eOrthopod Admin - eOrthopod.com

Vertebroplasty

A Patient’s Guide to Vertebroplasty

Introduction

Patients with osteoporosis are prone to compression fractures in the spine bones, or vertebrae. The front of a vertebra cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States. These fractures often cause poor back posture, debilitating pain, and difficulty completing routine activities.

Vertebroplasty restores the strength of the fractured bone, thereby reducing pain. More than 80 percent of patients get immediate relief of pain with this procedure.

This guide will help you understand

why the procedure becomes necessary
what surgeons hope to achieve with vertebroplasty
what to expect during recovery

Anatomy

What parts of the spine are involved?

The main section of each spine vertebra is a large, round block of bone called a vertebral body. Compression fractures cause this section of bone to collapse.
The collapsed vertebra gives the spine a hunched appearance, called kyphosis, and the loss of vertebral height shortens the muscles on each side of the spine.

This forces the back muscles to work harder, causing muscle fatigue and pain. The vertebral body is the main structure treated in the vertebroplasty procedure.

Rationale

What do surgeons hope to achieve?

In the past, surgeons used standard open surgery to fix compression fractures from osteoporosis. Open surgery requires larger incisions to give the surgeon more room to operate. The results of open surgery for this condition have generally been poor, mainly because it is difficult to do surgery on bones that are weak and soft from osteoporosis. In addition, some aging adults with fractures may not be physically able to tolerate such surgery.

Vertebroplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, vertebroplasty is a minimally invasive procedure. It requires small openings in the skin and small instruments. This lessens the chance of bleeding, infection, and injury to muscles and tissues.

Surgeons fix the bone in place by squeezing special cement into the broken bone. The cement strengthens and stiffens the vertebra, which reduces pain considerably and helps the patient return to normal activities.

This procedure doesn’t restore the original height of the broken vertebra, however. Nor does it prevent the kyphosis (hunchback) deformity that sometimes results from compression fractures.

Preparations

How will I prepare for the procedure?

The decision to proceed with vertebroplasty 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.

Vertebroplasty is normally done on an outpatient basis, meaning patients go home the same day as the surgery. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the procedure?

The patient lies on his or her stomach. To begin, the surgeon cleans the skin on the back with an antiseptic. Then the skin and muscles over the problem area are numbed using an anesthetic. Patients may also receive general anesthesia to put them to sleep during the procedure.

A small incision is made in the skin on each side of the spinal column. A long needle is inserted through each opening. The surgeon slides the needles through the back of the spinal column into the fractured vertebral body.

A fluoroscope is used to guide the needles. This is a special X-ray television camera adjusted above the patient’s back that lets the surgeon see the patient’s spine on a screen. Metal objects show up clearly on X-rays. The needles are easy for the surgeon to see on the fluoroscope screen. This helps the surgeon confirm that the needles reach the correct spot.

Once the needle is in place, special bone cement, called polymethylmethacrylate (PMMA), is injected
through the needle into the fractured vertebra.

View animation of cement injected

A chemical reaction in the cement causes it to harden in about 15 minutes. This fixes the bone so it can heal. Bandages are placed over the small openings where the needles were inserted.

Complications

What might go wrong?

Serious complications from vertebroplasty are rare, involving less than five percent of cases. As with other procedures, however, complications can occur. Some of the most common complications of vertebroplasty include

problems with anesthesia
thrombophlebitis
infection
cement leakage
ongoing pain

This is not intended to be a complete list of 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 procedures is rare but can be a very serious complication. Some infections may show up early, within the first few days after the procedure. 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 surgery to treat the infected portion of the spine.

Cement Leakage

The cement used in vertebroplasty is in a liquid form and is squeezed into the fractured vertebra under high pressure. Some of the cement commonly leaks out of the vertebra, but this usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.

Ongoing Pain

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

After Surgery

What happens after surgery?

Patients are monitored in the recovery room for two to three hours after the procedure before going home. Patients are instructed to move their backs only carefully and comfortably. Some patients who feel extra pain or other problems after the procedure may need to stay in the hospital overnight.

Patients rarely need to wear a brace after vertebroplasty, since bone cement immediately improves the strength and stiffness of the fractured vertebra.

Rehabilitation

What should I expect as I recover?

People often report greater ease with daily activities within a week after vertebroplasty. Pain also decreases rapidly, and most people require less pain medication within two weeks. Despite these quick improvements, most orthopedists consider that it takes about three months for the bone to heal after vertebroplasty.

Patients are encouraged to walk and do moderate activity as they recover. However, patients should avoid strenuous activity until the surgeon approves it.

When the fracture is from osteoporosis, the surgeon will suggest ways to prevent future problems. Patients may be prescribed medications and supplements (calcium and vitamin D) to maximize bone health. Lifestyle changes, such as quitting smoking and taking up exercising, may also be discussed.

Related Document: A Patient’s Guide to Osteoporosis

Patients who continue to have pain or who have lost muscle tone and strength may need the help of a physical therapist. These patients typically attend therapy sessions for four to six weeks.

The goal of therapy is to safely advance strength and function. The therapist may use treatments such as heat or ice, electrical stimulation, or massage to calm pain. Gentle exercise improves the strength of the spine and limbs. Patients learn how to move safely using healthy postures to reduce strain on the healing back. Exercises for the heart and lungs improve stamina and help with pain control.

As the therapy sessions come to an end, the therapist helps patients get back to the activities they enjoy. Ideally, patients are able to resume normal activities. They may be counseled on which activities are safe or how to change the way they go about their activities.

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

Avascular Necrosis of the Hip

A Patient’s Guide to Avascular Necrosis of the Hip

Introduction

Bones are living tissue, and like all living tissue they rely on blood vessels to bring blood to keep them alive. Most living tissues have blood vessels that come from many directions into the tissue. If one blood vessel is damaged it may not cause problems, since there may be a backup blood supply coming in from a different direction. But certain joints of the body have only a few blood vessels that bring in blood. One of these joints is the hip. This document will describe what happens when this blood supply is damaged and results in what is called avascular necrosis (AVN) of the hip. Another name for this condition is osteonecrosis (which means “bone death”).

This guide will help you understand

how AVN develops
how doctors diagnose the condition
what treatments are available

Anatomy

Where does AVN develop?

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thigh bone. The thigh bone itself is called the femur, and the ball on the end is the femoral head. Thick muscles of the buttock at the back and the thick muscles of the thigh in the front surround the hip.

The surface of the femoral head and the inside of the acetabulum are covered with articular cartilage. This material is about one-quarter of an inch thick in most large joints. Articular cartilage is a tough, slick material that allows the surfaces to slide against one another without damage.

All of the blood supply comes into the ball that forms the hip joint through the neck of the femur (the femoral neck), a thinner area of bone that connects the ball to the shaft. If this blood supply is damaged, there is no backup. Damage to the blood supply can cause death of the bone that makes up the ball portion of the femur. Once this occurs, the bone is no longer able to maintain itself.

Living bone is always changing. To maintain a bone’s strength, bone cells are constantly repairing the wear and tear that affects the bone tissue. If this process stops the bone can begin to weaken, just like rust can affect the metal structure of a bridge. Eventually, just like a rusty bridge, the bone structure begins to collapse.

When AVN occurs in the hip joint, the top of the femoral head (the ball portion) collapses and begins to flatten. This occurs because this is where most of the weight is concentrated. The flattening creates a situation where the ball no longer fits perfectly inside the socket. Like two pieces of a mismatched piece of machinery, the joint begins to wear itself out. This leads to osteoarthritis of the hip joint, and pain.

Related Document: A Patient’s Guide to Hip Anatomy

Causes

Why do I have this problem?

There are many causes of AVN. Anything that damages the blood supply to the hip can cause AVN.

Injury to the hip itself can damage the blood vessels. Fractures of the femoral neck (the area connecting the ball of the hip joint) can damage the blood vessels. A dislocation of the hip out of the socket can tear the blood vessels. It usually takes several months for AVN to show up, and it can even become a problem up to two years following this type of injury.

Some medications are known to cause AVN. Corticosteroids (cortisone) such as prednisone or methylprednisolone are the most common drugs known to lead to AVN. This is usually only a problem in patients who must take cortisone every day due to other diseases, such as advanced arthritis, or to prevent rejection of an organ transplant.

