon lays small grafts of bone over the problem area on the back of the spinal column. Most surgeons will also apply metal plates and screws to prevent the problem vertebrae from moving. This protects the graft so it can heal better and faster.

Related Document: A Patient’s Guide to Posterior Lumbar Fusion

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Even if you don’t need surgery, your doctor may recommend that you work with a physical therapist. Patients are normally seen a few times each week for four to six weeks. In severe cases, patients may need a few additional weeks of care.

The first goal of treatment is to control symptoms. Your therapist will help you find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used in the first few sessions. Lumbar traction may also be used at first to ease symptoms of lumbar disc herniation. In addition, your therapist may use hands-on treatments such as massage or spinal manipulation. These forms of treatment are mainly used to help reduce pain and inflammation so you can resume normal activity as soon as possible.

The therapist shows you how to keep your spine safe during routine activities. You’ll learn about healthy posture and how posture relates to the future health of your spine. You’ll learn about body mechanics, how the body moves and functions during activity. Therapists teach safe body mechanics to help you protect the low back as you go about your day. This includes the use of safe positions and movements while lifting and carrying, standing and walking, and performing work duties.

Next comes a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients begin moving easier and lessens the chances of future pain and problems.

Aerobic exercises such as walking or swimming are used for easing pain and improving endurance.

Your therapist will work closely with your doctor and employer to help you get back on the job as quickly as reasonably possible. You may be required to do lighter duties at first, but as soon as you are able, you’ll begin doing your normal work activities. Your therapist can do a work assessment to make sure you’ll be safe to do your job. Your therapist may suggest changes that could help you work safely, with less chance of re-injuring your back.

A primary purpose of therapy is to help you learn how to take care of your symptoms and prevent future problems. You’ll be given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist will also discuss strategies you can use if your symptoms flare up.

After Surgery

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may visit with a physical therapist in the hospital room soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients need physical therapy outside of the hospital. They see a therapist for one to three months, depending on the type of surgery. At first, therapists may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. They provide reassurance to help patients deal with fear and apprehension about pain. Then they teach patients how to move safely with the least strain on the healing back. Exercises are used to improve flexibility, strength, and endurance.

When your treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource for you. But you will be in charge of doing your exercises as part of an ongoing home program.

Lumbar Spondylolisthesis

A Patient’s Guide to Lumbar Spondylolisthesis

Introduction

Lumbar Spondylolisthesis

Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful.

This guide will help you understand

  • how the problem develops
  • how doctors diagnose the condition
  • what treatment options are available

Lumbar Spondylolisthesis

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is called the lumbar spine.

Lumbar Spondylolisthesis

The lumbar spine is made of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back a slight inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones.

Each vertebra is formed by a round block of bone, called a vertebral body.

Lumbar Spondylolisthesis

A circle of bone attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Lumbar Spondylolisthesis

The spinal cord only extends to L2. Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse’s tail.

Lumbar Spondylolisthesis

Two sets of bones form the spinal canal’s bony ring. Two pedicle bones attach to the back of each vertebral body. Two lamina bones complete the ring. The place where the lamina and pedicle bones meet is called the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring.

Intervertebral discs separate the vertebral bodies. The discs normally work like shock absorbers. They protect the spine against the daily pull of gravity. They also protect the spine during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

Lumbar Spondylolisthesis

The lumbar spine is supported by ligaments and muscles. The ligaments, which connect bones together, are arranged in layers and run in multiple directions. Thick ligaments connect the bones of the lumbar spine to the sacrum (the bone below L5) and pelvis.

Lumbar Spondylolisthesis

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

Lumbar Spondylolisthesis

The anatomy of the lumbar spine is often discussed in terms of spinal segments. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the facet joints that link each level of the spinal column.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Causes

Why do I have this problem?

Spondylolisthesis may very rarely be congenital, which means it is present at birth. It can also occur in childhood as a result of injury. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis.

Spondylolisthesis from degeneration usually affects people over 50 years old. This condition occurs in African Americans more often than in whites. Women are affected more often than men. The effect of the female hormone estrogen on ligaments and joints is to cause laxity or looseness. The higher levels of estrogen in women may account for the greater incidence of spondylolisthesis. Degenerative spondylolisthesis mainly involves slippage of L4 over L5.

In younger patients (under 20 years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this. First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction.

Facet joints are small joints that connect the back of the spine together. Normally, the facet joints connecting L5 to the sacrum create a solid buttress to prevent L5 from slipping over the top of the sacrum. However, when problems exist in the disc, facet joints, or bony ring of L5, the buttress becomes ineffective. As a result, the L5 vertebra can slip forward over the top of the sacrum.

Lumbar Spondylolisthesis

A condition called spondylolysis can lead to the slippage that happens with spondylolisthesis. Spondylolysis is a defect in the bony ring of the spinal column. It affects the pars interarticularis, mentioned earlier. This defect is most commonly thought to be a stress fracture that happens from repeated strains on the bony ring. Participants in gymnastics and football commonly suffer these strains. Spondylolysis can lead to the spine slippage when a fracture occurs on both sides of the bony ring. This slippage is called spondylolisthesis. The slippage is graded from I through IV, one being mild, IV often causing neurological symptoms. The back section of the bony ring separates from the main vertebral body, so the injured vertebra is no longer connected by bone to the one below it. In this situation, the facet joints can’t provide their normal support. The vertebra on top is then free to slip forward over the one below.

View animation of spondylolisthesis

Related Document: A Patient’s Guide to Spondylolysis

A traumatic fracture in the bony ring can lead to slippage when the fracture goes completely through both sides of the bony ring. The facet joints are no longer able to provide a buttress, allowing the vertebra with the crack in it to slip forward. This is similar to what happens when spondylolysis (mentioned earlier) occurs on both sides of the bony ring, but in this case it happens all at once.

Lumbar Spondylolisthesis

Degenerative changes in the spine (those from wear and tear) can also lead to spondylolisthesis. The spine ages and wears over time, much like hair turns gray. These changes affect the structures that normally support healthy spine alignment. Degeneration in the disc and facet joints of a spinal segment causes the vertebrae to move more than they should. The segment becomes loose, and the added movement takes an additional toll on the structures of the spine. The disc weakens, pressing the facet joints together. Eventually, the support from the facet joints becomes ineffective, and the top vertebra slides forward.

Symptoms

What does the condition feel like?

An ache in the low back and buttock areas is the most common complaint in patients with spondylolisthesis. Pain is usually worse when standing, walking, or bending backward and may be eased by resting or bending the spine forward. Leaning on a counter top, piece of furniture, or shopping cart are common ways to alleviate (reduce) the symptoms.

Spasm is also common in the low back muscles. The hamstring muscles on the back of the thighs may become tight.

The pain can be from mechanical causes. Mechanical pain is caused by wear and tear on the parts of the spine. When the vertebra slips forward, it puts a painful strain on the disc and facet joints.

Lumbar Spondylolisthesis

Slippage can also cause nerve compression. Nerve compression is a result of pressure on a nerve. As the spine slips forward, the nerves may be squeezed where they exit the spine. This condition also reduces space in the spinal canal where the vertebra has slipped. This can put extra pressure on the nerve tissues inside the canal. Nerve compression can cause symptoms where the nerve travels and may include numbness, tingling, slowed reflexes, and muscle weakness in the legs.

Nerve pressure on the cauda equina (mentioned earlier), the bundle of nerve roots within the lumbar spinal canal, can affect the nerves that go to the bladder and rectum. When this happens, bowel and/or bladder function can be affected. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Next the doctor examines you by checking your posture and the amount of movement in your low back. Your doctor checks to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Lumbar Spondylolisthesis

Doctors will usually order X-rays of the low back. The X-rays are taken with your spine in various positions. They can be used to see which vertebra is slipping and how far it has slipped.

If more information is needed, your doctor may order computed tomography (a CT scan). This is a detailed X-ray that lets the doctor see slices of the body’s tissue. If you have nerve problems, the doctor may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal, the subarachnoid space. During the CT scan, the dye highlights the spinal nerves. The dye can improve the accuracy of a standard CT scan for diagnosing the health of the nerves.

Your doctor may also order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It can help in the diagnosis of spondylolisthesis. It can also provide information about the health of nerves and other soft tissues.

Treatment

What treatment options are available?

Nonsurgical Treatment

Studies have not been done yet to determine the best treatment for this condition. Conservative care is preferred, especially when the vertebra hasn’t slipped very far. Most patients with symptoms from degenerative spondylolisthesis do not need surgery and respond well to nonoperative care. Medications may be prescribed to help ease pain and muscle spasm. In some cases, the patient’s condition is simply monitored to see if symptoms improve.

Your doctor may ask that you rest your back by limiting your activities. This is to help decrease inflammation and calm muscle spasm. You may need to take time away from sports or other strenuous activities to give your back a chance to heal.

Lumbar Spondylolisthesis

If your doctor diagnoses an acute pars fracture that has the potential to heal, it may be recommended that you wear a rigid back brace for two to three months. This usually occurs in children and teenagers who begin having back pain and see their doctor early on.

Lumbar Spondylolisthesis

X-rays may show a fresh fracture of the pars area of the vertebra on one, or both, sides. A CT scan or bone scan may be recommended to determine if the fracture is likely to heal. If so, a brace is recommended. X-rays or a CT scan may be ordered in six to eight weeks to see if the fracture is healing. IF not, the brace will be discontinued.

Lumbar Spondylolisthesis

Some patients who continue to have symptoms are given an epidural steroid injection (ESI). Steroids are powerful anti-inflammatories, meaning they reduce pain and swelling. In an ESI, medication is injected into the space around the lumbar nerve roots. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren’t working. But ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief.

Patients often work with a physical therapist. After evaluating your condition, your therapist can assign positions and exercises to ease your symptoms. Your therapist can design an exercise program to improve flexibility in your low back and hamstrings and to strengthen your back and abdominal muscles.

The use of a stationary bike can promote aerobic conditioning and puts you in the optimal position to open the spaces where the nerve roots exit. This type if exercise program can aid in reducing the painful symptoms.

Surgery

Surgery is used when the slip is severe and when symptoms are not relieved with nonsurgical treatments. Symptoms that cause an abnormal walking pattern, changes in bowel or bladder function, or steady worsening in nerve function require surgery. Deterioration of symptoms is common in patients with a history of significant neurologic symptoms who don’t have surgery to correct the problem.

If a reasonable trial of conservative care (three months or more) does not improve things and/or your quality of life is significantly reduced, then surgery may be the next best solution. The main types of surgery for spondylolisthesis include

  • laminectomy (decompression)
  • posterior fusion with or without instrumentation
  • posterior lumbar interbody fusion

Laminectomy

Lumbar Spondylolisthesis

When the vertebra slips forward, the nearby nerves that exit the spine can become pinched or irritated. In addition, the size of the spinal canal in the problem area shrinks, placing pressure on the nerves inside the canal. To fix this, the lamina of the bony ring is removed to ease pressure on the nerves. The procedure to remove the lamina and release pressure on the nerves is called laminectomy. Decompression alone is usually not advised. Studies show much better results when the operation is combined with a fusion of the involved vertebrae (see below).

Related Document: A Patient’s Guide to Lumbar Laminectomy

Posterior Fusion with Instrumentation

Lumbar Spondylolisthesis

A spinal fusion is normally done immediately after laminectomy for spondylolisthesis. The fusion procedure is designed to fuse the two vertebrae into one bone and stop the slippage from worsening. The fusion is used to lock the vertebrae in place and stop movement between the vertebrae, easing mechanical pain. When combined with laminectomy surgery (mentioned earlier), fusion helps relieve nerve compression.

In this procedure, the surgeon lays small grafts of bone over the back of the problem vertebrae.

Lumbar Spondylolisthesis

Sometimes fusion is done just with bone graft material. This is a fusion without fixation (non-instrumentation). Instrumentation is the use of metal plates or screws to stabilize the segment during healing. Most surgeons combine fusion with instrumentation to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.

Outcomes are improved when decompression is combined with fusion (compared with decompression alone). Fusion and functional improvement are even better when spinal instrumentation is used. There are fewer long-term problems with pain and pseudoarthrosis (formation of movement or false joints within the fusion).

Related Document: A Patient’s Guide to Posterior Lumbar Fusion

Posterior Lumbar Interbody Fusion

When fusion surgery is needed for mild spondylolisthesis (up to 50 percent slippage), posterior lumbar interbody fusion may be considered. In this procedure, the problem vertebrae are fused from the anterior (front) and posterior (back). Combining fusion of both portions of the spine increases the fusion surface area and improves the fusion rate. The surgeon works from the back of the spine and removes the disc between the problem vertebrae. Bone graft material is inserted from the back of the spine into the space between the two vertebrae where the disc was removed (the interbody space). The graft may be held in place with a special fusion cage that spreads and holds the vertebrae apart. Surgeons usually apply some form of instrumentation (described above) on the back of the vertebrae. In some cases, additional strips of bone graft are placed along the back surfaces of the vertebrae to be fused. This increases the mechanical strength of the spine.

Related Document: A Patient’s Guide to Posterior Lumbar Interbody Fusion

Fusion with Biologics

New materials for fusion are being developed and tested. For example, bone morphogenetic proteins (BMP) mixed with bone graft in a putty is under investigation. This substance may help reduce the need for instrumentation with fusion.

BMP helps promote faster and more bone growth in the unstable spinal segment. Studies of safety and effectiveness of this material have been very favorable so far. Without the need to harvest bone graft and place instrumentation, surgical time is much less with BMP putty. And the fusion rate is much higher with BMP alone compared with fusion alone or fusion with fixation.

Motion-Sparing Technologies

The Food and Drug Administration (FDA) is reviewing the use of devices inserted without invasive surgery to limit vertebral motion. For example, a special titanium implant has been designed to fit between the spinous processes of the vertebrae in your lower back.

These motion-sparing devices are currently used with patients who have spinal stenosis (narrowing of the spinal canal or foramen). With spondylolisthesis, the goal is to reduce the load on the disc and facets while increasing the space inside the spinal canal and foramen, thus relieving your symptoms. The vertebral segment is stabilized enough to prevent further progression of the spondylolisthesis.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Back pain associated with spondylolisthesis will gradually improve in up to one-third of all patients. Slippage of one vertebra over the other does not increase in this group. Worsening of symptoms is not expected in patients who don’t have neurologic symptoms at the time of diagnosis.

Nonsurgical treatment for spondylolisthesis commonly involves physical therapy. Your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care.

The first goal of treatment is to control symptoms. Your therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm. Patients are shown how to stretch tight muscles, especially the hamstring muscles on the back of the thigh.

As patients recover, they gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients move easier and lessens the chances of future pain and problems.

Lumbar Spondylolisthesis

A primary purpose of therapy is to help you learn how to take care of your symptoms and prevent future problems. You’ll be given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist will also describe strategies you can use if your symptoms flare up.

After Surgery

Rehabilitation after surgery is more complex. Patients who have surgery for spondylolisthesis usually stay in the hospital for a few days afterward.

Some surgeons require patients to wear a rigid brace or cast for up to four months after fusion surgery for spondylolisthesis. Patients who’ve had fusion surgery for a severe slip may also be required to stay off their feet for four months.

After lumbar fusion surgery for spondylolisthesis, patients must normally wait four months before beginning a rehabilitation program. This delay is needed to give the fusion a chance to start healing. Patients typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take at least 12 months.

Ideally, patients are able to return to their previous activities. However, some patients may need to modify or discontinue certain activities to avoid future problems.

When your treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource for you. But you will be in charge of doing your exercises as part of an ongoing home program.

Lumbar Spondylolysis

A Patient’s Guide to Lumbar Spondylolysis

Introduction

Lumbar Spondylolysis

Spondylolysis happens when a crack forms in the bony ring on the back of the spinal column. Most commonly, this occurs in the low back. In this condition, the bone that protects the spinal cord fractures as a result of excessive or repeated strain. The area affected is called the pars interarticularis, so doctors sometimes refer to this condition as a pars defect.

This condition appears in six percent of children. It mainly affects young athletes who participate in sports in which the spine is repeatedly bent backwards, such as gymnastics, football, and karate.

Although spondylolysis can affect people of any age, children and adolescents are most susceptible. This is because their spines are still developing, and the pars is the weakest part of the vertebra. Placing extra strain on this area of the spine during childhood increases the chance that a pars defect will occur.

This guide will help you understand

  • how the problem develops
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of spine in the lower back is called the lumbar spine.

Each vertebra is formed by a round block of bone, called a vertebral body. A circle of bone attaches to the back of the vertebra. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The protective ring that surrounds the spinal cord is a continuous ring of bone. Its sections include two pedicles which attach directly to the back of the vertebral body. Two laminae complete the ring.

The pedicles and laminae are two different areas of the bony ring. The area between them is not a joint. Rather, it is a location in the continuous ring of bone that doctors call the pars interarticularis, or “pars” for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Causes

What causes this problem?

Spondylolysis is thought to be caused by repeated strains that damage the lower spine over time. The repeated strains can eventually lead to an overuse injury in the pars interarticularis. The most common location for this to occur is in the lowest vertebra of the spine, which doctors call L5. This vertebra connects the spine to the pelvis. However, a problem with the pars can occur in any lumbar vertebra. It rarely happens in more than one vertebra at a time.

Lumbar Spondylolysis

The vertebra initially responds to the abnormal strain by adding new bone cells around the injured area. But if the injuries happen faster than the body can keep up with needed repairs, a crack may form in the weakened bone. This is called a stress fracture. This type of fracture occurs in the pars, the area of bony ring between the pedicle and lamina.

Lumbar Spondylolysis

The crack may affect only one side of the bony ring. However, it is equally common for the defect to occur on both sides. When this happens, the vertebra is no longer held firmly in place by the facet joints on the back of the ring. As a result, the vertebra is free to slip forward over the one below. This slippage, which is closely related to spondylolysis, is called spondylolisthesis.

Related Document: A Patient’s Guide to Spondylolisthesis

Lumbar Spondylolysis

Spondylolysis commonly occurs in young gymnasts who regularly practice backbends as part of their routines. Football linemen and dancers are also prone to spondylolysis. Symptoms sometimes appear when an athlete quickly ramps up his or her training intensity, applies incorrect technique, or uses poor equipment.

Symptoms

What does the condition feel like?

Lumbar Spondylolysis

People with spondylolysis may feel pain and stiffness in the center of the low back. Bending fully backward increases pain. Symptoms typically get worse with activity and go away with rest. Doctors refer to this type of back pain as mechanical pain because it most likely comes from excess movement between the vertebrae.

Individuals may eventually experience pain that radiates down one or both legs. This pain may come from pressure and irritation on the nerves that exit the spinal canal near the fracture. When nerve pressure in the low back causes leg pain, doctors refer it as neurogenic pain.

Lumbar Spondylolysis

The cause of this nerve pressure is a result of the body’s attempt to heal the stress fracture. Over time, the healing process may cause a bump of extra cartilage to grow at the site where the bones are trying to heal the overuse injury. If too much cartilage builds up, this bump may intrude into the opening where the nerves exit the spine. The bump may squeeze the nerve. This can produce pain and weakness in the leg. Reflexes become slowed. The person may also notice a pins and needles sensation in the skin where the spinal nerve travels.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how the problem is affecting your daily activities. You will be asked about your involvement in sports and your level of performance. Doctors may suspect a problem with spondylolysis in football linemen, gymnasts, and those in similar sports that require intensive levels of performance. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Next the doctor examines you by checking your posture and the amount of movement in your low back. Your doctor checks to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Your doctor may order an X-ray of your low back. An angled, or oblique, view is often used to check for a pars fracture. The doctor traces around the vertebral body and bony ring on the X-ray film. The outline normally forms an image that looks like a small dog. When a crack is present, however, the dog will appear to have a collar around its neck. This is referred to as the Scotty dog sign. It confirms a diagnosis of spondylolysis.

Small defects in the bone may not show up on X-ray. Also, a recent stress fracture won’t always appear on X-ray. As a result, your doctor may order a bone scan to get the most accurate information. This involves injecting chemical “tracers” into your blood stream. The tracers then show up on special spine X-rays. The tracers collect in areas of extra stress to bone tissue, such as a stress fracture of the pars interarticularis.

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body’s tissue. The image can show if the edges of the fractured bone have begun growing together. The scan shows whether the fracture is new or old, so doctors can decide which treatments will help the most.