Sometimes there is no choice, and cortisone has to be prescribed to treat a condition, knowing full well that AVN could occur. AVN has not been proven to be caused by local injection with cortisone, such as one or two injections into joints to treat arthritis or bursitis. But some patients have developed AVN within the first month of taking these drugs orally (pills by mouth). Patients taking both corticosteroids and statin drugs (cholesterol-lowering medications) seem to have the greatest risk for developing femoral head osteonecrosis.

A clear link exists between AVN and lifestyle choices such as smoking and alcohol abuse . Smoking causes blood vessels to constrict or narrow thereby limiting the amount of blood flow to an area such as the hip with its already limited backup supply. Excessive alcohol intake somehow damages the blood vessels and leads to AVN. Deep sea divers and miners who work under great atmospheric pressures also are at risk for damage to the blood vessels. The pressure causes tiny bubbles to form in the blood stream which can block the blood vessels to the hip, damaging the blood supply.

Then there is a long list of other diseases and conditions that are associated with increased incidence of femoral head osteonecrosis. These are referred to as nontraumatic causes. For example, there is a link between osteonecrosis and more commonly known problems like leukemia, sickle cell diseases, and HIV infection and less well-known diseases such as Gaucher disease, hyperuricemia (a condition commonly called “gout”), and Caisson’s disease.

Symptoms

What does AVN feel like?

The first symptom of AVN is pain when weight is placed on the hip. The pain can be felt in the groin area, the buttock area, and down the front of the thigh. As the problem progresses, the symptoms include development of a limp when walking and stiffness in the hip joint. Eventually, the pain will also be present at rest and may even interfere with sleep.

Diagnosis

How do doctors identify the condition?

The diagnosis of AVN begins with a history and physical examination. Your doctor will want to know about your occupation, what other medical problems you have, and your medication use. You’ll be asked whether you drink alcohol. A physical examination will be done to determine how much stiffness you have in the hip and whether you have a limp. Once this is done, X-rays will most likely be ordered.

X-rays will usually show AVN if it has been present for long enough. In the very early stages, it may not show up on X-rays even though you are having pain. In the advanced stages, the hip joint will be very arthritic, and it may be hard to tell whether the main problem is AVN or advanced osteoarthritis of the hip. Either way, the treatment is basically the same.

If the X-rays fail to show AVN, you may have a bone scan done to determine if the pain in your hip is coming from early AVN. A bone scan involves injecting tracers into your blood stream. Several hours later, a large camera is used to take a picture of the bone around the hip joint. If there is no blood supply to the femoral head, the picture will show a blank spot where the femoral head should be outlined on the film.

The bone scan has pretty much been replaced with magnetic resonance imaging (MRI) today. The MRI scan is probably the most common test used to look for AVN of the hip. The MRI scanner uses magnetic waves instead of radiation. Multiple pictures of the hip bones are taken by the MRI scanner. The images look like slices of the bones. The MRI scan is very sensitive and can show even small areas of damage to the blood supply of the hip, even just hours after the damage has occurred.

Your surgeon will use these imaging studies in order to plan the best treatment approach for you. He or she will look at where the damage has occurred, the size of any lesions, whether or not there has been any collapse of the bone, and if any arthritic changes have developed. Based on these findings, the condition will be classified as either mild, moderate, or severe.

Treatment

What can be done for the condition?

Once AVN has occurred, the treatment choices are determined by how far along the problem is and your symptoms. Other factors that guide treatment decisions include your age, activity level, general health (and any specific health problems present), and life expectancy. For example, patients with other serious health problems or with a limited life expectancy might be treated with nonoperative care. While the symptoms may be reduced with pain medications and anti-inflammatory medications, no medical treatments will restore the blood supply to the femoral head and reverse the AVN.

Nonsurgical Treatment

If AVN is caught early, keeping weight off the sore-side foot when standing and walking may be helpful. Patients are shown how to use a walker or crutches to protect the hip. The idea is to permit healing and to prevent further damage to the hip. Patients may be shown stretches to avoid a loss of range of motion in the hip.

Anti-inflammatory medicine is often used to ease pain. Bisphosphonates are another group of medications that can be helpful. One particular bisphosphonate (Fosamax normally used for the treatment of osteoporosis) has been shown effective in reducing the risk of femoral head collapse in patients with avascular necrosis. In some cases, surgeons also prescribe biophysical treatment modalities such as electrical stimulation or shock wave therapy in an attempt to get the bone to heal. Sometimes these measures may help delay the need for surgery, but they rarely reverse the problem.

Surgery

If the femoral head has not begun to collapse, your surgeon may suggest an operation to try to increase the blood supply to the femoral head. Several operations have been designed to do this.

Decompressing the Femoral Head

The simplest operation is to drill one or several holes through the femoral neck and into the femoral head, trying to reach the area that lacks blood supply. The drill bores out a plug of bone within the femoral head. This operation is thought to do two things: (1) it creates a channel for new blood vessels to quickly form into the area that lacks blood supply, and (2) it relieves some of the pressure inside the bone of the femoral head. Relieving this pressure seems to help decrease the pain patients experience from AVN.

Decompression is often accompanied by the use of bone grafts with or without growth factors, a procedure designed to stimulate bone growth at the site of the defect. The donated bone comes from the patient (taken from the pelvic bone or lower leg). The bone is crushed up into tiny pieces and applied to the hole or defect caused by the necrotic process.

The decompression operation (with or without bone grafting) is done through a very small incision in the side of the thigh. The surgeon watches on a fluoroscope as a drill is used. A fluoroscope is a type of X-ray that shows the bones on a TV screen. The surgeon uses the fluoroscope to guide the drill where it needs to go. This operation is usually done as an outpatient procedure, and you will be able to go home with crutches the same day.

Fibular Bone Graft

A more complicated procedure to try to increase the blood supply to the femoral head is a vascularized fibular bone graft procedure. This is actually a tissue transplant. The graft is taken from the fibula (the thin bone that runs next to the shin bone). The graft is vascularized, meaning it has a blood supply of its own. Because it supports the femoral head, the graft is also referred to as a strut graft.

The surgeon removes a piece of the small bone in your lower leg (the fibula) along with the blood vessels to the bone. The surgeon then drills a hole through the side of the femur and into the femoral head. The surgeon attaches the blood vessels from the fibula to one of the blood vessels around the hip. This creates instant blood flow into the bone graft and into the head of the femur. This operation does two things: (1) it brings blood flow to the femoral head through the bone graft, and (2) the fibular bone graft is strong and keeps the femoral head from collapsing as the bone heals itself. This procedure is an inpatient procedure and will require you to stay in the hospital for several days.

This is a very complicated operation and is not commonly done. It is not always successful because the blood supply to the graft is fragile and may not form completely.

Rotational Osteotomy

In cases of small lesions involving less than one-third of the surface of the femoral head, rotational osteotomy has been very successful. The procedure involves making a cut through the bone and turning the head of the femur so that the necrotic bone is no longer bearing any weight.

Artificial Hip Replacement

When AVN is in the advanced stages, the condition is no different from osteoarthritis of the hip joint. Your surgeon will probably recommend replacing the hip with an artificial hip joint. For those patients with a limited bone defect that only affects the femoral head and does not extend into the hip socket, a resurfacing procedure might be considered. Hip resurfacing arthroplasty is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement.

Rehabilitation

What should I expect following treatment?

Nonsurgical Rehabilitation

You may work with a physical therapist who will show you ways to safely move and stretch your hip. The goal is to keep your hip mobile and to avoid losing range of motion. Your therapist will also instruct you to use a walker or crutches. Keeping weight off your hip while you are standing or walking may help the bone to heal while protecting the femur from further damage.

After Surgery

After a simple drilling operation, you will probably use crutches for six weeks or so. The drill holes weaken the bone around the hip, making it possible to fracture the hip. Using crutches allows the bone to heal safely and reduce the risk that you may fracture your hip. Patients who have had bone and blood vessels grafted are required to limit how much weight they place on the hip for up to six months.

When you are safe in putting full weight through the leg, your doctor may have you work with a physical therapist to help regain hip range of motion and strength.

Patients who require hip resurfacing or artificial hip joint replacement follow a structured program of physical therapy beginning shortly after surgery.

Posterior Lumbar Fusion

A Patient’s Guide to Posterior Lumbar Fusion

Introduction

A posterior lumbar fusion is the most common type of fusion surgery for the low back. A fusion is a surgical procedure that joins two or more bones (in this case vertebrae) together into one solid bone. The procedure is called a posterior fusion because the surgeon works on the back, or posterior, of the spine.