When more information is needed, your doctor may order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It can help in the diagnosis of spondylolysis. It can also provide information about the health of nearby intervertebral discs and other soft tissues that don’t appear on X-rays.

Treatment

What treatment options are available?

Nonsurgical Treatment

Doctors often begin by prescribing nonsurgical treatment for spondylolysis. This is because symptoms from these stress fractures often resolve with rest or bracing. In some cases, doctors simply monitor their patients’ condition to see if symptoms improve. An X-ray may be taken every few months to check how well the area is healing.

If the doctor feels that the problem is due to a recent fracture, you may be placed in a rigid back brace or cast for three to four months. Keeping the spine from moving can help ease pain and inflammation. It can also improve the chances the bones will grow back together. Most people who require a brace or cast overcome symptoms and are able to eventually get back to activities free of pain. This can happen even when follow-up tests show that the bones haven’t completely healed.

Your doctor may ask that you rest your back by limiting your activities. The purpose of this is to help decrease inflammation and calm muscle spasm. You may need to take some time away from your sport, especially if it requires repeated back bending. This gives your back a chance to heal. Most patients who follow these measures get better. Patients are rarely counseled to completely discontinue participating in their sport, and only in severe cases.

Patients often work with a physical therapist. After evaluating your condition, a therapist can assign positions and exercises to ease your symptoms. The therapist may design an exercise program to improve the strength and control of your back and abdominal muscles. By watching you perform your sport activity, your therapist can suggest style, technique, or equipment changes to improve your performance and prevent future problems.

Surgery

Most patients with spondylolysis do not require surgery. When symptoms are not relieved with nonsurgical treatments, however, patients may require surgery. The main types of surgery for spondylolysis include

  • laminectomy
  • posterior lumbar fusion

Laminectomy

Lumbar Spondylolysis

Nerve compression can cause considerable pain and symptoms. If too much cartilage builds up where the fractured bones are trying to heal, the nerve that passes near the injured bone may get squeezed, as described earlier. To fix this, a section of the bony ring is removed to take pressure off the nerve. The procedure to remove the lamina from the bony ring and release pressure on the nerve is called laminectomy.

Related Document: A Patient’s Guide to Lumbar Laminectomy

Posterior Lumbar Fusion

A spinal fusion may be required after a surgeon performs a laminectomy procedure. Fusion is recommended when a spinal segment (a set of vertebrae) has become too loose or unstable.

Lumbar Spondylolysis

A spinal fusion allows two or more bones to grow together, or fuse, into one solid bone. This keeps the bones and joints from moving. In this procedure, the surgeon lays small grafts of bone over the problem area on the back of the spine. Some surgeons also apply metal plates and screws to prevent the two vertebrae from moving. However, this practice is controversial because fusion occurs in about 90 percent of children with spondylolysis when the procedure is done without plates and screws.

Related Document: A Patient’s Guide to Posterior Lumbar Fusion

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Recovery from this condition is much like nonsurgical treatment mentioned earlier. Once you have rested your back to allow it to heal, your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In severe cases, patients may need a few additional weeks of physical therapy.

The first goal of treatment is to control symptoms. The therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm.

As you recover, you will gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients begin moving easier and lessens the chances of future pain and problems.

When needed, a therapist can work closely with a sports coach on strategies for a patient’s safe return to his or her sport. The two may provide suggestions on technique, equipment, and training frequency and intensity.

Lumbar Spondylolysis

If the patient is a working adult, the therapist may also work with the patient’s doctor and employer to help the patient get back on the job as quickly as reasonably possible. The patient may be required to do lighter duties at first. As soon as the patient is able, he or she will do normal work activities. The therapist may also suggest changes that could help the patient work safely, with less chance of re-injuring his or her back.

A primary purpose of therapy is to help patients learn how to take care of their symptoms and prevent future problems. Patients are given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist also describes strategies you can use if your symptoms flare up.

Most adolescents get better after wearing a brace or cast for three months. Even then, a CT scan sometimes shows an unhealed fracture. In these cases, however, symptoms often go away completely, allowing a safe return to sports. Patients do best when guided in a gradual manner with the supervision of a therapist and sports coach.

After Surgery

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may visit with a physical therapist in the hospital room soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients need physical therapy outside of the hospital. Patients who’ve had lumbar fusion surgery normally need to wait at least six weeks before beginning a rehabilitation program. This delay gives the fusion a chance to start healing. Patients typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take up to six months.

Lumbar Laminectomy

A Patient’s Guide to Lumbar Laminectomy

Introduction

Lumbar Laminectomy

Lumbar laminectomy is a surgical procedure to relieve pressure on the spinal nerves. Degeneration, or wear and tear, in the parts of the spine may narrow the spinal canal. This puts pressure on the nerves in the canal. This condition is called spinal stenosis. A laminectomy involves removing a section of the bony covering over the back of the spinal canal. This takes pressure off the spinal nerves.

This guide will help you understand

  • why the procedure becomes necessary
  • what surgeons hope to achieve
  • what to expect as you recover

Lumbar Laminectomy

Anatomy

What parts of the spine are involved?

Surgeons perform lumbar laminectomy surgery through an incision in the low back. The surgery involves the pedicle and lamina bones. These bones attach to the back of the spinal column, forming a bony ring that encloses the spinal canal. Surgeons may remove bone spurs from the facet joints

Lumbar Laminectomy

along the back of the spine during the laminectomy procedure, taking pressure off the spinal nerves.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Rationale

What do doctors hope to achieve?

Lumbar laminectomy can alleviate the symptoms of spinal stenosis, a condition in which the spinal nerves become compressed inside the spinal canal. Wear and tear on the spine from aging and from repeated stresses and strains can cause a spinal disc to weaken.

Lumbar Laminectomy

The outer rim of the disc bulges outward, and the disc may eventually protrude or even rupture into the spinal canal, narrowing the size of the canal. As a result, the nerves inside the canal are squeezed, leading to symptoms of spinal stenosis.

Lumbar Laminectomy

Degeneration also causes bone spurs to develop. These spurs commonly occur around the facet joints and along the edges of the vertebrae. When these spurs point into the spinal canal, they may squeeze against the spinal nerves. In a laminectomy, the surgeon removes a section of the lamina bone and any bone spurs, taking pressure off the spinal nerves. This enlarges the spinal canal so the spinal nerves have more room.

Preparations

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

Some surgeons have begun using spinal anesthesia in place of general anesthesia. Spinal anesthesia is injected in the low back into the space around the spinal cord. This numbs the spine and lower limbs. Patients are also given medicine to keep them sedated during the procedure.

This surgery is usually done with the patient kneeling face down in a special frame. The frame supports the patient so the abdomen is relaxed and free of pressure. This position lessens blood loss during surgery and gives the surgeon more room to work.

Lumbar Laminectomy

The surgeon makes a short incision down the middle of the low back. The skin and soft tissues are separated to expose the bones along the back of the spine. An X-ray of the low back ensures the surgeon works on the right vertebra. Some surgeons use a special surgical microscope during surgery to magnify the area they’ll be working on.

Lumbar Laminectomy

In a complete laminectomy, the spinous process (the bony projection off the back of the vertebra) and the lamina on each side are removed over the area where stenosis is occurring. To accomplish this, the surgeon cuts along the inside edge of the facet joint on each side and detaches the lamina bone completely from the pedicle bones. This opens a section in the bony ring. A small portion of the ligamentum flavum is removed. The ligamentum flavum runs all the way down the spinal canal between the lamina bones and the spinal cord. Removing a small section of this ligament exposes the nerves inside the spinal canal.

Lumbar Laminectomy

The surgeon may use small cutting instruments to carefully remove soft tissues near the spinal nerves. Then the surgeon takes out any disc fragments and scrapes off nearby bone spurs. In this way, the nerves inside the spinal canal are relieved of additional tension and pressure. The surgeon also enlarges the neural foramina, if needed. The neural foramina are the small openings between the vertebrae where the nerves travel out of the spinal canal.

The muscles and soft tissues are put back in place, and the skin is stitched together.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following lumbar laminectomy include

  • problems with anesthesia
  • thrombophlebitis
  • infection
  • nerve damage
  • segmental instability
  • ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

  • pressure stockings to keep the blood in the legs moving
  • medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Lumbar Laminectomy

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to the spinal cord or spinal nerves can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Segmental Instability

Laminectomy surgery can cause the spinal segment to loosen, making it unstable. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints that link each level of the spinal column.

The facet joints on the back of the spine normally give enough stability, even when the lamina is taken off. This is why surgeons prefer not to remove the facet joints. But these joints may have to be removed if they are enlarged with arthritis or are pushing on the spinal nerves, as explained earlier. When the facet joints must be removed, additional surgery (a fusion) may be needed to fix the loose segment.

Related Document: A Patient’s Guide to Posterior Lumbar Fusion

Ongoing Pain

Many patients get nearly complete relief of symptoms from the lumbar laminectomy procedure. As with any surgery, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are usually able to get out of bed within a few hours after surgery. However, you will be instructed to move your back only carefully and comfortably. Patients are able to return home when their medical condition is stable.

Most patients leave the hospital the day after surgery. They are safe to drive within a week or two. People generally get back to light work by four weeks. Heavier work and sports should wait two to three months. Workers whose jobs involve strenuous manual labor may be counseled to consider different work.

Outpatient physical therapy usually starts four to six weeks after surgery.

Rehabilitation

What should I expect as I recover?

Many surgeons prescribe outpatient physical therapy within six weeks after surgery. Physical therapy after lumbar laminectomy is generally only needed for a total of four to six weeks. You should expect full recovery to take up to four months.

At first, treatments help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Your therapist may also use massage and other hands-on techniques to ease muscle spasm and pain.

Active treatments are added slowly. These include exercises for improving heart and lung function. Walking and swimming are ideal cardiovascular exercises after lumbar laminectomy surgery. Therapists also teach patients specific exercises to help tone and control the muscles that stabilize the low back.

Lumbar Laminectomy

Your therapist works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your back in safe positions as you go about your work and daily activities. At first, this may be as simple as helping you learn how to move safely and easily in and out of bed, how to get dressed and undressed, and how to do some of your routine activities. Then you learn how to keep your back safe while you lift and carry items and as you begin more challenging activities.

As your condition improves, the therapist tailors your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job. Your therapist can also suggest alternate forms of work. You’ll learn to do your tasks in ways that keep your back safe and free of extra strain.

Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Low Back Pain

A Patient’s Guide to Low Back Pain

Introduction

Low Back Pain

Low back pain is one of the main reasons Americans visit their doctor. For adults over 40, it ranks third as a cause for doctor visits, after heart disease and arthritis.

Eighty percent of people will have low back pain at some point in their lives. And nearly everyone who has low back pain once will have it again.

Very few people who feel pain in their low back have a serious medical problem. Ninety percent of people who experience low back pain for the first time get better in two to six weeks. Only rarely do people with low back pain develop chronic back problems.

With these facts in mind, you can be assured that back pain is common, that it usually only causes problems for a short period of time, and that you can take steps to ease symptoms and prevent future problems.

This guide will help you understand

  • which parts make up the spine and low back
  • what causes low back pain, and what the most common symptoms are
  • what tests your doctor may run
  • how to manage your pain and prevent future problems

Anatomy

Which parts make up the lumbar spine, and how do they work?

Low Back Pain

The human spine is made up of 24 spinal bones, called vertebrae Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.

Low Back Pain

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The mid back, or thoracic spine curves outward. The outward curve of the thoracic spine is called kyphosis. The low back, also called the lumbar spine, curves slightly inward. An inward curve of the spine is called lordosis.

Low Back Pain

The lumbar spine is made up of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Some people have an extra, or sixth, lumbar vertebra. This condition doesn’t usually cause any particular problems.

Low Back Pain

Each vertebra is formed by a round block of bone, called a vertebral body. The lumbar vertebral bodies are taller and bulkier compared to the rest of the spine. This is partly because the low back has to withstand pressure from body weight and from daily actions like lifting, carrying, and twisting. Also, large and powerful muscles attaching on or near the lumbar spine place extra force on the lumbar vertebral bodies.

Low Back Pain

A bony ring attaches to the back of each vertebral body. When the vertebrae are stacked on top of each other, these rings form a hollow tube. This bony tube surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord extends down to the L2 vertebra. Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs.

Low Back Pain

The Latin term for this bundle of nerves is cauda equina, meaning horse’s tail.

Low Back Pain

As the spinal cord travels from the brain down through the spine, it sends out nerves on the sides of each vertebra called nerve roots. These nerve roots join together to form the nerves that travel throughout the body and form the body’s electrical system. The nerve roots that come out of the lumbar spine form the nerves that go to the lower limbs and pelvis. The thoracic spine nerves go to the abdomen and chest. The nerves coming out of the cervical spine go to the neck, shoulders, arms, and hands.

It is sometimes easier to understand what happens in the spine by looking at a spinal segment. A spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints that link each level of the spinal column.

The intervertebral disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Low Back Pain

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without pain.

Two spinal nerves exit the sides of each spinal segment, one on the left and one on the right. As the nerves leave the spinal cord, they pass through a small bony tunnel on each side of the vertebra, called a neural foramen. (The term used to describe more than one opening is neural foramina.)

The lumbar spine is supported by ligaments and muscles. The ligaments are arranged in various layers and run in multiple directions. Thick ligaments connect the bones of the lumbar spine to the sacrum (the bone below L5) and pelvis.

The muscles of the low back are also arranged in layers. Those closest to the surface are covered by a thick tissue called fascia.

The middle layer, called the erector spinae, has strap-shaped muscles that run up and down over the lower ribs, chest, and low back. They blend in the lumbar spine to form a thick tendon that binds the bones of the low back, pelvis, and sacrum.

The deepest layer of muscles connects along the back surface of the spine bones. The muscles also connect the low back, pelvis, and sacrum. These deepest muscles coordinate their actions with the muscles of the abdomen to help hold the spine steady during activity.

Causes

Why do I have low back pain?

There are many causes of low back pain. Doctors are not always able to pinpoint the source of a patient’s pain. But your doctor will make every effort to ensure that your symptoms are not from a serious medical cause, such as cancer or a spinal infection.

The vast majority of back problems are a result of wear and tear on the parts of the spine over many years. This process is called degeneration. Over time, the normal process of aging can result in degenerative changes in all parts of the spine.

Injuries to the spine, such as a fracture or injury to the disc, can make the changes happen even faster. There is strong evidence that cigarette smoking also speeds up degeneration of the spine. Scientists have found links among family members, showing that genetics plays a role in how fast these changes occur.

Degeneration

The intervertebral disc changes over time. At first, the disc is spongy and firm. The nucleus in the center of the disc contains a great deal of water. This gives the disc its ability to absorb shock and protect the spine from heavy and repeated forces.

Low Back Pain

The first change that occurs is that the annulus around the nucleus weakens and begins to develop small cracks and tears. The body tries to heal the cracks with scar tissue. But scar tissue is not as strong as the tissue it replaces. The torn annulus can be a source of pain for two reasons. First, there are pain sensors in the outer rim of the annulus. They signal a painful response when the tear reaches the outer edge of the annulus. Second, like injuries to other tissues in the body, a tear in the annulus can cause pain due to inflammation.

With time, the disc begins to lose water, causing it to lose some of its fullness and height. As a result, the vertebrae begin to move closer together.

Low Back Pain

As the disc continues to degenerate, the space between the vertebrae shrinks. This compresses the facet joints along the back of the spinal column. As these joints are forced together, extra pressure builds on the articular cartilage on the surface of the facet joints. This extra pressure can damage the facet joints. Over time, this may lead to arthritis in the facet joints.

These degenerative changes in the disc, facet joints, and ligaments cause the spinal segment to become loose and unstable. The extra movement causes even more wear and tear on the spine. As a result, more and larger tears occur in the annulus.

Low Back Pain

The nucleus may push through the torn annulus and into the spinal canal. This is called a herniated or ruptured disc. The disc material that squeezes out can press against the spinal nerves. The disc also emits enzymes and chemicals that produce inflammation. The combination of pressure on the nerves and inflammation caused by the chemicals released from the disc cause pain.

View animation of degeneration

As the degeneration continues, bone spurs develop around the facet joints and around the disc. No one knows exactly why these bone spurs develop. Most doctors think that bone spurs are the body’s attempt to stop the extra motion between the spinal segment. These bone spurs can cause problems by pressing on the nerves of the spine where they pass through the neural foramina. This pressure around the irritated nerve roots can cause pain, numbness, and weakness in the low back, buttocks, and lower limbs and feet.

A collapsed spinal segment eventually becomes stiff and immobile. Thickened ligaments and facet joints, scarred and dried disc tissue, and protruding bone spurs prevent normal movement. Typically, a stiff joint doesn’t cause as much pain as one that slides around too much. So this stage of degeneration may actually lead to pain relief for some people.

Mechanical and Neurogenic Pain

To best understand the cause of your pain, spine specialists sometimes divide low back pain into two categories:

  • mechanical pain
  • neurogenic pain

Mechanical Pain

Low Back Pain

Mechanical back pain is caused by wear and tear in the parts of the lumbar spine. This type of pain is similar in nature to a machine that begins to wear out. Mechanical pain usually starts from degenerative changes in the disc. As the disc begins to collapse and the space between the vertebrae narrows, the facet joints may become inflamed. Mechanical pain typically gets worse after activity due to strain on the moving parts of the spine. Mechanical pain is usually felt in the back, but it may spread into the buttocks, hips, and thighs. The pain rarely goes down past the knee. Mechanical back pain usually doesn’t cause weakness or numbness in the leg or foot, because the problem is not from pressure on the spinal nerves.

Neurogenic Pain

Low Back Pain

Neurogenic pain means pain from nerve injury. Neurogenic pain occurs when spinal nerves are inflamed, squeezed, or pinched. This can happen when a disc herniates or when a nerve gets pinched where it leaves the spine. Recently it has also become known that when a disc ruptures, chemicals are released that inflame the nerves even if there is no pressure directly on the nerve. Neurogenic symptoms concern doctors more than mechanical pain because they can signal damage to the nerves and lead to weakness or numbness in the lower extremities.

The nerve pressure causes symptoms in the areas where the nerve travels, rather than in the low back. This happens because pressure on the spinal nerve affects structures away from the spine, such as the muscles. As a result, a person’s back may not hurt, yet the person feels pain, numbness, or weakness in the leg or foot. This indicates there’s a problem with the body’s electrical wiring. The pressure on the nerve affects how the body functions. Muscles weaken. Reflexes slow. Sensations of pins, needles, and numbness may be felt where the nerve travels.

Spine Conditions

The effects of spine degeneration or back injury can lead to specific spine conditions. These include

  • annular tears
  • internal disc disruption
  • herniated disc
  • facet joint arthritis
  • segmental instability
  • spinal stenosis
  • foraminal stenosis

Annular Tears

Low Back Pain

Our intervertebral discs change with age, much like our hair turns gray. Perhaps the earliest stage of degeneration occurs due to tears that occur in the annulus. These tears can result from wear and tear over a period of time. They can also be the result of a sudden injury to the disc due to a twist or increased strain on the disc that overpowers the strength of the annulus. These annular tears may cause pain in the back until they heal with scar tissue.

View animation of annular tearing

Related Document: A Patient’s Guide to Lumbar Degenerative Disc Disease

Internal Disc Disruption

Multiple annular tears can lead to a disc that becomes weak. The disc starts to degenerate and collapse. The vertebrae begin to compress together. The collapsing disc can be the source of pain because it has lost the ability to be a shock absorber between the vertebrae. This condition is sometimes referred to as internal disc disruption. This type of problem causes primarily mechanical back pain due to inflammation of the disc and surrounding structures.

Herniated Disc

Low Back Pain

A disc that has been weakened may rupture or herniate. If the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc, or herniate. A disc herniation usually causes compressive problems if the disc presses against a spinal nerve. The chemicals released by the disc may also inflame the nerve root, causing pain in the area where the nerve travels down the leg. This type of pain is referred to as sciatica.

Even a normal disc can rupture. Heavy, repetitive bending, twisting, and lifting can place too much pressure on the disc, causing the annulus to tear and the nucleus to rupture into the spinal canal.

Related Document: A Patient’s Guide to Lumbar Disc Herniation

Facet Joint Arthritis

Low Back Pain

The facet joints along the back of the spinal column link the vertebrae together. They are not meant to bear much weight. However, if a disc loses its height, the vertebra above the disc begins to compress toward the one below. This causes the facet joints to press together. Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the facet joints can develop osteoarthritis as the articular cartilage wears away over time. Extra pressure on the facet joints, such as that from a collapsing disc, can speed the degeneration in the facet joints. The swelling and inflammation from an arthritic facet joint can be a source of low back pain.