Posterior fusion procedures in the lumbar spine are used to treat spine instability, severe degenerative disc disease, and fractures in the lumbar spine.

Other procedures are usually done along with the spinal fusion to take the pressure off nearby nerves. They may include removing bone spurs and injured portions of one or more discs in the low back. Most surgeons also apply metal screws and rods, called instrumentation, to hold the bones securely while they fuse.

This guide will help you understand

what surgeons hope to achieve
what happens during the procedure
what rehabilitation is like after surgery

Anatomy

What parts of the back and spine are involved?

Surgeons perform this procedure through an incision in the low back. The incision reaches to the spinous processes, the bony projections off the back of the vertebrae. The surgeon must move aside the muscles along the spine, called the paraspinal muscles. The fusion itself involves the lamina bone, the protective roof over the back surface of the spinal cord.

In some cases, the surgeon may enlarge the neural foramina the tunnels where the nerve roots leave the spinal cord.

Rationale

What do surgeons hope to achieve?

The main goal of the spinal fusion (also known as an arthrodesis) is to stop movement of one or more vertebrae. Keeping the fused section from moving helps stop mechanical pain. Mechanical pain occurs when damaged discs and joints that connect the vertebrae become inflamed from excessive motion between the vertebrae. This type of pain is commonly felt in the low back and may radiate into the buttocks and upper thighs.

The spinal nerves are also affected by too much vertebral motion. They begin to rub

where they pass through the neural foramina and become swollen and irritated. Also, the neural foramina narrow when a vertebra slides too far forward or backward over the vertebra below. This immediately pinches the nerves where they pass through the neural foramina. Nerve swelling, irritation, and pinching produce neurogenic pain. This type of pain often radiates down one or both legs below the knee. Fusion stops this harm to the nerves.

By fusing the vertebrae together, surgeons hope to slow down the process of degeneration at the fused segments and prevent future problems.

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.

During surgery the patient usually kneels face down on a special operating table. The special table supports the patient so the abdomen is relaxed and free of pressure. This position lessens blood loss during surgery. It also gives the surgeon more room to work.

An incision is made down the middle of the low back. The tissues just under the skin are separated. Then the small muscles along the sides of the low back are lifted off the vertebrae, exposing the back of the spinal column. Next, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct vertebrae.

The surgeon first removes any pressure from nearby nerves. This may involve removing part or all of the lamina bone. (The lamina forms the back portion of the bony ring covering the spinal canal.) 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 nerve roots are checked to see if they move freely in the spinal canal and as they leave the spine through the small holes between the vertebrae, the neural foramina. If not, the surgeon may cut a larger opening in the neural foramina. This procedure is called foraminotomy.

To prepare the area to be fused, the surgeon shaves a layer of bone off the back surfaces of the spinal column. The cut bone bleeds. The surgeon makes a second incision at the hip. Small strips of bone are removed from the top rim of the pelvis. This is called a bone graft. The surgeon lays the bone strips over the back of the spinal column. When the bone graft contacts the bleeding area, the body heals (or fuses) the bones together just as it would a fractured bone.

During posterior spinal fusion, the surgeon also fixes the bones in place using a combination of metal screws, rods, and plates. This instrumentation (or hardware, as it is sometimes called) holds the vertebrae to be fused together and prevents them from moving. The less motion there is between two bones trying to heal, the higher the chance they will successfully fuse. The use of instrumentation has increased the success rate of spinal fusions considerably.

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 you in a rigid brace to support your spine while it heals.

Complications

What might go wrong?

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

problems with anesthesia
thrombophlebitis
infection
nerve damage
problems with the graft or hardware
muscle disruption
nonunion
ongoing pain

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

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

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

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 these structures can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Problems with the Graft or Hardware

Posterior fusion surgery requires bone to be grafted onto the spinal column. The graft is commonly taken from the top rim of the pelvis. There is a risk of pain, infection, or weakness in the area where the graft is taken.

Sometimes the strips of bone graft don’t take and end up dissolving. A second surgery may be needed to remove the strips and apply more graft material. The doctor may need to apply additional metal hardware to hold the new grafts firmly in place.

When instrumentation is used, the screws, rods, or plates can also cause problems. They can loosen and irritate the nearby soft tissues. In rare cases, they may actually break. If your hardware loosens or breaks, the surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem.

Muscle Disruption

During the operation, the surgeon lifts off the small muscles that run along the back of the spinal column. Some of the nerves going to the muscles are cut. Lifting the muscles away from the bone impairs the blood supply to the muscles. Disruption of the nerve and blood supply can cause the muscles to fatigue easily, especially during a long work day and with heavy or repeated lifting. Exercises designed by a physical therapist boost strength and endurance in the nearby muscles, reducing symptoms from this problem.

Nonunion

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 that 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 usually adds more bone graft. Metal plates and screws may also be added to rigidly secure the bones so they will fuse together.

Ongoing Pain

Posterior lumbar fusion is a complex surgery. Not all patients get complete pain relief with this procedure. Successful fusion occurs in more than 80 percent of surgeries. But a solid fusion does not guarantee freedom from pain or the ability to return to normal activity. If you have pain that continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients may be 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. The drain tube is removed from the wound within 24 to 48 hours.

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 help 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 should avoid bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient physical therapy usually starts a minimum of six weeks after surgery.

Patients gradually do more activities and exercise with the goal of getting back to a normal and productive life.

Rehabilitation

What should I expect as I recover?

Rehabilitation after posterior lumbar fusion 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. You should expect full recovery to take up to eight months. Therapy can usually progress faster in patients who had an instrumented fusion.

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 after posterior lumbar fusion. Swimming and use of a stair-climbing machine are helpful in the later phases of treatment. Therapists also teach patients 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, 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. Training includes positions you use when sitting, lying, standing, and walking. You’ll also work on safe body mechanics for 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 how to avoid future problems.

Trigger Finger and Trigger Thumb

A Patient’s Guide to Trigger Finger and Trigger Thumb

Introduction

Trigger finger and trigger thumb are conditions affecting the movement of the tendons as they bend the fingers or thumb toward the palm of the hand. This movement is called flexion.

This guide will help you understand

how trigger finger and trigger thumb develop
how doctors diagnose the condition
what can be done for the problem

Anatomy

Where does the condition develop?

The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

Why do I have this problem?

Triggering is usually the result of a thickening in the tendon that forms a nodule, or knob. The pulley ligament may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule. Rheumatoid arthritis, partial tendon lacerations, repeated trauma from pistol-gripped power tools, or long hours grasping a steering wheel can cause triggering. Infection or damage to the synovium causes a rounded swelling (nodule) to form in the tendon.

Triggering can also be caused by a congenital defect that forms a nodule in the tendon. The condition is not usually noticeable until infants begin to use their hands.

Symptoms

What does a trigger finger or thumb feel like?

The symptoms of trigger finger or thumb include pain and a funny clicking sensation when the finger or thumb is bent. Pain usually occurs when the finger or thumb is bent and straightened. Tenderness usually occurs over the area of the nodule, at the bottom of the finger or thumb. The clicking sensation occurs when the nodule moves through the tunnel formed by the pulley ligaments. With the finger straight, the nodule is at the far edge of the surrounding ligament.

When the finger is flexed, the nodule passes under the ligament and causes the clicking sensation. If the nodule becomes too large it may pass under the ligament, but it gets stuck at the near edge. The nodule cannot move back through the tunnel, and the finger is locked in the flexed trigger position.

Diagnosis

How do doctors identify the condition?

The diagnosis of trigger finger and thumb is usually quite obvious on physical examination. Usually a palpable click can be felt as the nodule snaps under the first finger pulley. If the condition is allowed to progress, the nodule may swell to the point where it gets caught and the finger is locked in a bent, or flexed, position. No special tests or X-rays are required.

Treatment

What can be done for the condition?

Nonsurgical Treatment

Treatments provided by a physical or occupational therapist may be effective when triggering has been present for less than four months. Therapists often build a splint to hold and rest the inflamed area. Special exercises are used to encourage normal gliding of the tendon. You might be shown ways to change your activities to prevent triggering and to give the inflamed area a chance to heal. Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections.

A cortisone injection into the tendon sheath may be needed to decrease the inflammation and shrink the nodule. This can help relieve the triggering, but the results may be short lived. A splint may be used after the injection to rest the tendon and help decrease the inflammation and shrink the nodule.

Surgery

The usual solution for treating a trigger digit is surgery to open the pulley that is obstructing the nodule and keeping the tendon from sliding smoothly. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

The surgery can be done using a general anesthetic (one that puts you to sleep) or a regional anesthetic. 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. An incision will be made in the skin. There are several types of incisions that can be made, but most are made along the natural creases and lines in the hand. This will help make the scar less noticeable once the hand is healed.

The skin and fascia are separated so the doctor can see the tendon pulley. Special care is taken not to damage the nearby nerves and blood vessels.

Next, your surgeon carefully divides the tendon pulley. Once the tendon pulley has been separated, the skin is sewn together with fine stitches.

View animation of pulley divided

Rehabilitation

What should I expect following treatment?

Nonsurgical Rehabilitation

When triggering has been present for more than four months, nonsurgical treatment is usually short-lived. You may get some relief of symptoms with a cortisone injection. If you wear a splint, the nodule may shrink temporarily, but patients often end up needing surgery for this problem.

After Surgery

You’ll wear a bandage over the area after surgery until the stitches are removed. You will probably have a fairly large padded bandage on your hand when you return from surgery. This is to provide gentle compression and reduce the bleeding and swelling that occurs immediately after surgery. This can be removed fairly quickly, and usually only a bandage is required after the first 24 to 48 hours. You’ll begin gentle range-of-motion exercises a few days after surgery.

Most patients won’t need to participate in a formal rehabilitation program unless the finger or thumb was locked for a while before surgery. In these cases, the finger or thumb may not straighten out right away after the surgery. A physical or occupational therapist may apply a special brace to get the finger or thumb to straighten. The therapist may also apply heat treatments, soft-tissue massage, and hands-on stretching to help with the range of motion.

Some of the exercises you’ll begin to do are to help strengthen and stabilize the muscles and joints in the hand. Other exercises are used to improve fine motor control and dexterity. You’ll be given tips on ways to do your activities while avoiding extra strain on the healing tendon. You may need to return to therapy two to three sessions each week for up to six weeks.

Boutonniere Deformity of the Finger

A Patient’s Guide to Boutonniere Deformity of the Finger

Introduction

The tendons that allow each finger to straighten, the extensor tendons, at first appear to be relatively simple. But as the extensor tendon runs into the finger, it becomes a complex and elegantly balanced mechanism that allows very fine control of the motion of each joint of the finger. When this mechanism is damaged in certain areas, this balance can be destroyed. The result is a finger that doesn’t work properly. Over time, the imbalance can lead to contractures (tightening of the tendons) and other changes that result in a permanently crooked finger. The boutonniere deformity is one such problem that affects the extensor tendons of the finger.

This guide will help you understand

what parts of the finger are involved
what causes the boutonniere deformity
how the problem is treated
what to expect from treatment

Anatomy

What parts of the finger are involved?

The extensor tendons begin as muscles that arise from the backside of the forearm bones. These muscles travel towards the hand, where they eventually connect to the extensor tendons before crossing over the back of the wrist joint. As they travel into the fingers, the extensor tendons become the extensor hood. The extensor hood flattens out to cover the top of the finger and sends out branches on each side that connect to the bones in the middle and end of the finger. When the extensor muscle contracts, it shortens and pulls on these attachments to straighten the finger.

Small ligaments also connect the extensor hood with other tendons that travel into the finger to bend the finger. These connections help balance the motion of the finger so that all the joints of the finger work together, giving a smooth bending and straightening action. Problems arise when these ligaments become too tight or too loose.

The fingers are actually made up of three bones, called phalanges. The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The joint near the end of the finger is called the distal IP joint (DIP joint). (Distal means further away.) The proximal IP joint (PIP joint), is the middle joint between the main knuckle and the DIP joint. (Proximal means closer in.) The IP joints of the fingers work like hinge joints when you bend and straighten your hand.

A boutonniere deformity occurs when disease or injury causes the PIP joint to become flexed (bent) and the DIP joint is pulled up into too much extension (hyperextension).

Related Document: A Patient’s Guide to Hand Anatomy

Causes

How does this condition occur?

The boutonniere deformity happens when the extensor tendon attachment to the middle phalanx is injured. This area is called the central slip. This tendon attachment may be injured in many ways. The central slip may simply be damaged when a cut occurs over the back of the middle finger joint (PIP joint). More commonly the central slip tears or pops off its attachment on the bone when the finger is jammed from the end, forcing the PIP joint to bend. When a small amount of bone is pulled off with the tendon, doctors call it an avulsion fracture. The central slip can also be torn when the PIP joint is dislocated and the middle phalanx

dislocates towards the palm.

Other conditions that affect the central slip can cause the boutonniere deformity. For example, prolonged inflammation in the PIP joint from rheumatoid arthritis stretches and eventually ruptures the central slip. A severe burn on the hand can damage the central slip. Another problem affecting the hand, called Dupuytren’s contracture, can weaken the central slip and produce the boutonniere deformity.

The boutonniere deformity may not occur right away. It is the imbalance in the extensor hood that results from the torn tendon that eventually causes the deformity. Because the middle phalanx no longer is pulled by the central slip, the flexor tendon on the other side begins to bend the PIP joint without resistance. The lateral bands begin to slide down along the side of the finger where they continue to straighten the DIP joint. Eventually the finger becomes stiff in this position.

Symptoms

What do boutonniere deformities look and feel like?

Initially, the finger is painful and swollen around the PIP joint. The PIP joint may not straighten out completely under its own power. The finger can usually be straightened easily with help from the other hand. Eventually, the imbalance leads to the typical shape of the finger with a boutonniere deformity.

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. No other tests are required normally.

Treatment

What can be done for a boutonniere deformity of the finger?

Treatment for boutonniere deformity depends on whether the injury to the central slip is recognized immediately or if the deformity has been present for a long time. When the injury is the result of a laceration of the finger, the surgeon will usually repair the tendon as well as suture the skin.

Nonsurgical Treatment

If the injury to the central slip results from a simple avulsion (tearing) of the tendon from the bone, splinting of the PIP joint for six weeks should allow the bone to heal and prevent the boutonniere deformity from occurring. The DIP joint is free to move throughout this period and can be exercised to prevent stiffness in the DIP joint.

While a simple homemade splint will work, there are many splints that have been designed to make it easier to wear at all times. There are also special splints that have been designed that are similar to springs. These splints can be used to gently stretch out a contracture of the PIP joint over several weeks. The spring applies gentle pressure all the time, and the PIP joint slowly straightens.

A splint may also be needed to keep the DIP joint from hyperextending. Newer styles are shaped like jewelry rings and are available in stainless steel, sterling silver, or gold.

Splinting and a rigorous exercise program may even work when the condition has been present for some time. Many hand surgeons will try six weeks of splinting with the spring-type splint and exercise to see if the deformity lessens to a tolerable limit before considering surgery. This is desirable before surgery to stretch out a PIP contracture before repairing or reconstructing the extensor hood.

Surgery

Surgery is required in some cases of boutonniere deformity. Best results occur when the PIP joint is limber, rather than stuck in a bent position. If the PIP joint is stuck in a bent position, surgeons usually wait before doing surgery to see if splinting will help stretch and straighten the PIP joint.

Joint Fixation

When the deformity is the result of a dislocation of the PIP joint, surgery may be required to repair the damaged structures and prevent the later development of a boutonniere deformity. A pin is usually placed through the PIP joint to fix the joint in place for up to three weeks. Patients wear a splint to protect the joint for another three weeks after surgery.

Soft Tissue Repair

In cases where the balance cannot be restored to a tolerable limit with splinting or by simply pinning the PIP joint, surgery may be required to reconstruct and rebalance the extensor hood. There are numerous types of operations that have been designed to try and rebalance the extensor hood. None is completely successful.

Surgery to repair the soft tissues that are contributing to a boutonniere deformity carries a relatively high risk of failure to achieve completely normal functioning of the extensor mechanism of the finger. All of the repair and reconstruction procedures are dependant on a well designed and rigorous exercise program following the surgery. A physical therapist or occupational therapist will work closely with you during your recovery.

Fusion

If past treatments, including surgery, do not stop inflammation or deformity in the joint, finger joint fusion may be recommended. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from moving. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.

Rehabilitation

What will my recovery be like?