Related Document: A Patient’s Guide to Lumbar Facet Joint Arthritis

Segmental Instability

Low Back Pain

Segmental instability means that the vertebral bones within a spinal segment move more than they should. In the lumbar spine, this can develop if the disc has degenerated. Usually the supporting ligaments around the vertebrae have also been stretched over time.

Segmental instability also includes conditions in which a vertebral body begins to slip over the one below it. When a vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, this extra movement in the bones of the spine can create problems. It can lead to mechanical pain simply because the structures of the spine move around too much and become inflamed and painful. The extra movement can also cause neurogenic symptoms if the spinal nerves are squeezed as a result of the segmental instability.

Related Document: A Patient’s Guide to Lumbar Spondylolisthesis

Spinal Stenosis

Low Back Pain

Stenosis means closing in. Spinal stenosis refers to a condition in which the tissues inside the spinal canal are closed in, or compressed. The spinal cord ends at L2. Below this level, the spinal canal contains only spinal nerves that travel to the pelvis and legs. When stenosis narrows the spinal canal, the spinal nerves are squeezed inside the canal.

The pressure from the condition can cause problems in the way the nerves work. The resulting problems include pain and numbness in the buttocks and legs and weakness in the muscles supplied by the nerves. Because these nerves travel to the bladder and rectum, weakness in the these muscles can cause problems with control of the bladder and bowels.

Related Document: A Patient’s Guide to Lumbar Spinal Stenosis

Foraminal Stenosis

Low Back Pain

Spinal nerves exit the spinal canal between the vertebrae in a tunnel called the neural foramen. Anything that causes this tunnel to become smaller can squeeze the spinal nerve where it passes through the tunnel. This condition is called foraminal stenosis, meaning the foramen is narrowed. As the disc collapses and loses height, the vertebral body above begins to collapse toward the one below. The opening around the nerve root narrows, squeezing the nerve. Arthritis of the facet joints causes bone spurs to form and point into the foramen, causing further nerve compression and irritation. Foraminal stenosis can cause a combination of mechanical pain and neurogenic pain from the irritated nerve root.

Related Document: A Patient’s Guide to Lumbar Disc Herniation

Symptoms

What are some of the symptoms of low back problems?

Symptoms from low back problems vary. They depend on a person’s condition and which structures are affected. Some of the more common symptoms of low back problems are

  • low back pain
  • pain spreading into the buttocks and thighs
  • pain radiating from the buttock to the foot
  • back stiffness and reduced range of motion
  • muscle weakness in the hip, thigh, leg, or foot
  • sensory changes (numbness, prickling, or tingling) in the leg, foot, or toes

Rarely, symptoms involve changes in bowel or bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause symptoms of low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder.

Low Back Pain

This is an emergency.

If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.

Diagnosis

How will my doctor find out what’s causing my problem?

The diagnosis of low back problems begins with a thorough history of your condition. You might be asked to fill out a questionnaire describing your back problems. Your doctor will ask you questions to find out when you first started having problems, what makes your symptoms worse or better, and how the symptoms affect your daily activity. Your answers will help guide the physical examination.

Your doctor will then physically examine the muscles and joints of your low back. It is important that your doctor see how your back is aligned, how it moves, and exactly where it hurts.

Your doctor may do some simple tests to check the function of the nerves. These tests are used to measure the strength in your lower limbs, check your reflexes, and determine whether you have numbness in your legs or feet.

The information from your medical history and physical examination will help your doctor decide which further tests to run. The tests give different types of information.

Radiological Imaging

Radiological imaging tests help your doctor see the anatomy of your spine. There are several kinds of imaging tests that are commonly used.

X-rays

Low Back Pain

X-rays show problems with bones, such as infection, bone tumors, or fractures. X-rays of the spine also can give your doctor information about how much degeneration has occurred in the spine, such as the amount of space in the neural foramina and between the discs. X-rays are usually the first test ordered before any of the more specialized tests.

Flexion and Extension X-rays

Special X-rays called flexion and extension X-rays may help to determine if there is instability between vertebrae. These X-rays are taken from the side as you lean as far forward and then as far backward as you can. Comparing the two X-rays allows the doctor to see how much motion occurs between each spinal segment.

MRI Scans

Low Back Pain

The magnetic resonance imaging (MRI) scan uses magnetic waves to create pictures of the lumbar spine in slices. The MRI scan shows the lumbar spine bones as well as the soft tissue structures such as the discs, joints, and nerves. MRI scans are painless and don’t require needles or dye. The MRI scan has become the most common test to look at the lumbar spine after X-rays have been taken.

CT Scans

The computed tomography (CT) scan is a special type of X-ray that lets doctors see slices of bone tissue. The machine uses a computer and X-rays to create these slices. It is used primarily when problems are suspected in the bones.

Myelogram

Low Back Pain

The myelogram is a special kind of X-ray test where a special dye is injected into the spinal sac. The dye shows up on an X-ray. It helps a doctor see if there is a herniated disc, pressure on the spinal cord or spinal nerves, or a spinal tumor. Before the CT scan and the MRI scan were developed, the myelogram was the only test that surgeons had to look for a herniated disc. The myelogram is still used today but not nearly as often. The myelogram is usually combined with CT scan to give more detail.

Discogram

Low Back Pain

The discogram is another specialized X-ray test. A discogram has two parts. First, a needle is inserted into the problem disc, and saline is injected into the disc to create pressure inside the disc. If this reproduces your pain, then it suggests that the disc is the source of your pain. During the second part of the test, dye is injected into the disc. The dye can be seen on X-ray. Using both regular X-rays and CT scan images, the dye outlines the inside of the disc. This can show abnormalities of the nucleus such as annular tears and ruptures of the disc.

Bone Scan

A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special X-rays of your back. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem. Other tests such as the CT scan or MRI scan are then used to look at the area in detail.

Other Tests

Your doctor may also ask you to do other tests.

Electromyogram

Low Back Pain

An electromyogram (EMG) is a special test used to determine if there are problems with any of the nerves going to the lower limbs. EMGs are usually done to determine whether the nerve roots have been pinched by a herniated disc. During the test, small needles are placed into certain muscles that are supplied by each nerve root. If there has been a change in the function of the nerve, the muscle will send off different types of electrical signals. The EMG test reads these signals and can help determine which nerve root is involved.

Laboratory Tests

Not all causes of low back pain are from degenerative conditions. Doctors use blood tests to identify other conditions, such as arthritis or infection. Low back pain can be caused by problems that do not involve the spine, such as stomach ulcers, kidney problems, and aneurysms of the aorta. Other tests may be needed to rule out problems that do not involve the spine.

Treatment

What can be done to relieve my symptoms?

Ninety percent of people who experience low back pain for the first time get better in two to six weeks without any treatment at all. Patients often do best when encouraged to stay active and to get back to normal activities as soon as possible, even if there is still some pain. The pain may not go away completely. One goal of treatment is to help you find ways to control the pain and allow you to continue to do your normal activities.

Nonsurgical Treatment

Whenever possible, doctors prefer to use treatments other than surgery. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.

Bed Rest

In cases of severe pain, doctors may suggest a short period of bed rest, usually no more than two days. Lying on your back can take pressure off sore discs and nerves. Most doctors advise against strict bed rest and prefer that patients do ordinary activities using pain to gauge how much is too much.

Low Back Pain

Back Brace

A back support belt is sometimes recommended when back pain first strikes. It can help provide support and lower the pressure inside a problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, back muscles begin to rely on the belt and start to shrink (atrophy).

Medications

Many different types of medications are typically prescribed to help gain control of the symptoms of low back pain. There is no medication that will cure low back pain. Medications are prescribed to help with sleep disturbances and to help control pain, inflammation, and muscle spasm.

Physical Therapy and Exercise

In addition to other nonsurgical treatments, doctors often ask their patients to work with a physical therapist. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a rehabilitation program to address a particular condition and to help the patient prevent future problems. There is a great deal of scientific proof that exercise and increased overall fitness reduce the risk of developing back pain and can improve the symptoms of back pain once it begins.

Injections

Spinal injections are used for both treatment and diagnostic purposes. There are several different types of spinal injections that your doctor may suggest. These injections usually use a mixture of an anesthetic and some type of cortisone preparation. The anesthetic is a medication that numbs the area where it is injected. If the injection takes away your pain immediately, this gives your doctor important information suggesting that the injected area is indeed the source of your pain. The cortisone decreases inflammation and can reduce the pain from an inflamed nerve or joint for a prolonged period of time.

Low Back Pain

Some injections are more difficult to perform and require the use of a fluoroscope. A fluoroscope is a special type of X-ray that allows the doctor to see an X-ray picture continuously on a TV screen. The fluoroscope is used to guide the needle into the correct place before the injection is given.

  • Epidural Steroid Injection (ESI): Back pain from inflamed nerve roots and facet joints may benefit from an epidural steroid injection (ESI). In an ESI, the medication mixture is injected into the epidural space around the nerve roots. Generally, an ESI is given only when other nonoperative treatments aren’t working. ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief.
  • Selective Nerve Root Injection: Another type of injection to place steroid medication around a specific inflamed nerve root is called a selective nerve root injection. The fluoroscope is used to guide a needle directly to the painful spinal nerve root. The nerve root is then bathed with the medication. Some doctors believe this procedure gets more medication to the painful spot. In difficult cases, the selective nerve root injection can also help surgeons decide which nerve root is causing the problem before surgery is planned.
  • Facet Joint Injection: When the problem is thought to be in the facet joints, an injection into one or more facet joints can help determine which joints are causing the problem and ease the pain as well. The fluoroscope is used to guide a needle directly into the facet joint. The facet joint is then filled with medication mixture. If the injection immediately eases the pain, it helps confirm that the facet joint is a source of pain. The steroid medication will reduce the inflammation in the joint over a period of days and may reduce or eliminate your back pain.
  • Low Back Pain Trigger Point Injections: Injections of anesthetic medications mixed with a cortisone medication are sometimes given in the muscles, ligaments, or other soft tissues near the spine. These injections are called trigger point injections. These injections can help relieve back pain and ease muscle spasm and tender points in the back muscles.

Surgery

Only rarely is lumbar spine surgery scheduled right away. Your doctor may suggest immediate surgery if you are losing control of your bowels and bladder or if your muscles are becoming weaker very rapidly.

For other conditions, doctors prefer to try nonsurgical treatments for a minimum of three months before considering surgery. Most people with back pain tend to get better, not worse. Even people who have degenerative spine changes tend to gradually improve with time. Only one to three percent of patients with degenerative lumbar conditions typically require surgery. Surgery may be suggested when severe pain is not improving.

There are many different operations for back pain. The goal of nearly all spine operations is to remove pressure from the nerves of the spine, stop excessive motion between two or more vertebrae, or both. The type of surgery that is best depends on that patient’s conditions and symptoms.

Laminectomy

Low Back Pain

The lamina is the covering layer of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are being squeezed by a herniated disc or from bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal nerves.

Related Document: A Patient’s Guide to Lumbar Laminectomy

Discectomy

Low Back Pain

When the intervertebral disc has ruptured, the portion that has ruptured into the spinal canal may put pressure on the nerve roots. This may cause pain, weakness, and numbness that radiates into one or both legs. The operation to remove the portion of the disc that is pressing on the nerve roots is called a discectomy. This operation is performed through an incision in the low back immediately over the disc that has ruptured.

Many spine surgeons now perform discectomy procedures that require only small incisions in the low back (minimally invasive). The advantage of these minimally invasive procedures is less damage to the muscles of the back and a quicker recovery. Many surgeons are now performing minimally invasive discectomy as an outpatient procedure.

Related Document: A Patient’s Guide to Lumbar Discectomy

Lumbar Fusion

When there is excessive motion between two or more vertebrae, the excess motion can cause both mechanical pain and irritation of the nerves of the lumbar spine. In this case some type of spinal fusion is usually recommended. The goal of a spinal fusion is to force two or more vertebrae to grow together, or fuse, into one bone. A solid fusion between two vertebrae stops the movement between the two bones. The pain is reduced because the fusion reduces the constant irritation and inflammation of the nerve roots. There are many different types of spinal fusions.

  • Posterior Lumbar Fusion: In the past, the traditional operation to perform a fusion of the lumbar spine was to decorticate the back surface of the vertebrae. Decorticate means to remove the hard outside covering of a bone to create a bleeding bone surface. Once this was done, bone graft was taken from the pelvis and laid on top of the decorticated vertebrae. The body tries to heal this area just like it would a fractured bone. The bone graft and the bleeding bone grow together and fuse to create one solid bone.Low Back Pain Spinal fusions were not always successful, mainly because the vertebrae failed to fuse together in up to 20 percent of cases. Surgeons began looking for ways to increase the success of fusions. For many years, metal plates and screws have been used to treat fractures of other bones. The more rigid two bones can be held together while the healing phase occurs, the more likely the bones are to heal. Spine surgeons began looking for ways to hold the vertebrae together while the fusion took place.

    Related Document: A Patient’s Guide to Posterior Lumbar Fusion

  • Posterior Lumbar Instrumented Fusion: Low Back Pain Major advances have been made in recent years in developing metal rods, metal plates, and special screws that are designed to hold the vertebrae together while the fusion takes place. These new techniques of spinal fusion are referred to as instrumented fusions because of the special devices used to secure the vertebrae to be fused. Today the most common type of posterior fusion is performed using special screws called pedicle screws that are inserted into each vertebra and connected to either a metal plate or metal rod along the back of the spine. The vertebrae are still decorticated, and bone graft is still used to stimulate the bones to heal together and fuse into one solid bone.
  • Anterior Lumbar Interbody Fusion: Low Back Pain A fusion of the lumbar spine can be accomplished in other ways. In some cases, surgeons feel that it is best to perform a fusion from the front of the spine. This is termed an anterior interbody fusion. This type of fusion requires an incision in the side of the abdomen to allow the surgeon to see the front of the spine. The intervertebral disc is removed between two vertebral bodies and bone graft is inserted where the disc was removed. The two vertebral bodies heal together and fuse.Related Document: A Patient’s Guide to Anterior Lumbar Interbody Fusion
  • Anterior Lumbar Discectomy and Fusion with Cages: Low Back Pain Degeneration of the intervertebral disc allows the vertebrae to move closer together, which narrows the openings (the neural foramina) where the nerve roots leave the spinal canal.Surgeons realized that restoring the normal separation between the vertebrae would open the foramina and take pressure off the nerve roots. Over the last several years, devices called fusion cages have been designed that can be placed between

    Low Back Pain
    the vertebrae to hold them apart while the fusion occurs. Enlarging the space between two vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through them. The extra space also pulls taut the ligaments inside the spinal canal so they don’t buckle.

    Fusion cages are made of metal, bone, or graphite material. Some of these cages are shaped like cylinders. They are threaded like a screw on the outside and hollow on the inside. Some are rectangular in shape. The main purpose of the cage, regardless of the shape or material, is to hold the two vertebrae apart while the fusion becomes solid.

    Related Document: A Patient’s Guide to Anterior Lumbar Fusion with Cages

  • Posterior Lumbar Interbody Fusion: Low Back Pain Finally, surgeons may combine the two methods of anterior fusion and posterior fusion. Fusing both the anterior and posterior portions of the spine gives the most solid fusion. Placing intervertebral cages between the two vertebrae also allows the surgeon to restore the disc height and help take pressure off of the nerve roots that exit at that spinal segment. A common method of doing this is called a posterior lumbar interbody fusion, combined with a posterior lumbar instrumented fusion (described earlier).

Related Document: A Patient’s Guide to Posterior Lumbar Interbody Fusion

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

For acute back pain, you may be prescribed two to four weeks of physical therapy. You might need to continue therapy for two to four months for chronic back problems. Treatments are designed to ease pain and to improve your mobility, strength, posture, and function. You’ll also learn how to control your symptoms and how to protect your spine for the years ahead.

At first, your therapist may apply various forms of treatment to address your symptoms. These are especially helpful in the early weeks to improve your comfort so you can get back to your normal activities. You’ll be shown ways to position your spine for maximum comfort while you move, recline, or sleep. To help calm pain and muscle spasm, your therapist may apply heat or ice packs, electrical stimulation, and ultrasound.

If you have severe back pain, your therapist may work with you in a pool. Therapy done in water puts less stress on your low back, and the buoyancy allows you to move easier during exercise.

Hands-on treatments such as massage and specialized forms of soft-tissue mobilization may be used. They can help you begin moving with less pain and greater ease. Medical guidelines also include the early use of spinal manipulation, which has shown short-term benefits in people with acute low back pain. Commonly thought of as an adjustment, spinal manipulation helps reset the sensitivity of the spinal nerves and muscles, easing pain and improving mobility. It involves a high-impulse stretch of the spinal joints and is often characterized by the sound of popping as the stretch is done. It doesn’t provide effective long-term help when used routinely for chronic conditions.

You may be tempted to limit your activity because of your back pain. However, as a result of pain and inactivity, your muscles may become weak and deconditioned, and your back won’t function optimally. Therapists use active rehabilitation to prevent the harmful effects of deconditioning. With this active approach, you’ll be shown how to lift and move safely. And you’ll be shown how to strengthen your back muscles. In addition, aerobic exercises are used to improve your general fitness and endurance.

Aerobic exercises may include walking on a treadmill, riding a stationary bike, or swimming. These activities can relieve the stress of low back pain, and they can cause your body to release endorphins into the blood stream. Endorphins are your body’s own natural painkillers.

Low Back Pain

An active approach to therapy can help you attain better muscle function, so you can get your activities done easier. Active rehabilitation speeds recovery, reducing the possibility that back pain will become a chronic problem. Activity helps you resume normal activity as swiftly as possible. Though you’ll be cautioned about trying to do too much, too quickly, you’ll be guided toward a return to your usual activities. This approach gives you a greater sense of control. You’ll take an active role in learning how to care for your back pain. Treatment sessions focus on reassuring you that getting back to work and other normal activities swiftly won’t cause you harm and can actually help you get better faster.

When needed, you’ll be encouraged to take certain actions to improve your spine health. For example, if you smoke, you’ll be encouraged to get help to quit. Because of the limited blood supply in the tissues of the low back, smoking speeds the degenerative process and impairs healing. If you’re out of shape, you’ll be encouraged to get fit. This strategy makes it less likely that back pain or injury will strike again in the future.

Low Back Pain

Your therapist will show you how to keep your spine safe during routine activities. You’ll learn about healthy posture and how posture relates to the future health of your spine. And you’ll learn about body mechanics, how the body moves and functions during activity. Your therapist will also teach safe body mechanics to help you protect your low back as you go about your day. This includes the use of safe positions and movements while lifting and carrying, standing and walking, and performing work duties.

As you recover, you will gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles can help you begin moving easier and lessens the chances of future pain and problems.

As the rehabilitation program evolves, you will progress with more challenging exercises. The goal is to safely advance your strength and function.

Your therapist will work closely with your doctor and employer to help you get back on the job as quickly as reasonably possible. You may be required to do lighter duties at first, but as soon as you are able, you’ll begin doing your normal work activities. Your therapist can also do a work assessment to make sure you’ll be safe to do your job. Your therapist may suggest changes that could help you work safely, with less chance of re-injuring your back.

After Surgery

Rehabilitation after surgery is much more complex. Depending on what operation you’ve had, you may leave the hospital shortly after surgery. Some procedures, such as fusion surgery, require that you stay in the hospital for a few days. When you stay in the hospital, a physical therapist may visit you in your hospital room soon after surgery. Physical therapy sessions help you learn to move and begin doing routine activities without putting extra strain on your low back.

Low Back Pain

During recovery from surgery, you should follow your surgeon’s instructions about wearing a back brace or soft lumbar support belt. You should be cautious about overdoing activities in the first few weeks after surgery.

You may need therapy outside of the hospital. If you had a lumbar fusion, your surgeon may have you wait six weeks to three months before starting therapy. Once you start in therapy, you’ll usually go for one to three months, depending on your progress and the type of surgery you had.

At first, your therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Pool therapy is often helpful after lumbar surgery.

Low Back Pain

Exercises are used to improve flexibility in your trunk and lower limbs. Strengthening for your abdominal and low back muscles is started. You’ll be shown safe ways to sleep, sit, lift, and carry. And you’ll be given ideas on how to do your work activities safely.