Nonsurgical Rehabilitation

If nonsurgical treatment is successful, you may see improvement in eight to 12 weeks. After wearing a finger splint for up to eight weeks, doctors usually have you continue wearing the splint at night for at least another month. It is important during this time that the joints on either side of the splint be moved. This may require the help of a physical or occupational therapist.

After Surgery

You’ll wear a splint or brace after surgery. A protective finger splint holds the PIP joint straight and is used for at least three weeks after surgery. Surgeons may apply a dynamic splint to help gradually straighten the PIP joint. Physical or occupational therapy treatments usually start three to six weeks after surgery.

You will likely need to attend therapy sessions for three to four months, and you should expect full recovery to take up to six 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 started eight to 10 weeks after surgery. 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 your fine motor abilities with your hand and finger. 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.

Artificial Joint Replacement of the Finger

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

Introduction

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

This guide will help you understand

what parts make up the finger joint
how the operation is performed
what to expect before and after surgery

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 to the finger bone, or phalanx. 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 each finger joint together. These ligaments join to form the joint capsule of the finger 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 material 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 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 freedom of movement and less pain.

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 your recovery from anesthesia after surgery. In general, finger joint surgery can be done on an outpatient basis, meaning you can leave the hospital the same day.

Surgical Procedure

What happens during the operation?

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

The Artificial Finger Joint

Surgeons use silicon plastic implants to replace the original joint surfaces. The artificial joint functions the same way a hinge on a door does.

The Operation

The procedure takes about two hours to complete. 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 is made across the back of the finger joints that are to be replaced. The soft tissues are spread apart with a retractor. Special care is taken not to damage the nearby nerve that passes by the joint. The joint is exposed. The ends of the bones that form the finger 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 finger joint.

The surgeon then sizes the stem of the prosthesis to ensure a snug fit into the hollow bone marrow space of the bone. The prosthesis is inserted into the ends of both finger bones.

When the new joint is in place, the surgeon wraps the joint with a strip of nearby ligament to form a tight sac. This gives the new implant some added protection and stability.

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

View animation of removing the joint surfaces

View animation of forming the canal in the bones of the finger

View animation of inserting the new finger joint

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 finger joint replacement are

anesthesia
infection
nerve damage
prosthesis failure

Anesthesia

Infection

Any operation carries a small risk of infection. Replacing the finger 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. The surgeon will most likely fuse the joint rather than attempt another artificial joint replacement.

Nerve Damage

All of the nerves and blood vessels that go to the finger travel across, or 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 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 of the problems 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 and replace the prosthesis.

After Surgery

What happens immediately after surgery?

After surgery, your finger will be bandaged with a well-padded dressing and a splint for support. The splint will keep the finger in a straightened position during healing. Some patients are placed in an arm-length cast with the finger in a straightened position for about three weeks after the prosthesis is implanted. 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 have.

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. Recovery takes up to three months after a prosthesis is implanted.

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 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 new 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.

The 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 you are well underway, 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.

Ulnar Collateral Ligament Injuries of the Thumb

A Patient’s Guide to Ulnar Collateral Ligament Injuries of the Thumb

Introduction

Injury to the ulnar collateral ligament of the thumb is fairly common. This strong band of tissue is attached to the middle joint of the thumb, the joint next to the web space of the thumb. This condition is sometimes called gamekeeper’s thumb because Scottish gamekeepers commonly injured their thumbs as a result of their job.

This guide will help you understand

how the ulnar collateral ligament is injured
how doctors diagnose the condition
what treatments are available

Anatomy

Where does the condition develop?

The joint that is affected is called the metacarpophalangeal joint, or MCP joint. Any hard force on the thumb that pulls the thumb away from the hand (called a valgus force) can cause damage to the ulnar collateral ligaments. When the thumb is straight, the collateral ligaments are tight and stabilize the joint against valgus force. If the force is too strong, the ligaments can tear. They may even tear completely. A complete tear is also called a rupture.

When the collateral ligaments actually tear, the MCP joint becomes very unstable. It is especially unstable when the thumb is bent back. If one of the ligaments pulls away from the bone and folds backwards, it won’t be able to heal in the correct position. When this happens, surgery is needed to fix the ligament.

Sometimes the ligament itself will not tear but instead pulls a small piece of bone off the base of the thumb where it attaches. This is called an avulsion fracture. This can also lead to an unstable thumb joint if the fracture does not heal correctly.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

Why do I have this problem?

In Scottish gamekeepers, ligament damage in the MCP joint happened because the ligament stretched out after the gamekeepers repeated the same action over and over. Today, most cases of ligament damage in the MCP joint are caused from sports injuries. Now doctors tend to refer to the condition as skier’s thumb, since it happens so often in downhill ski accidents.

Any extreme force that pulls the thumb away from the palm of the hand can damage the ligaments. The most common way for this to happen is to fall on your hand with your thumb stretched out. When a skier falls down while holding a ski pole, the thumb may get bent out and back, leading to an injury in the ulnar collateral ligament of the thumb.

Symptoms

What does an injured ulnar collateral ligament of the thumb feel like?

When the ulnar collateral ligament of the thumb is injured, the MCP joint becomes painful and swollen, and the thumb feels weak when you pinch or grasp. You may see bruise-like discolorations on the skin around the joint. The loose end of the torn ligament may form a bump that can be felt along the edge of the thumb near the palm of the hand. A torn ligament makes it difficult to hold or squeeze things between your thumb and index finger.

Diagnosis

How do doctors identify the problem?

Your doctor will ask you to describe your injury and symptoms. Your doctor will also do a complete physical exam of both thumbs and hands.

You will need to have X-rays or other imaging tests.
X-rays are required to see if there is an associated avulsion fracture, since this may change the recommended treatment. X-rays cannot show all types of damage to ligaments. For example, an X-ray of your thumb can look perfectly normal, even if the ulnar collateral ligament is partially or completely torn.

To check the ligament, your doctor will perform a valgus stress test. This involves pushing your thumb backwards and out in different positions. Valgus tests can be painful, so you may be given a local anesthetic before being tested.

The stress test is done to determine how stable your joint is. If your joint holds steady, the ligaments may only have been strained or partially torn. If your joint is loose and unstable, your ligaments have probably completely ruptured. Your doctor may do the stress test at the same time your thumb is being X-rayed. The X-ray image shows how unstable the joint is when it is stressed.

Treatment

What can be done for the condition?

The MCP joint needs to be stable for the thumb to be strong enough to grasp objects. The goal of treatment is to help the ligaments heal so that the thumb can be restored to full function.

Nonsurgical Treatment

If the thumb ligaments are only partially torn, they usually heal without surgery. Your thumb will be immobilized for four to six weeks in a special cast, called a thumb spica cast. After that, you will begin to do exercises to regain your range of motion and to strengthen your grip.

Getting treatment soon after an injury to the ulnar collateral ligament of the thumb may improve your ability to regain strength and range of motion.

Surgery

If the ligaments are completely torn, you will most likely have surgery to repair them. A torn ligament cannot fully heal itself. Surgery for the thumb collateral ligaments is usually done as an outpatient procedure, meaning you will probably go home the same day as the surgery.

Suture Repair

In the surgery, your surgeon will make a small V- or S-shaped cut over the back of the MCP joint of the thumb. This helps isolate and protect the nerve branches running up your thumb. Your surgeon will then cut through a sheet of tissue called the adductor aponeurosis. This helps expose the MCP joint and the ligaments. The area around the injury is examined for any soft tissue damage. Your surgeon then repairs the ligaments with stitches that anchor them back to the bone.

Patients usually have good results when suture repair is done within four weeks after the injury. After surgery, pain and stiffness are usually minimal, and thumb strength will normally return.

In some patients, the MCP joint continues to be unstable. The joint feels painful when pinching or grasping and is generally weak. Most of the time, chronic instability tends to happen when the patient doesn’t get treatment or when a doctor wasn’t aware of a ruptured tendon. However, even when skilled surgery is performed, the thumb sometimes ends up being chronically unstable.

Fusion Surgery

A thumb that is loose and unstable will eventually develop arthritis. Some surgeons have had success by grafting in new tissue to reconstruct the ligaments. When the ligament has been unstable for a long time, surgery may be needed to keep the MCP joint from moving. This type of surgery is called fusion. A fusion procedure is often the best choice when a patient’s job involves heavy labor that would continue to put too much strain on his or her unstable thumb joint.

When the joint is fused together, a person’s ability to do day-to-day tasks isn’t affected that much. This is because some people have a very small range of motion in the MCP joint anyway. Fusion keeps the joint from moving, but it also protects it from eventually becoming arthritic and painful.

Surgery does carry some risks. In rare cases, some of the small nerves to the skin on the back of the thumb may be damaged during surgery. This may cause numbness on the back of the thumb. When this happens, it usually gets better on its own. Sometimes the MCP and other thumb joints become stiff. Physical or occupational therapy treatments are helpful for easing the stiffness and helping you regain thumb movement.

Rehabilitation

What should I expect following treatment?

Nonsurgical Rehabilitation

Patients who are treated nonsurgically with a thumb spica cast start an exercise program when the cast is removed, usually after four to six weeks. Motion and strength usually improve within another two to four weeks, allowing people to get back to normal activity.

After Surgery

You will be placed in a thumb spica cast after surgery for four weeks. Some surgeons will take the spica cast off at four weeks and then place your thumb in an immobilizing splint for another two weeks. Some patients work with a physical or occupational therapist to help regain range of motion and strength in the thumb. Most patients are able to return to normal activity three months after their surgery.

Guyon’s Canal Syndrome

A Patient’s Guide to Guyon’s Canal Syndrome

Introduction

Guyon’s canal syndrome is an entrapment of the ulnar nerve as it passes through a tunnel in the wrist called Guyon’s canal. This problem is similar to carpal tunnel syndrome but involves a completely different nerve. Sometimes both conditions can cause a problem in the same hand.

This guide will help you understand

how Guyon’s canal syndrome develops
how doctors diagnose the condition
what can be done to treat the problem

Anatomy

Where is the ulnar nerve, and what does it do?

The ulnar nerve actually starts at the side of the neck, where the individual nerve roots exit the spine through small openings between the vertebrae. The nerve roots then join together to form three main nerves that travel down the arm to the hand, one of which is the ulnar nerve.

After leaving the side of the neck, the ulnar nerve travels through the armpit and down the arm to the hand and fingers. As it crosses the wrist, the ulnar nerve and ulnar artery run through the tunnel known as Guyon’s canal. This tunnel is formed by two bones (the pisiform and hamate) and the ligament that connects them. After passing through the canal, the ulnar nerve branches out to supply feeling to the little finger and half the ring finger. Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm.

The hamate bone forms one side of Guyon’s canal. This bone has a small hook-shaped spur that sticks out to provide an attachment for several wrist ligaments. Known as the hook of hamate, this small bone can break off and press against the ulnar nerve within Guyon’s canal.

Related Document: A Patient’s Guide to Hand Anatomy

Causes

Why do I have this problem?

Guyon’s canal syndrome has several causes. Overuse of the wrist from heavy gripping, twisting, and repeated wrist and hand motions can cause symptoms. Working with the hand bent down and outward can squeeze the nerve inside Guyon’s canal.

Constant pressure on the palm of the hand can produce symptoms. This is common in cyclists and weight lifters from the pressure of gripping. It can also happen after running a jackhammer or when using crutches.

Pressure or irritation of the ulnar nerve can cause symptoms of Guyon’s canal syndrome. A traumatic wrist injury may cause swelling and extra pressure on the ulnar nerve within the canal. Arthritis in the wrist bones and joints may eventually irritate and compress the ulnar nerve. In rare cases, the ulnar artery that travels right beside the nerve may be damaged and form a blood clot. The symptoms caused by the clot mimic Guyon’s canal syndrome. The lack of blood supply to the ulnar nerve is believed to cause the symptoms.

As mentioned earlier, a fractured hamate bone in the wrist can pinch the nerve inside Guyon’s canal. This bone is sometimes fractured when golfers club the ground instead of the golf ball and when baseball players are batting.

Symptoms

What does Guyon’s canal syndrome feel like?

Symptoms usually begin with a feeling of pins and needles in the ring and little fingers, which is often noticed in the early morning when first awakening. This may progress to a burning pain in the wrist and hand followed by decreased sensation in the ring and little fingers. The hand may become clumsy when the muscles controlled by the ulnar nerve become weak. Weakness can affect the small muscles in the palm of the hand and the muscle that pulls the thumb into the palm. Gradual weakness in these muscles makes it hard to spread your fingers and pinch with your thumb.

This syndrome is much less common than carpal tunnel syndrome (CTS), yet both conditions can occur at the same time. The numbness caused by these two syndromes affects the hand in different locations. When the median nerve is compressed in CTS, pain and numbness spread into the thumb, index finger, middle finger, and half of the ring finger. Compression of the ulnar nerve in Guyon’s canal syndrome usually causes numbness in the pinky and half of the ring finger.

Diagnosis

How do doctors identify the problem?

The diagnosis of Guyon’s canal syndrome begins with a careful history and physical examination by your doctor. Compression can occur at several areas along the ulnar nerve, and your doctor will test to find exactly where the nerve is being affected. If it is unclear on the physical examination where the nerve is being squeezed, electrical studies may be ordered to try to find the area of compression.

Nerve conduction velocity (NCV) is a test that measures how fast nerve impulses travel along the nerve. Your doctor might want this test to be done to help pinpoint your problem. Special tests may be required to study the nerve.

The NCV is sometimes combined with an electromyogram (EMG). The EMG is done by testing the muscles of the forearm that are controlled by the ulnar nerve to determine if they are working properly. If the test shows a problem with the muscle, the nerve that goes to the muscle might not be working correctly. This is similar to checking whether the wiring in a lamp is working. If the light still doesn’t work after you’ve put in a new bulb, you can begin to tell if there’s a problem in the wiring.

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

Treatment

What can be done for the condition?

Nonsurgical Treatment

Activities that might be causing your symptoms need to be changed or stopped if at all possible. Avoid repetitive hand motions, heavy grasping, resting your palm against hard surfaces, and positioning or working with your wrist bent down and out.

A wrist brace will sometimes decrease the symptoms in the early stages of Guyon’s canal syndrome. A brace keeps the wrist in a resting position (neither bent back nor bent down too far). It 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 within the canal.

Anti-inflammatory medications may also help control the symptoms of Guyon’s canal syndrome. These medications include common over-the-counter medications such as ibuprofen and aspirin.

You may work with a physical or occupational therapist. The main focus of treatment is to reduce or eliminate the cause of pressure on the ulnar nerve. 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.

Surgery

If all attempts to control your symptoms fail, surgery may be suggested to reduce the pressure on the ulnar nerve.

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.

A small incision is made in the palm of the hand over the spot where the nerve goes through the canal.

The incision makes it possible for the surgeon to see the ligament that crosses over the top of the ulnar nerve. This ligament forms the roof over the top of Guyon’s canal. Once in view, this ligament is released using a scalpel or scissors.

Care is taken to make sure that the ulnar nerve is out of the way and protected. By cutting the ligament, pressure is taken off the ulnar nerve.

Upon releasing the ligament, the surgeon sutures just the skin together and leaves the loose ends of the ligament separated. The loose ends are left apart to keep pressure off the ulnar nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

Rehabilitation

What can I expect following 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 pressure on the palm of the hand.

After Surgery

Your hand will be wrapped in a bulky dressing following surgery. Take time during the day to support your arm with your hand elevated above the level of your heart. You are encouraged to move your fingers and thumb occasionally during the day. Keep the dressing on your hand until you return to the surgeon. Avoid getting the stitches wet. Your stitches will be removed 10 to 14 days after surgery.

Pain and numbness generally begin to improve after surgery, but you may have tenderness in the area of the incision for several months.

You will probably need to attend occupational or physical therapy sessions for six to eight weeks, and you should expect full recovery to take several months. 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.

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 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.

Spinal Compression Fractures

A Patient’s Guide to Spinal Compression Fractures

Introduction

Compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height.

Compression fractures are commonly the result of osteoporosis. About 700,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

An injury to the spine, such as from a hard fall on the buttocks or blow to the head, can cause a spinal compression fracture. Compression fractures may also occur if cancer from other parts of the body spreads to the spine. Cancer weakens the spine bones and makes them prone to fractures.

This guide will help you understand

how compression fractures happen
how doctors diagnose the problem
what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made 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 main section of each vertebra is a large, round structure called a vertebral body.

Compression fractures cause this section of bone to collapse. When the fracture is due to osteoporosis, it usually occurs in the lower part of the thoracic spine, near the bottom of the rib cage.