Ideally, you’ll be able to go back to your previous activities. However, you may need to modify your activities to avoid future problems.

When treatment is well under way, regular visits to the therapist’s office will you’re your therapist will continue to be a resource. But you are in charge of doing your exercises as part of an ongoing home program.

Lumbar Spinal Stenosis

A Patient’s Guide to Lumbar Spinal Stenosis

Introduction

Lumbar Spinal Stenosis

According to the North American Spine Society (NASS), spinal stenosis describes a clinical syndrome of buttock or leg pain. These symptoms may occur with or without back pain. It is a condition in which the nerves in the spinal canal are closed in, or compressed. The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, the tissues nearest the spinal canal sometimes press against the nerves. This helps explain why lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old.

This guide will help you understand

  • how the problem develops
  • how doctors diagnose the condition
  • what treatment options are available

Lumbar Spinal Stenosis

Anatomy

What part of the back is involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.

Lumbar Spinal Stenosis

The back portion of the spinal column forms a bony ring. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This bony tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Lumbar Spinal Stenosis

The spinal cord only extends to the second lumbar (low back) vertebra. Below this level, the spinal canal encloses a bundle of nerves that go to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse’s tail.

Lumbar Spinal Stenosis

An intervertebral disc fits between each vertebral body and provides a space between the spine bones. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.

Lumbar Spinal Stenosis

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Causes

Why do I have this problem?

In the lumbar spine, the spinal canal usually has more than enough room for the spinal nerves. The canal is normally 17 to 18 millimeters around, slightly smaller than a penny. Spinal stenosis develops when the canal shrinks to 12 millimeters or less. When the size drops below 10 millimeters, severe symptoms of lumbar spinal stenosis occur.

There are many reasons why symptoms of spinal stenosis develop. Some of the more common reasons include

  • congenital stenosis (being born with a small spinal canal)
  • spinal degeneration
  • spinal instability
  • disc herniation

Lumbar Spinal Stenosis

Congenital stenosis: Some people are born with (congenital) a spinal canal that is narrower than normal. They may not feel problems early in life. However, having a narrow spinal canal puts them at risk for stenosis. Even a minor back injury can cause pressure against the spinal cord. People born with a narrow spinal canal often have problems later in life, because the canal tends to become narrower due to the effects of aging.

Lumbar Spinal Stenosis

Degeneration: Degeneration is the most common cause of spinal stenosis. Wear and tear on the spine from aging and from repeated stresses and strains can cause many problems in the lumbar spine. The intervertebral disc can begin to collapse, and the space between each vertebrae shrinks. Bone spurs may form that stick into the spinal canal and reduce the space available to the spinal nerves. The ligaments that hold the vertebrae together may thicken and also push into the spinal canal. All of these conditions cause the spinal canal to narrow.

View animation of degeneration

Lumbar Spinal Stenosis

Spinal instability: Spinal instability can cause spinal stenosis. Spinal instability means that the bones of the spine move more than they should. Instability in the lumbar spine can develop if the supporting ligaments have been stretched or torn from a severe back injury. People with diseases that loosen their connective tissues may also have spinal instability. Whatever the cause, extra movement in the bones of the spine can lead to spinal stenosis.

Lumbar Spinal Stenosis

Disc herniation: Spinal stenosis can occur when an intervertebral disc in the low back herniates (ruptures). Normally, the shock-absorbing disc is able to handle the downward pressure of gravity and the strain from daily activities. However, if the pressure on the disc is too strong, such as landing from a fall in a sitting position, the nucleus inside the disc may rupture through the outer annulus and squeeze out of the disc. This is called a disc herniation. If an intervertebral disc herniates straight backward, it can press against the nerves in the spinal canal, causing symptoms of spinal stenosis.

Symptoms

What does the spinal stenosis feel like?

Spinal stenosis usually develops slowly over a long period of time. This is because the main cause of spinal stenosis is spinal degeneration in later life. Symptoms rarely develop quickly when degeneration is the source of the problem. A severe injury or a herniated disc may cause symptoms to develop immediately.

Patients with stenosis don’t always feel back pain. Primarily, they have severe pain and weakness in their legs, usually in both legs at the same time. Some people say they feel that their legs are going to give out on them.

Symptoms mainly affect sensation in the lower limbs. Nerve pressure from stenosis can cause a feeling of pins and needles in the skin where the spinal nerves travel. Reflexes become slowed. Some patients report charley horses in their leg muscles. Others report strange sensations like water trickling down their legs.

Symptoms change with the position of the low back. Flexion (bending forward) widens the spinal canal and usually eases symptoms. That’s why people with stenosis tend to get relief when they sit down or curl up to sleep. Activities such as reaching up, standing, and walking require the spine to straighten or even extend (bend back slightly). This position of the low back makes the spinal canal smaller and often worsens symptoms.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about your pain or if you have feelings of numbness or weakness in your legs.

Your doctor will also want to know whether your symptoms are worse when you’re up standing or walking and if they go away when you sit down. If your pain does not get worse when walking, then you probably don’t have stenosis. There may be some other cause of the painful symptoms.

The doctor does a physical examination to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested. A wide-based gait (legs far apart) is often observed. Special clinical tests can be done such as the Romberg test, hip extension test, and tests of neuromuscular function.

The Romberg test is a neurologic test for joint proprioception (sense of position). The nerve pathways for this sensation travel up the dorsal columns of the spinal cord. Dorsal means they are located towards the back where stenosis is more likely to occur. The test is done standing with feet together, eyes open, and hands by your sides. You will be asked to close your eyes for one full minute while your doctor observes you. Romberg’s test is positive if you can stand with your eyes open but fall (or start to fall, someone will be there to make sure you don’t fall down) when your eyes are closed. The test is not positive if you start to sway with your eyes closed but don’t lose your balance.

X-rays can show if the problems are from changes in the bones of the spine. The images can show if degeneration has caused the space between the vertebrae to collapse. X-rays may also show any bone spurs sticking into the spinal canal.

Lumbar Spinal Stenosis

The best way to see the effects and extent of lumbar spinal stenosis is with a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the spinal canal and whether the nerves inside are being squeezed. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle.

Computed tomography (a CT scan) may be ordered for those patients who can’t have an MRI for some reason, when the results of the MRI are unclear, or symptoms don’t match the MRI findings. The CT scan is a detailed X-ray that lets your doctor see slices of bone tissue. The image can show any bone spurs that may be sticking into the spinal column and taking up space around the spinal nerves.

Lumbar Spinal Stenosis

When there is a concern about neurologic problems, doctors may recommend electrodiagnostic tests of the nerves that go to the legs and feet. An electromyogram (EMG) checks whether the motor pathway of a nerve is working correctly. Motor impulses travel down the nerve and work to energize muscles.

Doctors may also order a somatosensory evoked potential (SSEP) test to locate more precisely where the spinal nerves are being squeezed. The SSEP is used to measure nerve sensations. These sensory impulses travel up the nerve, informing the body about sensations such as pain, temperature, and touch. The function of a nerve is recorded by an electrode placed over the skin in the area where the nerve travels.

Not all causes of spinal stenosis are from degenerative conditions. Doctors use blood tests to determine whether symptoms are coming from other conditions, such as arthritis or infection.

Treatment

What treatment options are available?

Nonsurgical Treatment

Unless your condition is causing significant problems or is rapidly getting worse, most doctors will begin with nonsurgical treatments. Up to one-half of all patients with mild-to-moderate lumbar spinal stenosis can manage their symptoms with conservative (nonsurgical) care. Neurologic decline and paralysis in this group is rare.

At first, doctors may prescribe ways to immobilize the spine. Keeping the back still for a short time can calm inflammation and pain. This might include one to two days of bed rest. Patients may find that curling up to sleep or lying back with their knees bent and supported gives the greatest relief. These positions flex the spine forward, which widens the spinal canal and can ease symptoms.

Lumbar Spinal Stenosis

A lumbar support belt or corset may be prescribed, though their benefits are controversial. Lumbosacral corsets do not appear to offer any long-term benefits. The support provides symptom relief only while you are wearing it. The support can limit pressure in the discs and prevent extra movement in the spine. But it can also cause the back and abdominal muscles to weaken. Some doctors have their patients wear a rigid brace that holds the spine in a slightly flexed position, widening the spinal canal. Health care providers normally only have patients wear a corset for one to two weeks.

Doctors sometimes prescribe medication for patients with spinal stenosis. Patients may be prescribed anti-inflammatory medication such as nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin. These medications can cause side effects in the kidneys and gastrointestinal tract. Also, because most stenosis patients are elderly, doctors closely monitor patients who are using these medications to avoid complications.

Narcotic drugs, such as codeine or morphine, are generally not prescribed for stenosis patients. They are addictive when used too much or improperly. Muscle relaxants are occasionally used to calm muscles in spasm.

Symptoms of stenosis can lead to mood changes. As a result, doctors sometimes prescribe anti-depressant medication, called tricyclics. Tricyclics help steady peoples’ moods, and some tricyclics even improve sleep by helping the body make an important hormone called serotonin. These medications also seem to calm back pain by affecting the membranes around pain nerves.

Lumbar Spinal Stenosis

Some patients are given an epidural steroid injection (ESI). The spinal cord is covered by a material called dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. This can reduce swelling and give the nerves more room inside the spinal canal.

Research shows that a single steroid injection offers only short-term relief. Multiple injections can produce long-term, lasting pain relief. Epidural injections should be given using contrast-enhanced fluoroscopy. Fluoroscopy is an imaging technique used by the surgeon to guide the needle to the right spot during the procedure. This type of imaging improves the accuracy of medication delivery.

Patients often work with a physical therapist. By evaluating your condition, your therapist can assign positions and exercises to ease your symptoms. Your therapist may suggest using traction. Traction is a common treatment for stenosis. It gently stretches the low back, taking pressure off the spinal nerves. Your therapist may also suggest strengthening and aerobic exercises. Strengthening exercises focus on improving the strength and control of the back and abdominal muscles. Aerobic exercises are used to improve heart and lung health and increase endurance in the spinal muscles. Stationary biking offers a good aerobic treatment and keeps the spine bent slightly forward, a position affording relief to many patients with lumbar stenosis.

Surgery

Lumbar Spinal Stenosis

If the symptoms you feel are mild and there is no danger they’ll get worse, surgery is not usually recommended. Some patients may benefit from the use of a device called the X-STOP®. The X-STOP® is a metal implant made of titanium. The implant is inserted through a small incision in the skin of your back. It is designed to fit between the spinous processes of the vertebrae in your lower back. It stays in place permanently without attaching to the bone or ligaments in your back.

There are several advantages of the X-STOP®. It can be inserted using local anesthesia on an outpatient basis. A small incision is made so the procedure is minimally invasive and no bone or soft tissue is removed. The implant is not close to nerves or the spinal cord. With the implant in place, you won’t have to bend forward to relieve your symptoms. The X-STOP® keeps the space between your spinous processes open. With the implant in place, you stand upright without pinching the nerves in your back.

But for anyone with severe symptoms of lumbar spinal stenosis, surgery may be needed. When there are signs that pressure is building on the spinal nerves, decompressive surgery may be required, sometimes right away. Decompression means that bone and/or soft tissue are removed from around the spinal nerves to take the pressure off. The signs doctors watch for when reaching this decision include weakening in the leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Pressure on the spinal nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. Surgery is recommended to remove pressure from the nerves.

The main surgical procedure used to treat spinal stenosis is lumbar laminectomy. Some patients also require fusion surgery immediately after the laminectomy procedure if spinal instability is present.

Lumbar Laminectomy

Lumbar Spinal Stenosis

The lamina is the covering layer of the bony ring of the spinal column. It forms a roof-like structure over the back of the spinal canal. When the nerves in the spinal canal are being squeezed by a herniated disc or bone spurs, a lumbar laminectomy removes the entire lamina to release pressure on the spinal nerves. This is the primary type of surgery used for lumbar spinal stenosis.

Related Document: A Patient’s Guide to Lumbar Laminectomy

Posterior Lumbar Fusion

Lumbar Spinal Stenosis

A posterior lumbar fusion may be needed after a surgeon performs a lumbar laminectomy. The fusion procedure is recommended when a spinal segment has become loose or unstable.

A fusion surgery joins two or more bones into one solid bone. This keeps the bones and joints from moving. In this procedure, the surgeon lays small grafts of bone over the back of the spine. Most surgeons also apply metal plates and screws to prevent the two vertebrae from moving.

Lumbar Spinal Stenosis

This protects the graft so it can heal better and faster.

Related Document: A Patient’s Guide to Posterior Lumbar Fusion

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Even if you don’t need surgery, your doctor may recommend that you work with a physical or occupational therapist. Patients are normally seen a few times each week for one to two months. In severe cases, patients may need a few additional weeks of care.

Your therapist creates a program to help you regain back movement, strength, endurance, and function. Treatments for lumbar spinal stenosis often include lumbar traction, described earlier. Hands-on treatments such as massage and specialized forms of soft-tissue mobilization may be used initially. They are used to help you begin moving with less pain and greater ease. Therapists also guide patients in a program of exercise designed to widen the spinal canal and take pressure off the spinal nerves.

It is important to improve the strength and coordination in the abdominal and low back muscles. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

After Surgery

After surgery, surgeons may have their patients work with a physical or occupational therapist. Patients who’ve had fusion surgery normally need to wait two to three months before beginning a rehabilitation program. They will probably need to attend therapy sessions for six to eight weeks and should expect full recovery to take up to six months.

Lumbar Spinal Stenosis

During therapy after surgery, the therapist may use treatments such as heat or ice, electrical stimulation, and massage to help calm pain and muscle spasm. Then patients begin learning how to move safely with the least strain on their healing back.

As the rehabilitation program evolves, patients do more challenging exercises. The goal is to safely advance strength and function. As the therapy sessions come to an end, therapists help patients get back to the activities they enjoy.

Lumbar Spinal Stenosis

Ideally, patients are able to resume normal activities. Patients may need guidance on which activities are safe or how to change the way they go about certain activities.

When treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource. But patients are in charge of doing their exercises as part of an ongoing home program.

Thoracic Spine Anatomy

A Patient’s Guide to Thoracic Spine Anatomy

Introduction

Thoracic Spine Anatomy

The section of the spine found in the upper back is called the thoracic spine. It goes from the base of the neck to the bottom of the rib cage. Knowing the main parts of the thoracic spine and how these parts work is important as you learn to care for your back problem.

Two common anatomic terms are useful as they relate to the thoracic spine. The term anterior refers to the front of the spine. The term posterior refers to the back of the spine. The front of the thoracic spine is therefore called the anterior thoracic area. The back of the thoracic spine is called the posterior thoracic area.

This guide gives a general overview of the anatomy of the thoracic spine. It should help you understand

  • what parts make up the thoracic spine
  • how these parts work

Important Structures

The important parts of the thoracic spine include

Thoracic Spine Anatomy

  • bones and joints
  • nerves
  • connective tissues
  • muscles
  • spinal segment

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column is the body’s main upright support.

Thoracic Spine Anatomy

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The thoracic spine curves outward. The low back, also called the lumbar spine, curves slightly inward. An inward curve in the spine is called lordosis. An outward curve, as in the thoracic spine, is called kyphosis. The kyphosis is shaped like a “C” with the opening in front.

Thoracic Spine Anatomy

The middle 12 vertebrae make up the thoracic spine. Doctors often refer to these vertebrae as T1 to T12. The large bump on the back of the lower part of the neck is the seventh cervical vertebra, called C7. It connects on top of T1. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

Each vertebra is made of the same parts. The main section of each thoracic vertebra from T1 to T12 is formed by a round block of bone, called the vertebral body. Each vertebra increases slightly in size from the neck down. The increased size helps balance and support the larger muscles that connect to the lower parts of the spine.

Thoracic Spine Anatomy

A bony ring attaches to the back of each vertebral body. This protective ring of bone surrounds the spinal cord, forming the spinal canal. Two pedicle bones connect directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other, the bony rings form a hollow tube that surrounds the spinal cord and nerves. The laminae provide a protective roof over these nerve tissues.

Thoracic Spine Anatomy

A bony knob projects out at the point where the two lamina bones join together at the back of the spine. You can feel these projections, called spinous processes, as you rub your fingers up and down the middle of your back. Bony knobs also point out from the side of the bony ring, one on the left and one on the right. These projections are called transverse processes.

Thoracic Spine Anatomy

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the thoracic spine allows freedom of movement as you twist back and forth or lean side to side.

Thoracic Spine Anatomy

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a slick, rubbery material that covers the ends of most joints. It allows the ends of bones to move against each other smoothly, without friction.

Thoracic Spine Anatomy

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc (described later) sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

Nerves

Thoracic Spine Anatomy

The hollow tube formed by the bony rings on the back of the spinal column surrounds the spinal cord. The spinal cord is like a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord travels down from the brain through the spinal column. In the thoracic spine, the spinal canal is narrower than in the rest of the spine, giving very little extra space for the spinal cord as it passes through the thoracic spine.

Thoracic Spine Anatomy

Between the vertebrae, two large nerves branch off the spinal cord, one on the left and one on the right. The nerves pass through the neural foramina of each vertebra. These spinal nerves group together to form the main nerves that go to the organs and limbs. The nerves of the thoracic spine mainly control the muscles and organs of the chest and abdomen.

Connective Tissues

Thoracic Spine Anatomy

Connective tissues are networks of fiber that hold the cells of the body together. Ligaments are strong connective tissues that attach bones to other bones. Several long ligaments connect on the front and back sections of the vertebrae. The anterior longitudinal ligament runs lengthwise down the front of the vertebral bodies. Two other ligaments run full length within the spinal canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The ligamentum flavum is a long elastic band that connects to the front surface of the lamina bones. Thick ligaments also connect the ribs to the transverse processes of the thoracic spine.

A special type of structure in the spine called an intervertebral disc is also made of connective tissue. The fibers of the disc are formed by special cells, called collagen cells. The fibers may be lined up like strands of nylon rope or crisscrossed like a net.

Thoracic Spine Anatomy

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

Discs in the thoracic spine are much thinner than in the cervical and lumbar spine. As a result, there is generally less movement between the vertebrae of the thoracic spine.

Muscles

Thoracic Spine Anatomy

The muscles of the thoracic spine are arranged in layers. Those closest to the skin’s surface run from the back of the vertebrae to the shoulder blades. Others wrap around the rib cage and connect to the shoulders. Strap-shaped muscles called erector spinae make up the middle layer of muscles. These muscles run up and down over the lower ribs and thorax (the rib cage), and cross to the low back. The deepest layer of muscles attaches along the back of the spine bones, connecting the vertebrae. Muscles also connect from one rib to the next.

Spinal Segment

Thoracic Spine Anatomy

A good way to understand the anatomy of the thoracic spine is by looking at a spinal segment.

Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal column at each vertebra, and the small facet joints that link each level of the spinal column.

Summary

Many important parts make up the anatomy of the thoracic spine. Understanding the regions and structures of the thoracic spine can help you become more involved in your health care and better able to care for your back problem.

Finger Fusion Surgery

A Patient’s Guide to Finger Fusion Surgery

Introduction

Arthritis of the finger joints may be surgically treated with a fusion procedure. Fusion keeps the problem joints from moving so that pain is eliminated.

This guide will help you understand

  • what parts make up the finger joint
  • why this type of surgery is used
  • how the operation is performed
  • what to expect before and after surgery

Anatomy

Finger Fusion Surgery

What parts of the finger are involved?

The finger joints work like hinges when the fingers bend and straighten. The main knuckle joint is the metacarpophalangeal joint (MCP joint). It is formed by the connection of the metacarpal bone in the palm of the hand with the finger bone, or phalange. Each finger has three phalanges, separated by two interphalangeal joints (IP joints).

Finger Fusion Surgery

The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint).

Ligaments are tough bands of tissue that connect bones together. Several ligaments hold the joints together in the finger. These ligaments join to form the joint capsule of the finger joint, a watertight sac around the joint.

Finger Fusion Surgery

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful.

Related Document: A Patient’s Guide to Hand Anatomy

Rationale

What does the surgeon hope to achieve?

Arthritic finger joints cause pain and make it difficult to perform normal movements, such as grasping and pinching. Advanced arthritis can also loosen the joint and may begin to cause finger joint deformity. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from rubbing on one another. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.

Preparation

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The length of time you spend in the hospital depends a lot on you.

Surgical Procedure

What happens during the operation?

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution.

Finger Fusion Surgery

An incision is made on the back part of the finger over the surface of the joint that is to be fused. Special care is taken not to damage the nearby nerves going to the finger.

The joint capsule surrounding the finger joint is then opened so that the surgeon can see the joint surfaces. The articular cartilage is removed from both joint surfaces to leave two surfaces of raw bone. The bottom of the phalange is hollowed with a special tool to form a socket. The other surface is shaped into a rounded cone that fits inside the socket.

The surgeon places a metal pin through the center of both bones and then connects the cone and socket snugly together. The metal pin allows the surgeon to hold the two bones in the correct alignment and prevents the bones from moving too much as they grow together, or fuse.

The soft tissues over the joint are sewn back together. The forearm and hand are then placed in a cast until the bones completely fuse together. This takes about six weeks.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following finger fusion surgery are

  • anesthesia
  • infection
  • nerve damage
  • nonunion

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Finger fusion surgery is no different. You will probably be given antibiotics before the operation to reduce the risk of infection.

If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the fusion.

Nerve Damage

There are nerves and blood vessels near the finger joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during fusion surgery. The result may be temporary if the nerves have been stretched by retractors holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.

Nonunion

Sometimes the finger bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (Pseud means false, and arthro means joint; a pseudarthrosis refers to the motion at a false joint.) If the motion from a nonunion continues to cause pain, you may need a second operation to try to get the bones to completely fuse. This may mean adding a bone graft and making sure that any metal pins that have been used are holding the bones still to allow the fusion to occur.

After Surgery

What happens immediately after surgery?

After surgery, you will wear an elbow-length cast for about six weeks. This gives the ends of the bones time to fuse together. Your surgeon will want to check your hand in five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medicine to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

Rehabilitation

What should I expect during my rehabilitation period?

As mentioned, you’ll wear a cast on your arm and hand for about six weeks to give the fusion time to heal. When the cast is removed, you may have stiffness in the joints closest to the fused joint. If you have pain or stiffness that doesn’t improve, you may need a physical or occupational therapist to direct your recovery program.

The first few therapy treatments will focus on controlling the pain and swelling from surgery. Your therapist may use gentle massage and other hands-on treatments to ease muscle spasm and pain.

Then you’ll begin gentle range-of-motion exercise for the joints nearest the fusion. Strengthening exercises are used to give added stability around the finger joint. You’ll learn ways to grip and support items in order to do your tasks safely and with the least amount of stress on your finger joint. As with any surgery, you need to avoid doing too much, too quickly.

Some of the exercises you’ll do are designed to get your hand and fingers working in ways that are similar to your work tasks and daily activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your finger joint. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Your therapist’s goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your hand and fingers. When your treatment is well under way, regular visits to your therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

PIP Joint Injuries of the Finger

A Patient’s Guide to PIP Joint Injuries of the Finger

Introduction

We use our hands constantly, placing them in harm’s way continuously. Injuries to the finger joints are common and usually heal without significant problems. Some injuries are more serious and may develop problems if not treated carefully. One such injury is a sprain of the proximal interphalangeal joint, or PIP joint, of the finger. This joint is one of the most unforgiving joints in the body to injury. What appears at first to be a simple sprain of the PIP joint may result in a painful and stiff finger, making it difficult to use the hand for gripping activities.

This guide will help you understand

  • what parts make up the PIP finger joint
  • what types of injuries affect this joint
  • how the injury is treated
  • what to expect from treatment

Anatomy

PIP Joint Injuries of the Finger

What parts of the finger are involved?

The finger joints work like hinges when the fingers bend and straighten. The main knuckle joint is the metacarpophalangeal joint (MCP joint). It is formed by the connection of the metacarpal bone in the palm of the hand with the finger bone, or phalange. Each finger has three phalanges, separated by two interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint).

Ligaments are tough bands of tissue that connect bones together. Several ligaments hold the joints together. In the PIP joint, the strongest ligament is the volar plate. This ligament connects the proximal phalanx to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the joint from hyperextending. There is also a collateral ligament on each side of the PIP joint. The collateral ligaments tighten when the joint is bent sideways and keep the joint stable from side to side.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

How do these injuries of the PIP joint occur?

A sprain is a general term that means a ligament is injured. Doctors usually use this term to mean that the ligament has been stretched and partially torn. If the ligament is stretched too far, it ruptures or tears completely.

Injury to the volar plate can occur when the joint is hyperextended. If a complete tear occurs, the ligament usually ruptures or tears from its attachment on the middle phalanx. There may be a small piece of bone avulsed (pulled away) from the middle phalanx when this occurs. If it is small it is usually of no consequence, but if it is large and involves a significant amount of the joint surface it may require surgery to fix the fragment and restore the joint surface.

Injury to the collateral ligaments can occur when the joint is forced to bend too far sideways until one of the collateral ligaments ruptures. These ligaments can also be injured if the PIP joint is actually dislocated, with the middle phalanx dislocating behind the proximal phalanx.

Symptoms

What do PIP joint injuries look and feel like?

Initially, the finger is painful and swollen around the PIP joint. If the joint has completely dislocated it will appear deformed.

Diagnosis

What tests will my doctor do?

Usually the diagnosis is evident just from the physical examination. X-rays are required to see if there is an associated avulsion fracture since this may change the recommended treatment. X-rays are also useful to see if the joint is aligned properly after an injury or after the reduction of a dislocation. No other tests are required normally.

Treatment

How will my PIP joint injury be treated?

Nonsurgical Treatment

When the ligaments have been sprained or partially torn, treatment may simply consist of a short period of splinting and early exercise. The PIP joint is very sensitive to injury and becomes stiff very rapidly when immobilized for even short periods of time. The faster the joint begins to move the less likely there will be a problem with stiffness later on. Many sprains can be treated with simple buddy taping to the adjacent finger. This allows the good finger to brace to the injured finger while at the same time using the good finger to bend the injured finger as the hand is used.

When the volar plate has been completely ruptured or when the joint has been dislocated, nonsurgical treatment is still usually suggested. The goal is to keep the joint in a stable position while beginning motion as soon as possible. Since the injury results from hyperextension, a brace to prevent the joint from straightening completely while still allowing the joint to bend accomplishes both of these goals. This brace is called a dorsal blocking splint. The brace is usually worn for three to four weeks until the ligament heals enough to stabilize the joint.

In some cases when the volar plate ruptures, it may get caught in the joint and prevent the doctor from reducing (realigning) the joint without surgery.

Surgery

In severe cases, surgery is necessary to repair extensive damage to the collateral ligaments or volar plate. Surgery is also necessary to remove the volar plate if it becomes trapped in the joint and prevents the surgeon from realigning the joint without surgery.

Rehabilitation

What will my recovery be like?

Nonsurgical Rehabilitation

If nonsurgical treatment is successful, you may see improvement in three to six weeks. By wearing a dorsal blocking splint, the joint continues to bend freely but is kept from straightening completely.

After three to four weeks, the joint should heal enough to remove the splint and begin strengthening exercises. These exercises may be directed by a physical or occupational therapist.

Injuries to the PIP joint remain swollen for long periods of time. Commonly, the joint will be permanently enlarged due to the scarring of the healing process. This may cause problems with getting rings on and off. It is a good idea to wait for about one year before the ring is resized since the scarring will continue to remodel. The joint will gradually get smaller and in some cases may return to its original size.

After Surgery

You’ll wear a splint or brace for three weeks after surgery to give the repair time to heal. Patients may be seen for physical or occupational therapy afterward. You will likely need to attend therapy sessions for two to three months, and you should expect full recovery to take up to four months.

The first few therapy treatments will focus on controlling the pain and swelling from surgery. Then you’ll begin gentle range-of-motion exercise. Strengthening exercises are used to give added stability around the finger joint. You’ll learn ways to grip and support items in order to do your tasks safely and with the least amount of stress on your finger joint. As with any surgery, you need to avoid doing too much, too quickly.

Eventually, you’ll begin doing exercises designed to get your hand and fingers working in ways that are similar to your work tasks and daily activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your finger joint. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Your therapist’s goal is to help you keep your pain under control, improve your strength and range of motion, and regain fine motor abilities with your hand and finger. When your are well under way, regular visits to your therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Mallet Finger Injuries

A Patient’s Guide to Mallet Finger Injuries

Introduction

When you think about how much we use our hands, it’s not hard to understand why injuries to the fingers are common. Most of these injuries heal without significant problems, however some do not. One such injury is an injury to the distal interphalangeal, or DIP, joint of the finger. This joint is commonly injured during sporting activities such as baseball. If the tip of the finger is struck with the ball, the tendon that attaches to the small bone underneath can be injured. Untreated, this can cause the end of the finger to fail to straighten completely, a condition called mallet finger.

This guide will help you understand

  • what parts make up the DIP finger joint
  • what types of injuries affect this joint
  • how the injury is treated
  • what to expect from treatment

Anatomy

What parts of the finger are involved?

The finger joints work like hinges when the fingers bend and straighten. The main knuckle joint is the metacarpophalangeal joint (MCP joint). It is formed by the connection of the metacarpal bone in the palm of the hand with the first finger bone, or proximal phalanx. Each finger has three phalanges, or small bones, separated by two interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint).

The extensor tendon is attached to the base of the distal phalanx. When it tightens, the DIP joint straightens. Another tendon, the flexor tendon, is attached to the palm of the finger. When it pulls, the DIP joint bends.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

How do these injuries of the DIP joint occur?

A mallet finger results when the extensor tendon is cut or torn from the attachment on the bone. Sometimes, a small fragment of bone may be pulled, or avulsed, from the distal phalanx. The result is the same in both cases: the end of the finger droops down and cannot be straightened.

Symptoms

Mallet Finger Injuries

What do mallet finger injuries look and feel like?

Initially, the finger is painful and swollen around the DIP joint. The end of the finger is bent and cannot be straightened voluntarily. The DIP joint can be straightened easily with help from the other hand. If the DIP joint gets stuck in a bent position and the PIP joint (middle knuckle) extends, the finger may develop a deformity that is shaped like a swan’s neck. This is called a swan neck deformity.

Related Document: A Patient’s Guide to Swan Neck Deformity of the Finger

Diagnosis

Mallet Finger Injuries

What tests will my doctor do?

Usually the diagnosis is evident from the physical examination. X-rays are required to see if there is an associated avulsion fracture since this may change the recommended treatment. No other tests are normally required.

Treatment

What can be done for the problem?

Nonsurgical Treatment

Mallet Finger Injuries

Treatment for mallet finger is usually nonsurgical. If there is no fracture, then the assumption is that the end of the tendon has been ruptured, allowing the end of the finger to droop. Usually continuous splinting for six weeks followed by six weeks of nighttime splinting will result in satisfactory healing and allow the finger to extend.

The key is continuous splinting for the first six weeks. The splint holds the DIP joint in full extension and allows the ends of the tendon to move as close together as possible. As healing occurs, scar formation repairs the tendon. If the splint is removed and the finger is allowed to bend, the process is disrupted and must start all over again. The splint must remain on at all times, even in the shower.

Mallet Finger Injuries

While a simple homemade splint will work, there are many splints that have been designed to make it easier to wear at all times. In some extreme cases where the patient has to use the hands to continue working (such as a surgeon), a metal pin can be placed inside the bone across the DIP joint to act as an internal splint and allow the patient to continue to use the hand. The pin is removed at six weeks.

Splinting may even work when the injury is quite old. Most doctors will splint the finger for eight to 12 weeks to see if the drooping lessens to a tolerable amount before considering surgery.

Surgery

DIP Fixation

Mallet Finger Injuries

Surgical treatment is reserved for unique cases. The first is when the result of nonsurgical treatment is intolerable. If the finger droops too much, the tip of the finger gets caught as you try to put your hand in a pocket. This can be quite a nuisance. If this occurs, the tendon can be repaired surgically, or the joint can be fixed in place. A surgical pin acts like an internal cast to keep the DIP joint from moving so the tendon can heal. The pin is removed after six to eight weeks.

Mallet Finger Injuries

Fracture Pinning

The other case is when there is a fracture associated with the mallet finger. If the fracture involves enough of the joint, it may need to be repaired. This may require pinning the fracture. If the damage is too severe, it may require fusing the joint in a fixed position.

Finger Joint Fusion

Mallet Finger Injuries

If the damage cannot be repaired using pin fixation, finger joint fusion may be needed. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from rubbing on one another. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.

Related Document: A Patient’s Guide to Finger Fusion Surgery

Rehabilitation

What will my recovery be like?

Nonsurgical Rehabilitation

When the injury is new, the DIP joint is splinted nonstop in full extension for six to eight weeks. A mallet finger that is up to three months old may require splinting in full extension for eight to 12 weeks. The splint is then worn for shorter periods that include nighttime splinting for six more weeks. Skin problems are common with prolonged splinting. Patients should monitor the skin under their splint to avoid skin breakdown. If problems arise, a new or different splint may be needed. Nearby joints may be stiff after keeping the finger splinted for this length of time. Therapy and exercise may be needed to assist in finger range of motion and to reduce joint stiffness.

After Surgery

Rehabilitation after surgery for mallet finger focuses mainly on keeping the other joints mobile and preventing stiffness from disuse. A physical or occupational therapist may be consulted to teach you home exercises and to make sure the other joints do not become stiff. After the surgical pin has been removed, exercises may be instituted gradually to strengthen the finger and increase flexibility.

Carpal Tunnel Syndrome

A Patient’s Guide to Carpal Tunnel Syndrome

Introduction

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

This guide will help you understand

  • where the carpal tunnel is located
  • how CTS develops
  • what can be done for the condition

Anatomy

Carpal Tunnel Syndrome

Where is the carpal tunnel, and what does it do?

The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. (Ligaments connect bones together.) This opening forms the carpal tunnel.

The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips of each finger on the same hand, a motion called opposition.

The median nerve and flexor tendons pass through the carpal tunnel. The median nerve rests on top of the tendons, just below the transverse carpal ligament. The flexor tendons are important because they allow movement of the fingers, thumb, and hand, such as when grasping. The tendons are covered by a material called tenosynovium. The tenosynovium is a slippery covering that allows the tendons to glide next to each other as they contract and relax to move the hand and fingers.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

What causes CTS?

Carpal Tunnel Syndrome

Any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of CTS. The carpal tunnel cannot expand so any condition that causes abnormal pressure in the tunnel can produce symptoms of CTS. And any increase in pressure within the carpal tunnel can reduce blood flow to the nerve, leading to loss of nerve function.

Various types of arthritis can cause swelling and pressure in the carpal tunnel. The way people do their tasks can put them at risk for problems of CTS. Some of these risks include

  • force
  • posture
  • wrist alignment
  • repetition
  • temperature
  • vibration

One of these risks alone may not cause a problem. But doing a task that involves several factors may pose a greater risk. And the longer a person is exposed to one or more risks, the greater the possibility of having a problem with CTS. However, scientists believe that other factors such as smoking, obesity, and caffeine intake may actually be more important in determining whether a person is more likely to develop CTS.

In other instances, CTS can start when the tenosynovium thickens from irritation or inflammation. This thickening causes pressure to build inside the carpal tunnel. But the tunnel can’t stretch any larger in response to the added swelling, so the median nerve starts to squeeze against the transverse carpal ligament. If the pressure continues to build up, the nerve is eventually unable to function normally.

When pressure builds on the median nerve, the blood supply to the outer covering of the nerve slows down and may even be cut off. The medical term for this is ischemia. At first, only the outside covering of the nerve is affected. But if the pressure keeps building up, the inside of the nerve will start to become thickened. New cells (called fibroblasts) form within the nerve and create scar tissue. This is thought to produce the feelings of pain and numbness in the hand. If pressure is taken off right away, the symptoms will go away quickly. Pressure that isn’t eased right away can slow or even stop the chances for recovery.

Trauma such as a wrist fracture, fracture/dislocation, infection, burns or other thermal injuries, bleeding disorders, and high-pressure injection injuries can result in a condition called i>acute carpal tunnel syndrome. This is much less common than the chronic compressive neuropathy caused by any of the risk factors described in this document.

A traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel. The area inside the tunnel can also be reduced after a wrist fracture or dislocation if the bone pushes into the tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on the flexor tendons.

Other conditions in the body can produce symptoms of CTS. Pregnancy can cause fluid to be retained, leading to extra pressure in the carpal tunnel. Diabetics may report symptoms of CTS, which may be from a problem in the nerve (called neuropathy) or from actual pressure on the median nerve. People with low thyroid function (called hypothyroidism) are more prone to problems of CTS. Tumors or cysts in the wrist, on the tendons, or in the carpal tunnel can also cause CTS.

Symptoms

What does CTS feel like?

Carpal Tunnel Syndrome

One of the first symptoms of CTS is gradual tingling and numbness in the areas supplied by the median nerve. This is typically followed by dull, vague pain where the nerve gives sensation in the hand. The hand may begin to feel like it’s asleep, especially in the early morning hours after a night’s rest.

In the case of acute CTS, symptoms are sudden and severe, occurring over a matter of hours rather than weeks or months with the more chronic form of this condition.

Carpal Tunnel Syndrome

Whether acute or chronic, pain associated with carpal tunnel syndrome may even spread up the arm to the shoulder. If the condition progresses, the thenar muscles of the thumb can weaken, causing the hand to be clumsy when picking up a glass or cup. If the pressure keeps building in the carpal tunnel, the thenar muscles may begin to atrophy (shrink).

Touching the pad of the thumb to the tips of the other fingers becomes difficult, making it hard to grasp items such as a steering wheel, newspaper, or telephone.

Diagnosis

How do doctors identify the condition?

Your doctor begins the evaluation by obtaining a history of the problem, followed by a thorough physical examination. Your description of the symptoms and the physical examination are the most important parts in the diagnosis of CTS. Commonly, patients will complain first of waking in the middle of the night with pain and a feeling that the whole hand is asleep.

Carpal Tunnel Syndrome

Careful investigation usually shows that the little finger is unaffected. This can be a key piece of information to make the diagnosis. If you awaken with your hand asleep, pinch your little finger to see if it is numb also, and be sure to tell your doctor if it is or isn’t. Other complaints include numbness while using the hand for gripping activities, such as sweeping, hammering, or driving.

If your symptoms started after a traumatic wrist injury, X-rays may be needed to check for a fractured bone or a fracture with dislocation.

If more information is needed to make the diagnosis, electrical studies of the nerves in the wrist may be requested by your doctor. Several tests are available to see how well the median nerve is functioning, including the nerve conduction velocity (NCV) test. This test measures how fast nerve impulses move through the nerve.

Treatment

What can be done for CTS?

The American Academy of Orthopaedic Surgeons has published guidelines on the treatment of carpal tunnel syndrome. These guidelines reflect current research evidence and are included in this document. For the complete online version of the guidelines, see www.aaos.org/guidelines.

Nonsurgical Treatment

Activities that are causing your symptoms need to be changed or stopped if at all possible. Avoid repetitive hand motions, heavy grasping, holding onto vibrating tools, and positioning or working with your wrist bent down and out. If you smoke, talk to your doctor about ways to help you quit. Lose weight if you are overweight. Reduce your caffeine intake.

Carpal Tunnel Syndrome

A wrist brace will sometimes decrease the symptoms in the early stages of CTS. A brace keeps the wrist in a resting position, not bent back or bent down too far. When the wrist is in this position, the carpal tunnel is as big as it can be, so the nerve has as much room as possible inside the carpal tunnel. A brace can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues in the carpal tunnel.

Anti-inflammatory medications may also help control the swelling and reduce symptoms of CTS. These include common over-the-counter medications such as ibuprofen and aspirin. Oral steroid medication may also offer some relief. In some studies, high doses of vitamin B-6 have been shown to help in decreasing CTS symptoms. Some types of exercises have also shown to help prevent or at least control the symptoms of CTS.

Carpal Tunnel Syndrome

If these simple measures fail to control your symptoms, an injection of cortisone into the carpal tunnel may be suggested. This medication is used to reduce the swelling in the tunnel and may give temporary relief of symptoms.

A cortisone injection may help ease symptoms and can aid your doctor in making a diagnosis. If you don’t get even temporary relief from the injection, it could indicate that some other problem is causing your symptoms. When your symptoms do go away after the injection, it’s likely they are coming from a problem within the carpal tunnel. Some doctors feel this is a signal that a surgical release of the transverse carpal ligament would have a positive result.