A bony ring attaches to the back of each vertebral body. When the vertebrae are stacked on one another, the bony rings form a hollow tube. This tube, or canal, surrounds the spinal cord. The spinal cord is like a long wire made of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Severe compression fractures from forceful impact on the spine, as can happen in a car accident, can cause fragments of the vertebral body to push into the spinal canal and press against the spinal cord. This can cause damage to the spinal cord that can result in partial or complete paralysis below the waist. It is rare for a typical compression fracture from osteoporosis to cause damage to the spinal cord.

Causes

Why do I have this problem?

Strong, healthy bones are able to withstand the forces and strains of normal activity. Compression fractures in the spine happen when either the forces are too great or the bones of the spine aren’t strong enough. The vertebral body cracks under pressure. Fractures from forceful impact on the spine tend to crack the back (posterior) part of the vertebral body. Fractures from osteoporosis usually occur in the front (anterior) part of the vertebral body.

Osteoporosis is a disease that weakens bone. Sometimes the bones in the spine weaken to the point that even mild forces can lead to a compression fracture. A simple action like reaching down to pull on a pair of socks can cause a weakened vertebra to fracture. The front of the vertebra (the part closest to the front of the body) crumbles, causing the round vertebral body to become wedge-shaped. This angles the spine forward, producing a hunch-backed appearance, called kyphosis.

Related Document: A Patient’s Guide to Osteoporosis

Diseases or conditions that affect the parathyroid gland can also weaken bones. Four pea-sized parathyroid glands are located just behind the thyroid gland in the throat. They produce a substance called parathyroid hormone (PTH), which normally regulates the amount of calcium in the blood stream. An overactive parathyroid gland releases too much PTH, causing the body to leach calcium from bones, even when there is more than enough calcium circulating in the blood stream. This disorder is called hyperparathyroidism It occurs when a tumor, called an adenoma, forms in one of the parathyroid glands. Cancers that affect the kidney, skin, or parathyroid gland may also cause the parathyroid gland to malfunction. If the problem isn’t fixed, bones continue to lose calcium and eventually weaken. Weakening in the spine bones makes the vertebrae more prone to crack in front, as is typical with osteoporosis.

Cancers that form in other parts of the body have a tendency to spread, or metastasize, to the spine. When this happens, the cancer weakens the spine bones, making them susceptible to compression fractures. Doctors may suspect unrecognized cancer if a patient has a compression fracture without any particular cause or reason.

Spine trauma can produce mild or severe compression fractures. Compression fractures from trauma usually involve high forces that impact the spine when it is bent forward. This is typically what happens when a person falls onto the buttocks or strikes his head on the windshield in a car accident. Again, these traumatic fractures usually affect the back part of the vertebral body.

Symptoms

What does the condition feel like?

Compression fractures caused by thin, weakened bones may cause little or no pain at first. Sometimes pain is centered over the area where the fracture has occurred. The collapsed vertebra gives the spine a hunched appearance, and the loss of vertebral height shortens the muscles on each side of the spine. This forces the back muscles to work harder, causing muscle fatigue and pain. When pain does occur, it usually goes away after a few weeks. However, back pain sometimes escalates to the point that patients seek medical help.

Traumatic compression fractures can produce intense pain in the back that spreads into the legs. If the fracture severely damages the vertebral body, bone fragments may lodge in the spinal canal, pressing on the spinal cord. This can paralyze muscles and impair sensation in the areas supplied by the damaged nerve tissue. Such a fracture may also cause the spine to become unstable. When this happens, the spine eventually tilts forward into increased kyphosis, and the potential grows for future complications with the spinal cord.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. The doctor asks questions about your symptoms and how your problem is affecting your daily activities. These include questions about where you feel pain and if you have numbness or weakness in your limbs. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Then the doctor examines you to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested. The doctor uses gentle pressure to feel the tissues over the sore area, since compression fractures often cause soreness and tenderness in the muscles over fractured vertebra.

If the doctor believes there is a compression fracture, X-rays are ordered. X-rays can show fractures of the vertebrae.

When an X-ray confirms a compression fracture, computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets the doctor see slices of the body’s tissue. The image can show whether the compression fracture has caused the area to become unstable from the injury.

If symptoms suggest problems with the spinal cord, 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). When the CT scan is performed, the dye highlights the spinal cord and spinal nerves. The dye can improve the accuracy of a standard CT scan for diagnosing the health of the spinal cord and spinal nerves.

Magnetic resonance imaging (MRI) can show the doctor problems affecting the nerves or causing pain. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It shows problems in other soft tissues such as the discs and spinal cord. 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.

Your doctor may order a bone scan to get additional information. This involves injecting chemical tracers into your blood stream. The tracers then show up on special X-rays of your spine. The tracers build up in areas of extra stress to bone tissue. This test can show if there are any old compression fractures, which would alert the doctor to problems with osteoporosis. If you have osteoporosis, the doctor will suggest ways to prevent future problems.

Treatment

What treatment options are available?

Nonsurgical Treatment

The majority of patients with compression fractures are treated without surgery. Most compression fractures heal within eight weeks with simple remedies of medicine, rest, and a special back brace.

Most patients are given medication to control pain. Although medications can help ease pain, they are not designed to heal the fracture. With pain under control, patients find it easier to get up and move about, avoiding the problems that come from remaining immobile in bed.

Patients are usually prescribed a short period of rest. This gives the fracture a chance to heal and aids in pain control. In some cases, the doctor may have a patient stay in bed for up to one week.

Most patients are fit with a special back brace, called an orthosis. This type of brace is molded to the patient’s body. It limits spine movement in general, though the brace is usually fashioned to keep patients from bending forward. This protects the fractured vertebral body so it can heal. Patients who wear a special brace may be advised to move about but to limit strenuous activities, such as lifting and bending

Surgery

Open surgical treatment for spinal compression fractures due to osteoporosis is infrequently needed. (Open procedures require larger incisions to give the surgeon more room to operate.) In rare cases of severe trauma, however, open surgery is sometimes required. Open surgery is done if the spinal segment has loosened and bone fragments have damaged the spinal cord and spinal nerves.

Surgeons have begun using two new procedures to treat compression fractures caused by osteoporosis. Both are considered minimally invasive. Minimally invasive means the incisions used are very small, and there is little disturbance of the muscles and bones where the procedure is done. These two procedures help the fracture heal without the problems associated with more involved surgeries. These new procedures are

vertebroplasty
kyphoplasty

Vertebroplasty

This procedure is most helpful for reducing pain. It also strengthens the fractured bone, enabling patients to rehabilitate faster.

To perform vertebroplasty, the surgeon uses a fluoroscope to guide a needle into the fractured vertebral body. A fluoroscope is a special X-ray television that allows the surgeon to see your spine and the needle as it moves. Once the surgeon is sure the needle is in the right place, bone cement, called polymethylmethacrylate (PMMA), is injected through the needle into the fractured vertebra. A reaction in the cement causes it to harden within 15 minutes. This fixes the bone so that it does not collapse any further as it heals. More than 80 percent of patients get immediate pain relief with this procedure.

Related Document: A Patient’s Guide to Vertebroplasty

Kyphoplasty

Kyphoplasty is another way for surgeons to treat vertebral compression fractures. Like vertebroplasty, this procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent kyphosis.

Two long needles are inserted through the sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling two holes into the vertebral body. The surgeon uses a fluoroscope (mentioned above) to make sure the needles and drill holes are placed in the right spot.

View animation of inflating the balloons

The surgeon then slides a hollow tube with a deflated balloon on the end through each drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity. Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. This fixes the bone in its corrected size and position.

Related Document: A Patient’s Guide to Kyphoplasty

Rehabilitation

What should I expect as I recover?

Rehabilitation after traumatic vertebral fractures can be a slow process. In these cases, patients sometimes need to attend therapy sessions for two to three months and should expect full recovery to take up to one year.

Most spinal compression fractures caused by osteoporosis get better within eight weeks. As mentioned, most patients who suffer compression fractures from osteoporosis don’t require surgery. Instead they are treated conservatively.

Patients who were fit with a special brace are usually able to begin increasing their activity level after about one week. However, patients are encouraged to avoid strenuous activity until their doctor approves resuming normal levels of activity.

People who have back pain generally find their pain improves as the fracture heals. However, the fracture changes the way the spine works, so it is not unusual for patients to have some lingering soreness in the muscles and joints near the fractured vertebra. If pain continues, let your doctor know.