Your doctor may suggest that you work with a physical or occupational therapist. The main focus of treatment is to reduce or eliminate the cause of pressure in the carpal tunnel. Your therapist may check your workstation and the way you do your work tasks. Suggestions may be given about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems. You might also receive treatments to reduce inflammation and to encourage normal gliding of the tendons and median nerve within the carpal tunnel.

Surgery

If all attempts to control your symptoms fail, surgery may be suggested to reduce the pressure on the median nerve. Surgery may not be advised if there is advanced nerve damage. Persistent pain and numbness may not go away with surgery. If you have muscle atrophy and weakness and/or loss of sensation, you may not be a good candidate for surgery.

And surgery may not be advised if electrodiagnostic studies show normal results. In such cases, patients seeking pain relief will be advised to continue with conservative (nonoperative) care.

In the case of acute CTS, surgery is required right away to decompress the nerve and save it from permanent damage. This is called nerve-sparing decompression. If a patient experiences a traumatic wrist or hand injury with worsening symptoms and increasing loss of hand function, carpal tunnel release is required.

When surgery is needed, several different surgical procedures have been designed to relieve pressure on the median nerve. By releasing the pressure on the nerve, the blood supply to the nerve improves, and most people get relief of their symptoms. However, if the nerve pressure has been going on a long time, the median nerve may have thickened and scarred to the point that recovery after surgery is much slower.

Open Release

The standard surgery for CTS is called open release. Open surgical procedures use a small skin incision. In open release for CTS, an incision as small as one inch can be made down the front of the wrist and palm. By creating an open incision, the surgeon is able to see the wrist structures and to carefully do the operation. The surgeon cuts the transverse carpal ligament in order to take pressure off the median nerve.

After dividing the transverse carpal ligament, the surgeon stitches just the skin together and leaves the loose ends of the transverse carpal ligament separated. The loose ends are left apart to keep pressure off the median nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue.

Related Document: A Patient’s Guide to Open Carpal Tunnel Release

Endoscopic Release

Some surgeons are using a newer procedure called endoscopic carpal tunnel release. The surgeon merely nicks the skin in order to make one or two small openings for inserting the endoscope. An endoscope is a thin, fiber-optic TV camera that allows the surgeon to see inside the carpal tunnel as the transverse carpal ligament is carefully released.

Carpal Tunnel Syndrome

Upon inserting the endoscope, the surgeon can see the wrist structures on a TV screen. A special knife is used to cut only the transverse carpal ligament. The palmar fascia and the skin over the wrist are not disturbed.

As in open release, the loose ends of the transverse carpal ligament are left apart after endoscopic release to keep pressure off the median nerve. The gap eventually fills in with scar tissue.

Related Document: A Patient’s Guide to Endoscopic Carpal Tunnel Release

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

If nonsurgical treatment is successful, you may see improvement in four to six weeks. You may need to continue wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and vibration in the hand.

After Surgery

It generally takes longer to recover after open carpal tunnel release. Pain and symptoms usually begin to improve, but you may have tenderness in the area of the incision for several months after surgery.

Patients who wait too long to seek medical advice sometimes have difficulty adjusting after surgery. Poor coping skills in the presence of persistent pain and numbness may result in disappointment or dissatisfaction with the results of surgery. Recovery may take longer than expected when nerve damage is severe. In some cases, symptoms are not entirely alleviated.

When the stitches are removed, your surgeon may have you work with a physical or occupational therapist for six to eight weeks. Treatments are used at first to ease pain and inflammation. Gentle massage to the incision can help reduce sensitivity in and around the incision and limit scar tissue from building up. Special exercises are used to encourage normal gliding of the tendons and median nerve within the carpal tunnel.

As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand, wrist, and arm. Other exercises are used to improve fine motor control and dexterity of the hand. Your therapist will work with you to help you do your daily and work activities safely and with the least amount of strain on your wrist and hand.

Thumb Arthritis

A Patient’s Guide to Arthritis of the Thumb

Introduction

When you stop to think about how much you use your thumbs, it’s easy to see why the joint where the thumb attaches to the hand can suffer from wear and tear. This joint is designed to give the thumb its rather large range of motion, but the tradeoff is that the joint suffers a lot of stress over the years. This can lead to painful osteoarthritis of this joint, thumb arthritis, that may require surgical treatment as the arthritis progresses.

This guide will help you understand

  • how arthritis of the thumb develops
  • how it is diagnosed
  • what can be done for the condition

Arthritis of the Thumb

Anatomy

Where is the CMC joint, and what does it do?

Arthritis of the Thumb

The CMC joint (an abbreviation for carpometacarpal joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition. The CMC joint is sometimes referred to as a universal joint because of the wide range of movements possible.

Arthritis of the Thumb

Several strong, thick ligaments hold the CMC joint together. The ligaments allow for motion but keep the joint from sliding too far and prevent thumb dislocation. This function is called ligamentous restraint. These ligaments can be injured, such as when you sprain your thumb. There are also nine muscles that provide dynamic stabilization of the CMC joint. These muscles coordinate together to create a balance of stability. They put the thumb in positions that allow optimal function for thumb-pinch activities.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

What causes arthritis of the thumb?

Arthritis of the Thumb

Arthritis is a condition in which a joint becomes inflamed (red, swollen, hot, and painful). Degenerative arthritis is a condition in which a joint wears out, usually slowly over a period of many years. Doctors sometimes also describe this same condition as degenerative arthrosis. It is also called osteoarthritis.

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. An injury to the CMC joint of the thumb, even if it does not injure the articular cartilage directly, can alter how the joint works. After a fracture of the thumb metacarpal, the bone fragments may heal in slightly different positions. The joints may then line up differently. This is also true when the ligaments around the CMC joint are damaged by a sprain. When an injury results in a change in the way the joint moves, the injury may increase the forces on the articular cartilage surfaces. This is similar to any mechanical device or machinery. If the mechanism is out of balance, it tends to wear out faster.

Arthritis of the Thumb

Over many years this imbalance in the joint mechanics can lead to damage on the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Eventually, the joint is no longer able to compensate for the increasing damage, and it begins to hurt. Damage has occurred well before the pain begins.

Women are three time more likely than men to develop arthritis of the CMC joint. There are several reasons for this. Women have higher amounts of certain hormones that are linked with joint laxity (looseness). There are also some anatomic differences in the joint surfaces between men and women. Increased joint motion from laxity combined with differences in the shape and surface of the bones add to the risk of CMC arthritis in women.

Adults with increased body mass index (BMI) are also at risk for CMC arthritis. There are two possible reasons for this relationship. First, increased mechanical loading seems to occur at the CMC joint in obese adults. This is true even though the thumb is not a weight-bearing joint. Over time, increased load translates into wear and tear on the joint.

Second, patients with a higher body mass index also have elevated levels of lipids (fats), hormones, and insulin-like growth factor around the joint. Local biochemical changes from these hormones may speed up joint degeneration.

Symptoms

What does arthritis of the thumb feel like?

Arthritis of the Thumb

Pain is the main problem with degenerative arthritis of any joint. This pain occurs at first only related to activity. Usually, once the activity gets underway there is not much pain, but after resting for several minutes the pain and stiffness increase. Later, when the condition worsens, pain and aching may be present even at rest. The most noticeable problem with CMC joint arthritis is that it becomes difficult to grip anything. It causes a sharp pain at the base of the thumb in the thick part of the heel of the hand.

When the articular cartilage starts to wear off the joint surface, the joint may make a squeaking sound when moved. Doctors refer to this sound as crepitus. The joint often becomes stiff and begins to lose motion. Moving the thumb away from the palm may become difficult. This is referred to as a contracture.

Arthritis of the Thumb

Osteoarthritis may cause the CMC joint of the thumb to loosen and to bend back too far (hyperextension). If the middle thumb joint (MCP joint) becomes flexed and the furthest thumb joint also becomes hyperextended, the deformity is named a thumb swan neck deformity. A similar finger deformity sometimes occurs in people with finger arthritis.

Related Document: A Patient’s Guide to Swan Neck Deformity of the Finger

Diagnosis

How do doctors identify this problem?

The diagnosis of CMC joint arthritis of the thumb begins with your doctor taking a detailed history of the problem. Specifics about any injuries that may have occurred to the hand are important because they may suggest other reasons why the condition exists.

Following the history, the doctor will examine your hand and possibly other joints in your body. The doctor will need to see how the motion of the CMC joint has been affected.

X-rays will be taken to see how much the joint is damaged. This test usually determines how bad the degenerative arthritis has become. How much articular cartilage remains in the joint can be estimated with the X-rays.

Using X-ray findings, the condition is classified as stage I, II, III, or IV, depending on the condition of the joint cartilage and the joint space. In Stage I, there are no obvious changes on X-ray. By stage IV, bone spurs, narrowed joint space, and even joint dislocation may be seen. Although X-rays are important, radiographic staging of the disease does not predict the severity of symptoms or guide treatment.

Treatment

What can be done for CMC joint arthritis?

The treatment of degenerative arthritis of the CMC joint of the thumb is based on the severity of symptoms. The goals of treatment are to relieve pain, decrease disability, and prevent deformity. Treatment can be divided into the nonsurgical means to control the symptoms and the surgical procedures that are available to treat the condition. Surgery is usually not considered until the symptoms have become impossible to control without it.

Nonsurgical Treatment

Treatment usually begins when the CMC joint first becomes painful. This may only occur with heavy use and may simply require mild anti-inflammatory medications, such as aspirin or ibuprofen. Reducing the activity, or changing from occupations that require heavy repetitive gripping with the hand, may be necessary to help control the symptoms.

Rehabilitation services, such as physical and occupational therapy, have a critical role in the nonoperative treatment plan for CMC joint arthritis. A primary goal is to help you learn how to control symptoms and maximize the health of your thumb. You’ll learn ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs. Adaptive devices to assist with household chores, self-care, or even on-the-job tasks may be recommended.

A brace or splint may also be prescribed to support the thumb. These devices are designed to help reduce pain, prevent deformity, or keep a thumb deformity from getting worse. A thumb stabilizer is a type of thumb splint that is often custom-made of heat-moldable plastic. It is designed to fit the forearm, wrist, and thumb. Patients with CMC joint arthritis usually only wear the splint at night and when the joint is flared up. It should also be worn to protect the thumb during heavy or repeated hand and thumb activities.

Range-of-motion and stretching exercises are prescribed to improve your thumb motion. Strengthening exercises for the arm and hand help steady the hand and protect the thumb joint from shock and stress. Strengthening improves joint stability and prevents deformity and/or dislocation. Your therapist will go over tips on how you can get your tasks done with less strain on the joint.

Arthritis of the Thumb

An injection of cortisone into the joint can give temporary relief. Cortisone is a very powerful anti-inflammatory medication. When injected into the joint itself, it can help relieve the pain. Pain relief is temporary and usually only lasts several weeks to months. There is a small risk of infection with any injection into the joint, and cortisone injections are no exception.

Studies do not support the use of cortisone injections alone. Although temporary pain relief is possible, there is no long-term improvement in hand function, joint stiffness, or tenderness. Steroid injection(s) combined with splinting has been shown more successful in patients during the early stages of CMC arthritis.

Surgery

The surgical treatment for arthritis of the CMC joint includes several options. At one time, joint replacement with an artificial joint made with silicone was very popular. Problems with silicone implants in other parts of the body have led many surgeons to return to more traditional operations such as fusion and excision arthroplasty instead.

Newer artificial joints are being developed, and in the future we may see more surgeons using them. The best method to reduce pain and provide optimal function still remains uncertain. Research is underway to provide surgeons with evidence-based practice guidelines.

CMC Joint Fusion

Arthritis of the Thumb

A fusion, or arthrodesis, of any joint is designed to eliminate pain by allowing the bones that make up the joint to grow together, or fuse, into one solid bone. Fusions are used in many joints and were very common before the invention of artificial joints for the replacement of arthritic joints. Even today, joint fusions are still commonly used in many different joints for treating the pain of arthritis.

A fusion of the CMC joint of the thumb is done quite often in younger people who need a strong grip or pinch more than they need the fine motion of the thumb. People who use their hands for heavy work will probably prefer a fusion to an arthroplasty (described below).

Related Document: A Patient’s Guide to Thumb Fusion Surgery

Artificial Joint Replacement (Arthroplasty)

Artificial joints are available for the CMC joint. These plastic or metal prostheses are used by some hand surgeons to replace the joint. The prosthesis acts as a spacer to fill the gap created when the arthritic surfaces of the two bones that make up the CMC joint are removed.

Long-term results using silicone and Zirconia implants have not been widely successful. Early wear (after two years) has been reported as a result of the shear and compressive forces across the implant. In some cases, the implant sinks down into the bone causing increased pain and weakness. Titanium implants have reportedly excellent results but not all studies have had equally good outcomes. More research is needed to reduce complications and extend the life of the implant.

Related Document: A Patient’s Guide to Artificial Joint Replacement of the Thumb

Resection (also called Excision) Arthroplasty

Arthritis of the Thumb

The traditional operation for treating CMC joint arthritis is resection (excision) arthroplasty. This method has been used for many years and has withstood the test of time. Patients with severe symptoms in stage III or IV CMC arthritis who have failed nonsurgical treatment are good candidates for resection arthroplasty.

The purpose of resection arthroplasty is to remove the arthritic joint surfaces of the CMC joint and replace them with a cushion of material that will keep the bones separated. The trapezium bone is removed in a procedure called a trapeziectomy.

A rolled up piece of tendon is placed into the space created by removing the bone. This procedure is called a resection arthroplasty with ligament reconstruction and tendon interposition (LRTI). During the healing phase after surgery, this tendon turns into tough scar tissue that forms a flexible connection between the bones, similar to a joint. Sometimes the surgeon uses a silicone-based or metal implant or disc made of costochondral tissue instead of a rolled up tendon for the interpositional material. Costochondral allografts are plugs of tissue taken from the material between the breastbone and the ribs.

Resection arthroplasty with or without LRTI can be combined with a ligament reconstruction of the joint. Tendons in the area are used to create a ligament sling between the metacarpal bone of the thumb and the carpal bone of the index finger. This helps hold the thumb in place and keeps the space between the bones from collapsing.

Your surgeon decides whether to perform resection arthroplasty with or without tendon interposition and/or ligament reconstruction. Studies so far have not shown a biomechanical or clinical advantage to interposition. If there’s no evidence that this procedure improves pain, reduces stiffness, or increases pinch or grip strength, then it may fall out of favor. Surgeons will look for something more effective to achieve the intended treatment goals.

Related Document: A Patient’s Guide to Resection (Excision) Arthroplasty of the Thumb

There can be complications with any surgical procedure. Infection, nerve injury, or continued pain can occur after surgery for CMC arthritis. When tendons are used as graft material for ligament reconstruction, problems can occur such as tendon rupture or tethering. Tethering means the tendon develops scarring or adhesions that bind it and keep it from gliding smoothly inside its sheath or outer covering.

With joint implants, there can be an inflammatory reaction, subsidence (the implant sinks down into the bone), dislocation, or other cystic changes.

Rehabilitation

What should I expect following treatment?

Nonsurgical Rehabilitation

If you don’t need surgery, range-of-motion exercises for the thumb should be started as pain eases. Your therapist will work with you to obtain or create a special thumb splint (mentioned earlier) when needed. The program advances to include strength exercises for the thumb and fingers. Dexterity and fine motor exercises are used to get your hand and thumb moving smoothly. You’ll be given tips on keeping your symptoms controlled. You will probably progress to a home program within four to six weeks.

After Surgery

Your postoperative recovery and rehab program may depend on the type of surgery you had. For example, arthroscopy is much less invasive than open surgery and requires less time to recover. Your hand will be bandaged with a well-padded dressing and a thumb splint for support after arthroscopic, joint replacement, or ligament reconstructive surgery.

With fusion, there’s a high risk of nonunion so a cast is used to immobilize the joint for as much as three months. Often the thumb is fused in a functional position. The preferred position is a thumb key pinch. This means you can use the thumb to pinch and hold objects, but you won’t be able to open your hand flat. Getting your hand into a pocket will be more difficult, especially a pocket in tight pants.

Physical or occupational therapy sessions may be needed after surgery for up to eight weeks. The first few treatments are used to help control the pain and swelling after surgery. Some of the exercises you’ll begin to do are to help strengthen and stabilize the muscles around the thumb joint.

Other exercises are used to improve fine motor control and dexterity of your hand. You’ll be given tips on ways to do your activities while avoiding extra strain on the thumb joint.

Artificial Joint Replacement of the Thumb

A Patient’s Guide to Artificial Joint Replacement of the Thumb

Introduction

If nonsurgical treatments are not successful in easing problems of thumb arthritis, your doctor may recommend replacing the surfaces of the joint. Joint replacement surgery is called arthroplasty.

This guide will help you understand

  • which parts of the thumb are involved
  • how surgeons perform this surgery
  • what to expect before and after surgery

Anatomy

Which parts of the thumb are involved?

Thumb Joint Replacement

The CMC joint (an abbreviation for carpometacarpal joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition.

Several ligaments (bands of strong tissue) hold the joint together. These ligaments join to form the joint capsule of the CMC joint. The joint capsule is a watertight sac around the joint.

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful.

Related Document: A Patient’s Guide to Hand Anatomy

Rationale

Thumb Joint Replacement

What does the surgeon hope to achieve?

Arthritic joint surfaces can be a source of stiffness, pain, and swelling. The artificial joint is used to replace the damaged joint surfaces so patients can do their activities with less pain. Unlike a fusion surgery that simply binds the joint together, arthroplasty can help take away pain while allowing the thumb joint to retain movement.

Related Document: A Patient’s Guide to Arthritis of the Thumb

Preparation

How should I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

A second purpose of the preoperative visit is to prepare you for your surgery. You’ll begin learning some of the exercises you’ll use during your recovery. And your therapist can help you anticipate any special needs or problems you might have at home, once you are released from the hospital.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during surgery?

Before we describe the procedure, let’s look first at the artificial thumb joint itself.

The Artificial Thumb Joint

Surgeons have several ways to replace the thumb joint surfaces. One way is to attach the ends of a prosthesis implant into the bones of the thumb joint. A newer method uses a small, marble-shaped implant to form the new joint surfaces. This spherical implant works like a ball bearing to give the joint a smooth arc of movement.

The Operation

The procedure to put in the prosthesis implant takes about two hours to complete. The newer method using the ball implant takes 30 to 60 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution.

Prosthesis Implant

In this procedure, an incision is made across the base of the thumb. The soft tissues are spread apart with a retractor. Special care is taken not to damage the nearby nerves going to the thumb. The joint capsule is opened, exposing the CMC joint. The ends of the bones that form the CMC joint surfaces are taken off, forming flat surfaces.

A burr (a small cutting tool) is used to make a canal into the bones that form the thumb joint. The surgeon sizes the stem of the prosthesis to ensure a snug fit into the canal and inserts it. When the new joint is in place, the surgeon wraps the joint with a strip of nearby tendon. This gives the new implant some added protection and stability.

The skin is stitched together and a splint applied.

View animation of joint surface removal

View animation of of canal formation

View animation of stem sizing and insertion

View animation of tendon strip addition

Spherical Implant

A new method for replacing the thumb joint is to use a spherical implant that looks much like a marble. The surgeon makes a small, one-inch incision at the base of the thumb joint. The ends of the bones that form the CMC joint surfaces are removed, forming flat surfaces.

A burr is used to make a small notch, or canal, in the ends of the two bones. The surgeon shapes the notch so the ball-shaped implant will fit snugly in the joint. The implant is placed between the ends of the shaped bones.

The soft tissues are sewn together, and the thumb is splinted and bandaged.

View animation of joint surface removal

View animation of notch formation

View animation of shaping the notch

View animation of implanting the sphere

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following artificial thumb joint replacement are

  • anesthesia
  • infection
  • nerve damage
  • prosthesis failure

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Replacing the CMC joint with an artificial joint is no different. You will probably be given antibiotics before the operation to reduce the risk of infection. If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around either implant. In these cases, the artificial joint will need to be removed. A second operation will probably be necessary to fuse the thumb or to perform an arthroplasty that does not require an artificial prosthesis.

Nerve Damage

All of the nerves and blood vessels that go to the thumb travel across, or near, the CMC joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerves have been stretched by retractors holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.

Prosthesis Failure

One problem that occurs with artificial replacements is that they can fail. The older silicon-type prosthesis has been shown to break apart and fragment. Most types of prostheses can displace, or move out of the correct position, causing problems. Most of these problems will require a second operation to remove the prosthesis and may need to be repaired with a procedure called an excision arthroplasty.

Related Document: A Patient’s Guide to Resection (Excision) Arthroplasty of the Thumb

After Surgery

What happens after surgery?

After surgery, your thumb will be bandaged with a well-padded dressing and a splint for support. The splint will keep the thumb in a natural position during healing. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medicine to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

Rehabilitation

What should I expect during my rehabilitation?

A physical or occupational therapist will direct your recovery program. The time it takes to rehabilitate depends on the type of procedure used. Recovery takes up to three months after replacement with a prosthesis implant. Patients wear an arm-length cast with the thumb pointing out for about three weeks after this type of joint replacement surgery.

Patients are able to return to normal activity within three to five weeks after having spherical implant surgery. Recovery is faster because the procedure doesn’t require the surgeon to disturb the tendons near the joint. Range-of-motion exercises can start within one week after surgery using the ceramic ball.

The first few physical therapy treatments will focus on controlling the pain and swelling from surgery. Heat treatments may be used. Your therapist may also use gentle massage and other hands-on treatments to ease muscle spasm and pain.

Then you’ll begin gentle range-of-motion exercise. Strengthening exercises are used to give added stability around the thumb joint. You’ll learn ways to grip and support items in order to do your tasks safely and with the least amount of stress on your thumb joint. As with any surgery, you need to avoid doing too much, too quickly.

Some of the exercises you’ll do are designed get your hand and thumb working in ways that are similar to your work tasks and daily activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your thumb joint. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Your therapist’s goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your hand and thumb. When you are well under way, regular visits to your therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Resection (Excision) Arthroplasty of the Thumb

A Patient’s Guide to Resection (Excision) Arthroplasty of the Thumb

Introduction

Thumb arthritis may be surgically treated with a procedure called resection arthroplasty or sometimes called excision arthroplasty. The term excision means to take out. In this surgery, the surgeon takes out a small bone at the base of the thumb and fills in the space with a rolled up section of tendon. The soft tissue forms a false joint that keeps the thumb somewhat mobile and stops pain by preventing the joint surfaces from rubbing together.

This guide will help you understand

  • which parts of the thumb are involved
  • why this type of surgery is used
  • what happens during the procedure
  • what to expect before and after surgery

Anatomy

Which parts of the thumb are involved?

Thumb Excision Arthroplasty

The CMC joint (an abbreviation for carpometacarpal joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC is this joint that allows you to move your thumb into your palm, a motion called opposition.

Thumb Excision Arthroplasty

Several ligaments (strong bands of tissue) hold the joint together. These ligaments join to form the joint capsule of the CMC joint. The joint capsule is a watertight sac around the joint.

Thumb Excision Arthroplasty

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful.

Related Document: A Patient’s Guide to Hand Anatomy

Rationale

What does the surgeon hope to achieve?

The main goal of this surgery is to ease pain where the surfaces of the thumb joint are rubbing together. The surgeon uses a piece of tendon to form a spacer that separates the surfaces of the CMC joint. Unlike a fusion surgery that simply binds the joint together, excision arthroplasty can help take away pain while allowing the thumb joint to retain some movement.

Related Document: A Patient’s Guide to Arthritis of the Thumb

Preparation

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during surgery?

Thumb Excision Arthroplasty

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution. An incision will be made that angles along the back of the thumb to the edge of the wrist. Special care is taken not to damage the nearby nerve going to the thumb.

The CMC joint and surrounding tissues are exposed.
Next, the joint capsule surrounding the CMC joint is opened. The surgeon takes out (excises) the trapezium bone at the base of the thumb.

Then the surgeon removes a small section of one of the tendons near the thumb. The piece of tendon is sewn into a small ball and placed into the space where the trapezium bone was removed. The remaining portion of the tendon is sewn to the thumb metacarpal to stabilize the joint. The surgeon may also insert a surgical pin to connect and hold the metacarpal bones of the thumb and index finger. The pin protects the reconstructed joint and is usually removed three weeks after the surgery.

The soft tissues over the joint are sewn back together. The thumb is placed in a splint, and the hand is wrapped in a bulky dressing.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following resection arthroplasty are

  • anesthesia
  • infection
  • nerve damage

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Resection arthroplasty of the thumb is no different. You will probably be given antibiotics before the operation to reduce the risk of infection. If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the arthroplasty.

Nerve Damage

All of the nerves and blood vessels that go to the thumb travel across, or near, the CMC joint. Because the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during surgery. The result may be temporary if the nerves have been stretched by retractors holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.

After Surgery

What happens after surgery?

After surgery, your thumb will be bandaged with a well-padded dressing and a splint for support. The splint will keep the thumb in a natural position during healing. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. If a surgical pin was used, it will be removed three weeks after surgery. You may have some discomfort after exicision arthroplasty. You will be given pain medicine to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

Rehabilitation

What should I expect during my recovery period?

After surgery, you’ll wear a thumb brace for up to six weeks to give the repair time to heal. Then a physical or occupational therapist will probably direct your recovery program. You will likely need to attend therapy sessions for one to two months, and you should expect full recovery to take up to four months.

The first few therapy treatments will focus on controlling the pain and swelling from surgery. Heat treatments may be used. Your therapist may also use gentle massage and other hands-on treatments to ease muscle spasm and pain.

Then you’ll begin gentle range-of-motion exercise. Strengthening exercises are used to give added stability around the thumb joint. You’ll learn ways to grip and support items in order to do your tasks safely and with the least amount of stress on your thumb joint. As with any surgery, you need to avoid doing too much, too quickly.

Some of the exercises you’ll do are designed get your hand and thumb working in ways that are similar to your work tasks and daily activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your thumb joint. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Your therapist’s goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your hand and thumb. When you are well under way, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Dupuytren’s Contracture Surgery

A Patient’s Guide to Dupuytren’s Contracture Surgery

Introduction

Dupuytren's Contracture Surgery

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. The disorder may occur suddenly but more commonly progresses slowly over a period of years. It is more common in men of a Northern European descent. The disease usually doesn’t cause symptoms until after the age of 40.

A partial palmar fasciectomy remains the “gold standard” surgical procedure, although at earlier stages of this disease a less invasive surgical procedure called a needle aponeurectomy may be done.

Surgical treatment does not stop or cure this disease process, so recurrence is not uncommon.

Related Document: A Patient’s Guide to Dupuytren’s Contracture

This guide will help you understand

  • what your surgeon hopes to achieve
  • what happens during the operation
  • what to expect after the procedure

Anatomy

What part of the hand is affected?

Dupuytren's Contracture Surgery

The palmar fascia lies under the skin on the palm of the hands and fingers. This fascia is a thin sheet of connective tissue shaped somewhat like a triangle. It covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against the front of the fingers. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren’s contracture forms when the palmar fascia begins to thicken and tighten, causing the fingers to bend.

Dupuytren's Contracture Surgery

The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form and the tissues thicken and shorten until the finger cannot be fully straightened.

Related Document: A Patient’s Guide to Hand Anatomy

Rationale

What is the goal of surgery?

Many cases of Dupuytren’s contracture progress to the point where surgery is needed. The goal of surgery is to remove the diseased fascia, allowing the finger to straighten out again. By removing the tight cords and fascia, the tension on the finger is released. Once the fibrous tissue is removed, the skin is sewn together with fine stitches.

In some cases, grafting extra skin is necessary in the area close to the incision to give the finger more flexibility to straighten. Skin grafting is more commonly necessary in severe Dupuytren’s contractures that have been present for many years. Over time the skin also contracts. When the contracture or the cord is released, the skin cannot stretch enough to allow the finger to straighten. Skin is added, or grafted into place to allow the finger to straighten without being held back by the skin of the palm.

Preparation

How should I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

Surgery for Dupuytren’s Disease is commonly performed as an outpatient – you will probably go home the same day. The surgical procedure may be performed in an operating room in a surgery center or hospital. The needle aponeurotomy may be performed in the office setting. On the day of your surgery, you will arrive at the location chosen by the surgeon and the staff will register and prepare you for the procedure. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Needle Aponeurotomy (Percutaneous Fasciotomy)
Dupuytren's Contracture Surgery

The needle aponeurotomy is available when the disease is at an early stage. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough so that when the surgeon straightens the finger the cord will snap or rupture and allow the finger to straighten. The diseased tissue is not removed. This can be done in an office setting.

Dupuytren's Contracture Surgery

Needle aponeurotomy may be used when a patient has a contracture that’s due to a palpable cord lying beneath the skin. It does not work for non-Dupuytren’s related contractures. The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is there can be a high recurrence rate because the diseased tissue remains and can continue to contract. There is also the potential for nerve injury, infection, and hematoma (pocket of blood) formation similar to the open procedure.

Palmar Fascia Removal (palmar fasciectomy)

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic (one that puts you to sleep during surgery), or a local anesthetic (one that only numbs the hand). With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ-killing solution. An incision will be made in the skin. Several types of incisions can be made, but yours will most likely be made along the natural creases and lines in the hand. This will help make the scar less noticeable once the hand is healed.

Once the palmar fascia is exposed, it will be carefully separated from nerves, arteries, and tendons. Special care is taken not to damage the nearby nerves and blood vessels.

Then your surgeon will remove enough of the diseased palmar fascia to allow you to straighten your finger(s). After the diseased tissue is removed, and if the patient has ignored this problem for a long time, the joint capsule or the ligaments of the joint may be stiffened or contracted. Therefore the surgeon may also need to release this tissue in order to allow the finger to straighten up normally. Once the fibrous tissue is removed, the skin is sewn together with fine stitches.

A skin graft may be needed if the skin surface has contracted so much that the finger cannot relax as it should and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following surgery for Dupuytren’s contracture are

  • anesthesia
  • infection
  • nerve and blood vessel damage

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection of the incision is one possible complication after surgery. Therefore, check your incision every day as instructed by your surgeon. If you think you have a fever, take your temperature. If you have signs of infection or other complications, call your surgeon right away.

Nerve or Blood Vessel Damage

There are many nerves and blood vessels in the hand. It is possible, though uncommon, that these structures can be injured during surgery. If an injury occurs, it can be a serious complication. Injury to nerves can cause numbness or weakness of the hand. Repairing an injury to the blood vessels may require additional surgery.

After Surgery

What happens after surgery?

After a needle aponeurotomy, small adhesive bandages may be applied, or a light gauze wrap. Elevation and ice are recommended for several days following the procedure.

After a partial palmar fasciectomy, your hand will be bandaged with a well-padded dressing and a splint for support after surgery. The splint will keep the hand open and the fingers straight during healing. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, though most of your stitches will be absorbed into your body. Because many nerves are found in the hand, you may have some discomfort after surgery. You will be given pain medicine to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

Rehabilitation

What should I expect during my recovery?

Usually physical therapy is not required after a needle aponeurotomy. NO strenuous gripping for one week. After one week, return to activities as tolerated. Occasionally a splint is prescribed for night use.

After a partial palmar fasciectomy, physical or occupational therapy sessions will be needed for up to six weeks. Therapy visits usually include heat treatments, soft tissue massage, and vigorous stretching. Therapy can make the difference in a successful result after surgery. These sessions are important in limiting the buildup of scar tissue, preventing the return of contractures, and getting the most benefit from surgery.

You’ll gradually be able to put your hand to use. You should be able to straighten all joints within four to eight weeks, sometimes a little longer.

You’ll probably need to wear a splint at night for up to six months after surgery. It is used to keep the joints straight, preventing new contractures from forming. Take all medicine exactly as prescribed by your surgeon, and be sure to keep all follow-up appointments.

Endoscopic Carpal Tunnel Release

A Patient’s Guide to Endoscopic Carpal Tunnel Release

Introduction

Carpal tunnel syndrome (CTS) is a condition affecting the wrist and hand. While the most common surgical procedure for a carpal tunnel release is still the open-incision technique, some surgeons are using a new procedure, called endoscopic carpal tunnel release.

The procedure is done using an endoscope (a small, fiber-optic TV camera) to look into the carpal tunnel through a small incision just below the wrist. Using the camera allows the surgeon to release the ligament without disturbing the overlying tissues.

This guide will help you understand

  • what part of the wrist is treated during surgery
  • how surgeons perform the operation
  • what to expect before and after the procedure

Related Document: A Patient’s Guide to Carpal Tunnel Syndrome

Anatomy

What part of the wrist is treated during surgery?

The carpal tunnel is an opening through the wrist into the hand that is formed by the bones of the wrist (carpal bones) on one side and the transverse carpal ligament on the other. (Ligaments connect bones together.) The transverse carpal ligament is at the base of the wrist and crosses from one side of the wrist to the other. (Transverse means across.) It is sometimes referred to as the carpal ligament.

The median nerve and the flexor tendons pass through the carpal tunnel. The median nerve rests on top of the tendons, just below the carpal ligament. Between the skin and the carpal ligament is a thin sheet of connective tissue called the palmar fascia.

Related Document: A Patient’s Guide to Hand Anatomy

Rationale

What does the surgeon hope to achieve?

The surgery releases the carpal ligament, taking pressure off the median nerve. By using the endoscope, surgeons can accomplish this without disrupting the nearby tissues.

Proponents of the procedure feel that patients heal faster, are able to use their hand faster, and have fewer problems of tenderness in the palmar incision. Other physicians are not convinced that this procedure for releasing the carpal ligament is better than the open-incision technique.

Related Document: A Patient’s Guide to Open Carpal Tunnel Release

The endoscopic method is more technically demanding and can be more expensive in most hospitals. There may be a higher complication rate with this procedure involving incomplete release of the carpal ligament or injury to the median nerve inside the carpal tunnel. As more and more surgeons choose to use this method, these questions will probably be resolved.

Preparation

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

Surgical Procedure

What happens during the operation?

The surgery is occasionally done using a general anesthetic (one that puts you to sleep). More often, a regional anesthetic is used. A regional anesthetic blocks the nerves going to only a portion of the body. Injection of medications similar to lidocaine are used to block the nerves for several hours. This type of anesthesia could be an axillary block (only the arm is asleep) or a wrist block (only the hand is asleep). The surgery can also be performed by simply injecting lidocaine around the area of the incision.

Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ-killing solution.

The surgeon nicks the skin to create a small opening just below the crease in the wrist where the palm starts. This opening allows the surgeon to place the endoscope into the carpal tunnel. Some surgeons make a second small incision within the palm of the hand.

The procedure using a single incision is becoming more popular. The incision allows the surgeon to open the carpal tunnel just below the carpal ligament.

Once the surgeon is sure that the instruments can be passed into the carpal tunnel, a metal or plastic cannula (a tube with a slot on the side) is placed alongside the median nerve. The endoscope can be placed into the tube to look at the underside of the carpal ligament, making sure that the nerves and arteries are safely out of the way.

A special knife is inserted through the cannula. This knife has a hook on the end that cuts backwards when the knife is pulled back out of the cannula. Once the knife is pulled all the way back, the carpal ligament is divided, without cutting the palmar fascia or the skin of the palm.

Once the carpal ligament is divided, the median nerve is no longer compressed and begins to return to normal.

After the carpal ligament is released, the surgeon stitches just the skin openings and leaves the loose ends of the carpal ligament separated. The loose ends are left apart to keep pressure off the median nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following endoscopic carpal tunnel release are

  • anesthesia
  • infection
  • incision pain
  • persistent symptoms
  • incomplete ligament release
  • hand weakness

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection is a possible complication after surgery, especially infection of the incision. Therefore, check your incision every day as instructed by your surgeon. If you think you have a fever take your temperature. If you have signs of infection or other complications, call your surgeon right away.

These are warning signs of infection or other complications:

  • pain in your hand that is not relieved by your medicine
  • discharge with an unpleasant odor coming from your incision
  • swelling, heat, and redness along your incision
  • chills or fever over 100.4 degrees Fahrenheit
  • bright red blood coming from your incision

Incision Pain

Some patients report having pain along the palm incision, but this happens less than when people have an open release procedure. Sometimes people still feel some numbness and tingling after surgery, especially if they had severe pressure on the median nerve prior to surgery. When the thenar (thumb) muscles are notably shrunken (atrophied) from prolonged pressure on the median nerve, strength and sensation may not fully return even after having this type of surgery.

Persistent Symptoms

There is a small chance that problems of carpal tunnel syndrome don’t go away completely. Sometimes symptoms come back after having the endoscopic release surgery. A return of symptoms is rare, but the likelihood is greatest in workers who go back to a job where they hold on to vibrating tools for long hours.

Incomplete Ligament Release

Releasing the carpal ligament using an endoscope requires skill and experience. One drawback of this procedure is incomplete release of the carpal ligament. When this occurs, symptoms may not go away completely. Some patients end up needing a second surgery to completely release the carpal ligament.

Hand Weakness

Muscles that are used to squeeze and grip may seem weak after surgery. During normal gripping, the tendons of the wrist press outward against the carpal ligament. This allows the carpal ligament to work like a pulley to improve grip strength. People used to think that the tendons lose this mechanical advantage after the carpal ligament has been released. However, recent studies indicate that hand weakness is more likely from pain or swelling that occurs in the early weeks after the procedure. With the exception of patients who have severe atrophy at the time of surgery, most people achieve normal hand strength within two to four months of surgery. Those with severe atrophy commonly see improvements in hand strength, but they rarely regain normal size of the thenar muscles.

After Surgery

What happens immediately after surgery?

After surgery, the incision is wrapped in a soft dressing or simply covered with a bandage. Your surgeon may splint and wrap the wrist.

In the days following surgery, keep emergency phone numbers handy. Call your surgeon’s office if you feel your hand is not healing as it should.

Rehabilitation

What should I expect after surgery?

You’ll be scheduled to see your doctor in 10 to 12 days for a follow-up. Your surgeon may need to take out one or two of the stitches if they haven’t already been absorbed into your body.

Finger motions are safe to begin within one day after surgery. But you need to avoid heavy grasping or pinching with your hand for six weeks. These actions need to be avoided to keep the tendons from pushing out against the healing carpal ligament. After six weeks, you should be safe to resume gripping and pinching without irritating the wrist.

Your surgeon may have you work with a physical or occupational therapist for four to six weeks after the surgery. You’ll begin doing active hand movements and range-of-motion exercises. Therapists also use ice packs, soft-tissue massage, and hands-on stretching to help with the range of motion. When the stitches are removed, you may start carefully strengthening your hand by squeezing and stretching special putty with your hand and fingers. Therapists also use a series of fist positions to encourage the finger tendons to slide within the carpal tunnel.

As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you’ll do are designed to get your hand working in ways that are similar to your work tasks and sport activities.

Your therapist will help you find ways to do your tasks that don’t put too much stress on your hand and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Thumb Fusion Surgery

A Patient’s Guide to Thumb Fusion Surgery

Introduction

Thumb arthritis may be surgically treated with a fusion procedure. The bones that form the thumb joint are set so they can grow together, or fuse. After fusing, the joint won’t move, and your pain should go away.

This guide will help you understand

  • which parts of the thumb are involved
  • why this type of surgery is used
  • what happens during surgery
  • what to expect before and after surgery

Anatomy

Thumb Fusion Surgery

Which parts of the thumb are involved?

The CMC joint (an abbreviation for carpometacarpal joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition.

Thumb Fusion Surgery

Several ligaments (bands of strong tissue) hold the joint together. These ligaments join to form the joint capsule of the CMC joint. The joint capsule is a watertight sac around the joint.

Thumb Fusion Surgery

The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily. When this material wears out, the joint develops a type of arthritis called osteoarthritis and becomes painful.

Related Document: A Patient’s Guide to Hand Anatomy

Rationale

Thumb Fusion Surgery

What does the surgeon hope to achieve?

When the articular cartilage wears out, the CMC joint becomes arthritic. The joint becomes painful when the thumb is used for gripping and pinching.

Related Document: A Patient’s Guide to Arthritis of the Thumb

Joint fusion is a procedure that joins the surfaces of the thumb metacarpal and the trapezium so they don’t move or cause pain. This surgery is usually done on younger patients who have to have a lot of thumb strength on the job, such as carpenters who need to use a hammer all day. Once the CMC joint is fused, their pain goes away. They lose joint movement, but they still have a good ability to grip and pinch.

Preparations

What should I do to prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won’t be able to see the surgery.

Thumb Fusion Surgery

Once you have anesthesia, your surgeon will make sure the skin of your hand is free of infection by cleaning the skin with a germ-killing solution. An incision is made on the side of the thumb just over the CMC joint. Special care is taken not to damage the nearby nerves going to the thumb.

The joint capsule surrounding the CMC joint is then opened so that the surgeon can see the joint surfaces. The articular cartilage is removed from both joint surfaces to leave two surfaces of raw bone. A special tool is used to hollow the end of the thumb metacarpal to form a socket. The surface of the trapezium is shaped into a rounded cone that fits into the socket inside the thumb metacarpal.

The surgeon places a metal pin through the center of both bones and then connects the cone and socket snugly together. A metal pin allows the surgeon to hold the two bones in the correct alignment and prevents the bones from moving too much as they grow together, or fuse.

The soft tissues over the joint are then sewn back together. The forearm and hand are placed in a cast until the bones completely fuse together. This takes about six weeks.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following thumb fusion are

  • anesthesia
  • infection
  • nerve damage
  • nonunion

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. Thumb fusion surgery is no different. You will probably be given antibiotics before the operation to reduce the risk of infection. If an infection occurs you will most likely need antibiotics to cure it. You may need additional operations to drain the infection if it involves the area around the fusion.

Nerve Damage

All of the nerves and blood vessels that go to the thumb travel across, or near, the CMC joint. Since the operation is performed so close to these important structures, it is possible to injure either the nerves or the blood vessels during fusion surgery. The result may be temporary if the nerves have been stretched by retractors holding them out of the way. It is uncommon to have permanent injury to either the nerves or the blood vessels, but it is possible.

Nonunion

Sometimes the thumb bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (Pseud means false, and arthro means joint; a pseudarthrosis refers to the motion at a false joint.) If the motion from a nonunion continues to cause pain, you may need a second operation to try to get the bones to completely fuse. This usually means adding more bone graft and making sure that any metal pins that have been used are holding the bones still to allow the fusion to occur.

After Surgery

What happens after surgery?

After surgery, you will be fitted in an elbow-length cast. This gives the ends of the bones the opportunity to fuse together. Your surgeon will want to check your hand within five to seven days. Stitches will be removed in 10 to 14 days, though most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medicine to control the discomfort.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

Rehabilitation

What should I expect during my recovery period?

As mentioned, you’ll wear the cast for about six weeks to give the fusion time to heal. When the cast is removed, you may have stiffness in the joints on both sides of the fusion.

If you have pain or stiffness that doesn’t improve, you may need a physical or occupational therapist to direct your recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Your therapist may use gentle massage and other hands-on treatments to ease muscle spasm and pain.

Then you’ll begin gentle range-of-motion exercise for the joints above and below the fusion. Strengthening exercises are used to give added stability around the thumb joint. You’ll learn ways to grip and support items in order to do your tasks safely and with the least amount of stress on your thumb joint. As with any surgery, you need to avoid doing too much, too quickly.

Some of the exercises you’ll do are designed get your hand and thumb working in ways that are similar to your work tasks and daily activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your thumb joint. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Your therapist’s goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your hand and thumb. When your treatments are well under way, regular visits to your therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Dupuytren’s Contracture

A Patient’s Guide to Dupuytren’s Contracture

Introduction

Dupuytren's Contracture

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women. Although more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry researchers agree that genes are not a direct cause of this disease, but predisposes them to this condition.

The condition is noted to be secondary to an increase in fibroblast density – a complex biochemical and cellular interaction. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

This guide will help you understand

  • how Dupuytren’s contracture develops
  • how the disorder progresses
  • what treatment options are available

Anatomy

What part of the hand is affected?

The palm side of the hand contains many nerves, tendons, muscles, ligaments, and bones. This combination allows us to move the hand in many ways. The bones give our hand structure and form joints. Bones are attached to bones by ligaments. Muscles allow us to bend and straighten our joints. Muscles are attached to bones by tendons. Nerves stimulate the muscles to bend and straighten. Blood vessels carry needed oxygen, nutrients, and fuel to the muscles to allow them to work normally and heal when injured. Tendons and ligaments are connective tissue. Another type of connective tissue, called fascia, surrounds and separates the tendons and muscles of the hand.

Dupuytren's Contracture

Lying just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren’s contracture transforms the fascia into shortened cords.

The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Dupuytren's Contracture

The areas affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The MCP joints are what we usually refer to as the “knuckles.” The PIP joints are the middle joints between the knuckles and the joints at the tips of the fingers.

Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

Why do I have this problem?

Researchers have studied Dupuytren’s contracture and have found this to be a complex interaction of biochemical and cellular processes. The treatment options in the future will rely on pharmacologic interventions rather than surgery alone. This condition is rare in young people but becomes more common with age. When it appears at an early age, it usually progresses rapidly and is often very severe. The condition tends to progress more quickly in men than in women.

People who smoke have a greater risk of having Dupuytren’s contracture. Heavy smokers who abuse alcohol are even more at risk. Recently, scientists have found a connection with the disease among people who have diabetes. It has not been determined whether or not work tasks can put a person at risk or speed the progression of the disease.

Symptoms

What does Dupuytren’s contracture feel like?

Normally, we are able to control when we bend our fingers and how much. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. People lose this control as the disorder develops and the palmar fascia contracts, or tightens. This contracture is like extra scar tissue just under the skin. As the disorder progresses, the bending of the finger becomes more and more severe, which limits the motion of the finger.

Dupuytren's Contracture

Without treatment, the contracture can become so severe that you cannot straighten your finger, and eventually you may not be able to use your hand effectively. Because our fingers are slightly bent when our hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually seek medical advice for cosmetic reasons or the loss of use of their hand. The condition usually isn’t painful, but the nodules can be sensitive to touch. For this reason many patients are worried that something serious is wrong with their hand.

Diagnosis

How do doctors identify the problem?

Your doctor will ask you the history of your problem, such as how long you have had it, whether you’ve noticed it getting worse, and whether it has kept you from doing your daily activities. The doctor will then examine your hands and fingers.

Your doctor can tell if you have a Dupuytren’s contracture by looking at and feeling the palm of your hand and your fingers. Usually, special tests are unnecessary. Abnormal fascia will feel thick. Cords and small nodules in the fascia may be felt as small knots or thick bands under the skin. These nodules usually form first in the palm of the hand. As the disorder progresses, nodules form along the finger. These nodules can be felt through the skin, and you may have felt them yourself. Depending on the stage of the disorder, your finger may have started to contract, or bend.

Dupuytren's Contracture

The amount you are able to bend your finger is called flexion. The amount you are able to straighten the finger is called extension. Both are measured in degrees. Normally, the fingers will straighten out completely. This is considered zero degrees of flexion (no contracture). As the contracture causes your finger to bend more and more, you will lose the ability to completely straighten out the affected finger. How much of the ability to straighten out your finger you have lost is also measured in degrees.

Measurements taken at later follow-up visits will tell how well treatments are working or how fast the disorder is progressing. The progression of the disorder is unpredictable. Some patients have no problems for years, and then suddenly nodules will begin to grow and their finger will begin to contract.

The tabletop test may also done. The tabletop test will show if you can flatten your palm and fingers on a flat surface. You can follow the progression of the disorder by doing the tabletop test yourself at relatively regular intervals. Put your hand flat on a table and if you can see sunlight between your hand and the table, it’s time to start to consider treatment for the condition. Your doctor will tell you what to look for and when you should return for a follow-up visit.

Treatment

What can be done for the condition?

There are two types of treatment for Dupuytren’s contracture: nonsurgical and surgical. The best course of treatment is determined by how far the contractures have advanced. Palmar Fascia Removal (palmar fasciectomy) or release of the diseased cords still remains the “gold standard” of care for advanced Dupuytren’s contracture.

Bracing and stretching of the fingers alone has not been proven to help in the long term progression of this condition.

Nonsurgical and surgical treatments are to treat the contracture itself. This does not cure the disease. Dupuytren’s disease continues to slowly form the bands although it may be years before the contracture presents itself again.

Nonsurgical Treatment

The nodules of Dupuytren’s contracture are almost always limited to the hand. If you receive regular examinations, you will know when to proceed with the next treatment step. Dupuytren’s contracture is a progressive disease, early treatment, determined by the stage of the disease, is important to release the contracture and to prevent disability in your hand. Treatment is determined based on the severity of the contracture.

Enzymatic Fasciotomy

Ongoing research of this condition has resulted a less invasive method of treatment called an enzymatic fasciotomy, if only the MCP joint is contracted, and there are only one or two cords involved, this procedure may be possible. It may eventually replace surgery. Until then, surgical release of the cords will likely remain the gold standard.

The U.S. Food and Drug Administration (FDA) recently approved a new injectable drug (Xiaflex) for nonsurgical treatment of this problem. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken, most often he/she is able to break apart the cord himself/herself.

Dupuytren's Contracture

Generally patients return within 24 hours for recheck. If the cord hasn’t broken apart, your physician may have to numb the finger and then stretch the finger to break apart the cord to regain full motion of the finger. That sounds dramatic — it’s not! The treatment is safe and effective. But further study is needed to assess the long-term effects, especially recurrence rates.

There are a few possible (minor) side effects but very few major or long-term complications with this new treatment. During the control trials conducted with patients, most people had a local skin reaction (swelling, redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including skin infection, tendon rupture, finger deformity, complex regional pain syndrome (pain and stiffness), and hives that had to be treated with medication.

Early studies show a good success rate (77 per cent) in reducing MCP contractures using this injection treatment. Almost all of the patients (92 per cent) were able to straighten the MCP joints with less than a 30-degree flexion contracture. Results were not quite as good for the PIP joints. Less than half (44 per cent) of the patients with PIP contractures had regained full motion of the affected joint. The long-term results and recurrence rates with enzyme fasciotomy are unknown at this time.

Surgery

No hard and fast rule exists as to when surgery is needed. But the sooner a contracture is treated, the better the results of a return to full function. Many patients are instructed to keep an eye on the disease and return for follow-up once their “tabletop test” shows light between their hand and the table.
Surgery is usually recommended when the MCP joint (at the knuckle) of the finger reaches 30 degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life. When the problem comes back or causes severe contractures, surgeons may decide to fuse the individual finger joints together. In the worst case, amputation of the finger may be needed if the contracture restricts the nerves or blood supply to the finger.

Surgery for the main knuckle of the finger (at the base of the finger) has better long-term results than when the middle finger joint is tight. Tightness is more likely to return after surgery for the middle joint.

The goal of tissue release surgery is to release the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should be restored to normal. If the problem is not severe, it may be possible to free the contracture simply by cutting the cord under the skin.

Needle Aponeurotomy

A less invasive procedure called a needle aponeurotomy (also referred to as a percutaneous fasciotomy) is available when the disease is at an early stage. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough to stretch and extend or rupture it.

Dupuytren's Contracture

The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is a high recurrence rate and the potential for nerve injury, infection, and hematoma (pocket of blood) formation.

This procedure has replaced the “open fasciotomy” in many practices.

Palmar Fascia Removal (partial or limited palmar fasciectomy)

This remains the gold standard of treatment for Dupuytren’s contracture. Removal of the diseased palmar fascia causing the contracture but not then entire fascia will usually give a very good result. Final outcomes depend a great deal on the success of doing the postoperative physical or occupational therapy as prescribed. If you decide to have this surgery, you must commit to doing the therapy needed to make your surgery as successful as possible.

Removal of the entire palmar fascia (radical fasciectomy) requires extensive removal of involved and non-involved palmar and digital (finger) fascia. This procedure may be required in cases of severe or recurrent Dupuytren’s contacture. This approach has higher complication rates without providing better success rates so it is not done as often anymore.

Complications of a palmar fasciectomy can include permanent nerve damage, joint pain and stiffness, hematoma (pocket of blood), infections, and poor wound healing.

Surgery does not always fully restore range-of-motion and function but it usually increases the ability to extend (straighten) the affected fingers. You should also be aware that the problem can come back and/or spread. In other words, surgery is not always “curative.”

Skin Graft

A skin graft may be needed if more extensive removal of the palmar fascia is required. This may be the case when the skin surface has contracted so much that the finger cannot relax as it should and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin. The skin is grafted into the area near the incision to give the finger extra mobility for movement.

Related Document: A Patient’s Guide to Dupuytren’s Contracture Surgery

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

No formal physical therapy is generally needed for enzyme fasciotomy.

After Surgery

After a needle aponeurotomy usually physical therapy is not required. Patients are advised to keep their hand iced and elevated for two days following the procedure. NO strenuous gripping for one week. After one week, return to activities as tolerated. Occasionally a splint is prescribed for night use.

After a partial palmar fasciectomy, your hand will be bandaged with a well-padded dressing and a splint for support after surgery. Physical or occupational therapy sessions will be needed after surgery for up to six weeks. Visits will include heat treatments, soft tissue massage, and vigorous stretching. Therapy treatments after surgery can make the difference in a successful result after surgery. Palmar wounds from the incisions take about three to five weeks to heal.

Studies show that patients with more severe disease (especially affecting the proximal interphalangeal (PIP) joints) have a higher risk of disease recurrence. In fact, for all treatment approaches (surgical and nonsurgical), the metacarpophalangeal (MCP) joints are easier to treat with better outcomes and fewer cases of recurrence.

As many as half of all patients who have surgery report return of flexion contractures within five years of surgery. Patients with PIP contractures seem to have the highest recurrence rates.

Finger Joint Arthritis

A Patient’s Guide to Arthritis of the Finger Joints

Introduction

When you stop to think about how much you use your hands, it’s easy to see why the joints of the fingers are so important. Arthritis of the finger joints has many causes, and arthritic finger joints can make it hard to do daily activities due to pain and deformity. Unbearable pain or progressive deformity from arthritis may signal the need for surgical treatment.

This guide will help you understand

  • how arthritis of the finger joints develops
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

How do the finger joints normally work?

Finger Joint Arthritis

The bones in the palm of the hand are called metacarpals. One metacarpal connects to each finger and thumb. Small bone shafts called phalanges line up to form each finger and thumb.

Finger Joint Arthritis

The main knuckle joint is formed by the connection of the phalanges to the metacarpals. This joint is called the metacarpophalangeal joint (MCP joint). The MCP joint acts like a hinge when you bend and straighten your fingers and thumb.

The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint). The thumb only has one IP joint between the two thumb bones. The IP joints of the digits also work like hinge joints when you bend and straighten your hand.

Finger Joint Arthritis

The finger and thumb joints are covered on the ends with articular cartilage. This white, shiny material has a rubbery consistency. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to facilitate motion. There is articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

What causes arthritis?

Finger Joint Arthritis

Degenerative arthritis is a condition in which a joint wears out, or degenerates, usually slowly over a period of many years. Degenerative arthritis is usually called osteoarthritis. The term arthritis means joint inflammation (pain, redness, heat, and swelling). The term degenerative arthritis means inflammation of a joint due to wear and tear. You may also hear the term degenerative arthrosis used. Degenerative arthritis is usually called osteoarthritis.

Finger Joint Arthritis

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. An injury to any of the joints of the fingers, even if it does not injure the articular cartilage directly, can alter how the joint works. After a fracture, the bone fragments may heal in slightly different positions. This may make the joints line up differently. When an injury changes the way the joint lines up and moves, force can start to press against the surface of the articular cartilage. This is similar to how a machine that is out of balance wears out faster.

Over time, this imbalance in the joint can lead to damage to the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Eventually, the joint can no longer compensate for the increasing damage, and symptoms begin. The damage in the joint starts well before the symptoms of arthritis appear.

Symptoms

What does arthritis feel like?

Pain is the main problem with arthritis. At first, the pain usually only causes problems when you begin an activity. Once the activity gets underway, the pain eases. But after resting for several minutes the pain and stiffness increase. When the arthritis condition worsens, pain may be felt even at rest. The sensitive joint may feel enlarged and warm to the touch from inflammation.

Finger Joint Arthritis

In rheumatoid arthritis, the fingers often become deformed as the disease progresses. The MCP joints of the fingers may actually begin to point sideways (towards the little finger). This is called ulnar drift. Ulnar drift can cause weakness and pain, making it difficult to use your hand for daily activities.

Both rheumatoid arthritis and osteoarthritis can affect the IP joints of the fingers. The IP joints may begin to flex (bend) or hyperextend (over straighten), causing characteristic finger deformities. Swan neck deformity occurs when the middle finger joint (the PIP joint) becomes loose and hyperextended, while the DIP joint becomes flexed. When the PIP joint flexes and the DIP joint extends, a boutonniere deformity forms.

Related Document: A Patient’s Guide to Swan Neck Deformity of the Finger

Related Document: A Patient’s Guide to Boutonniere Deformity of the Finger

Both forms of arthritis can cause enlarged areas over the back of the PIP joints. These areas tend to be sore and swollen. They are known as Bouchard’s nodes . Osteoarthritis causes similar enlargements over the DIP joints, called Heberden’s nodes.

Diagnosis

How do doctors identify arthritis?

The diagnosis of arthritis of the finger joints begins with a history of the problem. Details about any injuries that may have occurred to the hand are important and may suggest other reasons why the condition exists.

Following the history, a physical examination of the hand and possibly other joints in the body will be done. Your doctor will need to see how the motion of each joint has been affected.

X-rays will be taken to see how much the joint has changed. These tests can help determine how bad the degenerative damage from the arthritis has become. The X-rays also help the doctor estimate how much articular cartilage is still on the surface of the joints.

Treatment

What can be done for the condition?

Nonsurgical Treatment

Treatment usually begins when the joint first becomes painful. This may only occur with heavy use and may simply require mild anti-inflammatory medications, such as aspirin or ibuprofen. Reducing the activity, or changing from occupations that require heavy repetitive hand and finger motions, may be necessary to help control the symptoms.

Finger Joint Arthritis

An injection of cortisone into the finger joint can give temporary relief. Cortisone is a very powerful anti-inflammatory medication. When injected into the joint itself, it can help relieve the pain. Pain relief is temporary and usually only lasts several weeks to months. There is a small risk of infection with any injection into the joint, and cortisone injections are no exception.

Rehabilitation services, such as physical and occupational therapy, play a critical role in nonoperative treatment of finger joint arthritis. A primary goal is to help you learn how to control symptoms and maximize the health of your hand and fingers. You’ll learn ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs.

A custom finger brace or splint may be prescribed to support the finger joints. These devices are designed to help reduce pain, prevent deformity, or keep a finger deformity from getting worse.

Range-of-motion and stretching exercises are prescribed to improve your finger movement. Strengthening exercises for the arm and hand help steady the hand and protect the finger joints from shock and stress. Your therapist will also go over tips on how you can get your tasks done with less strain on the joint.

Surgery

Fusion

Finger Joint Arthritis

A fusion (or arthrodesis) of any joint is designed to eliminate pain by allowing the bones that make up the joint to grow together, or fuse, into one solid bone. Fusions are used in many joints and were very common before the invention of artificial joints for the replacement of arthritic joints. Even today, joint fusions are still very commonly used in many different joints for treating the pain and potential deformity of arthritis. Fusions are more commonly used in the PIP or the DIP joints in the fingers. A fusion of these joints is far easier and more reliable than trying to save the motion by replacing the joint.

Related Document: A Patient’s Guide to Finger Fusion Surgery

Artificial Joint Replacement

Finger Joint Arthritis

Artificial joints are available for the finger joints. These plastic or metal prostheses are used by some hand surgeons to replace the arthritic joint. The prosthesis forms a new hinge, giving the joint freedom of motion and pain relief. The procedure for putting in a new joint is called arthroplasty.

Related Document: A Patient’s Guide to Artificial Joint Replacement of the Finger

Rehabilitation

What should I expect following treatment?

Nonsurgical Rehabilitation

If you don’t need surgery, range-of-motion exercises for the finger should be started as pain eases, followed by a program of strengthening. Your therapist will work with you to obtain or create special finger splints or braces (mentioned earlier) when needed. The rehabilitation program advances to include strength exercises for the fingers and hand. Dexterity and fine motor exercises are used to get your hand and fingers moving smoothly. You’ll be given tips on keeping your symptoms controlled. You will probably progress to a home program within four to six weeks.

After Surgery

Your hand will be bandaged with a well-padded dressing and a finger splint for support after surgery. Physical or occupational therapy sessions may be needed after surgery for up to eight weeks. The first few treatments are used to help control the pain and swelling after surgery. Some of the exercises you’ll begin to do help strengthen and stabilize the muscles around the finger joint. Other exercises are used to improve fine motor control and dexterity of your hand. You’ll be given tips on ways to do your activities while avoiding extra strain on the finger joint.