After six to eight weeks, doctors may have their patients begin a period of physical therapy. This is especially true when patients lose muscle tone, are deconditioned from having to limit their activities, or have ongoing pain.

Treatments are also used to improve posture. A combination of flexibility, strength, and postural exercise may be all that is needed to help your posture. Sometimes patients may need additional support with either a rigid brace or a fabric corset.

Your therapist also 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 and avoid extra strain near the fracture 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.

The therapist periodically tests your posture, balance, and strength to see how well you are improving. The therapist’s goal for you is to become proficient and safe with your exercises and improve your posture, strength, and flexibility. The therapist gives you tips on how to avoid future problems.

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

Thoracic Disc Herniation

A Patient’s Guide to Thoracic Disc Herniation

Introduction

A rise in the use of magnetic resonance imaging (MRI) has led to the discovery that many people, perhaps as many as 15 percent of Americans, have a thoracic disc herniation. Seeing a herniated thoracic disc on MRI is often incidental, meaning it shows up when the person has MRI testing for another problem.

Few people with a thoracic disc herniation feel any symptoms or have any problems as a result of this condition. In rare cases when symptoms do arise, the main concern is whether the herniated disc is affecting the spinal cord.

Although people often refer to a thoracic disc herniation as a slipped disc, the disc doesn’t actually slip out of place. Rather, the term herniation means that the material in the center of the disc has squeezed out of the normal space. In the thoracic spine, this condition mostly affects people between 40 and 60 years old.

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 formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The main section of each vertebra is a round block of bone, called the vertebral body.

The thoracic spine is made up of the middle 12 vertebrae.

Doctors often refer to these vertebrae as T1 to T12. The thoracic spine starts at the base of the neck. 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.

The upper half of the thoracic spine is much less mobile than the lower section, making disc herniations in the upper thoracic spine rare. About 75 percent of thoracic disc herniations occur from T8 to T12, with the majority affecting T11 and T12.

The intervertebral disc is a specialized connective tissue structure that separates the vertebral bodies. The 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 ligament rings surrounding it. Ligaments are strong 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 and during activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal canal is a hollow tube inside the spinal column. It surrounds the spinal cord as it passes through the spine. The spinal cord is similar to 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 canal is narrow in the thoracic spine. Any condition that takes up extra space inside this canal can injure the spinal cord.

Blood vessels that run up and down the spine nourish the spinal cord. However, only one vessel, the anterior spinal artery, goes to the front of the spinal cord in the area between T4 and T9. Doctors call this section of the spine the critical zone. If this single vessel is damaged, as can happen with pressure from a herniated thoracic disc, the spinal cord has no other way to get blood. Left untreated, this section of the spinal cord dies, which can lead to severe problems of weakness or paralysis below the waist.

Causes

Why do I have this problem?

View animation of degeneration

Thoracic disc herniations are mainly caused by wear and tear in the disc. This wear and tear is known as degeneration. As a disc’s annulus ages, it tends to crack and tear. These injuries are repaired with scar tissue. Over time the annulus weakens, and the nucleus may squeeze (herniate) through the damaged annulus. Spine degeneration is common in T11 and T12. T12 is where the thoracic and lumbar spine meet. This link is subject to forces from daily activity, such as bending and twisting, which lead to degeneration. Not surprisingly, most thoracic disc herniations occur in this area.

Less commonly, a thoracic disc may herniate suddenly (an acute injury). A thoracic disc may herniate during a car accident or a fall. A thoracic disc may also herniate as a result of a sudden and forceful twist of the mid-back.

Diseases of the thoracic spine may lead to thoracic disc herniation. Patients with Scheuermann’s disease, for example, are more likely to suffer thoracic disc herniations. It appears these patients often have more than one herniated disc, though the evidence is not conclusive.

The spinal cord may be injured when a thoracic disc herniates. The spinal canal of the thoracic spine is narrow, so the spinal cord is immediately in danger from anything that takes up space inside the canal. Most disc herniations in the thoracic spine squeeze straight back, rather than deflecting off to either side. As a result, the disc material is often pushed directly toward the spinal cord. A herniated disc can cut off the blood supply to the spinal cord. Discs that herniate into the critical zone of the thoracic spine (T4 to T9) can shut off blood from the one and only blood vessel going to the front of the spinal cord in this section of the spine. This can cause the nerve tissues in the spinal cord to die, leading to severe problems of weakness or paralysis in the legs.

Symptoms

What does the condition feel like?

Symptoms of thoracic disc herniation vary widely. Symptoms depend on where and how big the disc herniation is, where it is pressing, and whether the spinal cord has been damaged.

Pain is usually the first symptom. The pain may be centered over the injured disc but may spread to one or both sides of the mid-back. Also, patients commonly feel a band of pain that goes around the front of the chest. Patients may eventually report sensations of pins, needles, and numbness. Others say their leg or arm muscles feel weak. Disc material that presses against the spinal cord can also cause changes in bowel and bladder function.

Disc herniations can affect areas away from the spine. Herniations in the upper part of the thoracic spine can radiate pain and other sensations into one or both arms. If the herniation occurs in the middle of the thoracic spine, pain can radiate to the abdominal or chest area, mimicking heart problems. A lower thoracic disc herniation can cause pain in the groin or lower limbs and can mimic kidney pain.

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. These include questions about where you feel pain, if you have numbness or weakness in your arms or legs, and if you are having any problems with bowel or bladder function. Your doctor will also want to know what positions or activities make your symptoms worse or better.

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

X-rays show the bones. They normally don’t show the discs, unless one or more of the discs have calcified. This is significant in the diagnosis of thoracic disc herniation. A calcified disc that appears on X-ray to poke into the spinal canal is a fairly reliable sign that the disc has herniated. It isn’t clear why a problem thoracic disc sometimes hardens from calcification, though past injury of the disc is one possibility.

The best way to diagnose a herniated thoracic disc is with 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 one has herniated. 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. This test has shown doctors that many people without symptoms have thoracic disc herniations. This has led some doctors to suggest that thoracic disc herniations not causing symptoms are normal.

Before MRI, doctors relied mainly on myelography to diagnose thoracic disc herniations. By itself, myelography only helps diagnose this condition in about half the cases. Myelography is a kind of X-ray test. A special dye is injected into the space around the spinal canal. The dye shows up on an X-ray. It helps a doctor see if the disc is pushing into the spinal canal.

Computed tomography (CT scan) may be ordered. This is a detailed X-ray that lets doctors see the body’s tissue in images that also look like slices. The images provide more information about calcified discs. Doctors may combine the CT scan with myelography. When the CT scan is performed, the myelography dye highlights the spinal cord and nerves. The dye can improve the accuracy of a standard CT scan for diagnosing a herniated thoracic disc.

Doctors rely mostly on MRI for diagnosing thoracic disc herniations. However, they may use myelography and CT scans when preparing to do surgery to fix a herniated thoracic disc.

Treatment

What treatment options are available?

Nonsurgical Treatment

Doctors closely monitor patients with symptoms from a thoracic disc herniation, even when the size of the herniation is small. If the disc starts to put pressure on the spinal cord or on the blood vessels going to the spinal cord, severe neurological symptoms can develop rapidly. In these cases, surgery is needed right away. However, unless your condition is affecting the spinal cord or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may recommend immobilizing your back. Keeping the back still for a short time can calm inflammation and pain. This might include one to two days of bed rest, since lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients do ordinary activities, using pain to gauge how much activity is too much. Another option for immobilizing the back is a back support brace worn for up to one week.

Doctors prescribe certain types of medication for patients with thoracic disc herniation. Patients may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Muscle relaxants may be prescribed if the back muscles are in spasm. Pain that spreads into the arms or legs is sometimes relieved with oral steroids taken in tapering dosages.

Your doctor will probably have a physical therapist direct your rehabilitation program. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a rehabilitation program for your condition that helps you prevent future problems.

Most people with a herniated thoracic disc get better without surgery. Doctors usually have their patients try nonoperative treatment for at least six weeks before considering surgery.

Surgery

Surgeons may recommend surgery if patients aren’t getting better with nonsurgical treatment, or if the problem is becoming more severe.

When there are signs that the herniated disc is affecting the spinal cord, surgery may be required, sometimes right away. The signs surgeons watch for when reaching this decision include weakening in the arm or leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Surgical treatment for this condition includes

costotransversectomy and discectomy
transthoracic decompression
video assisted thoracoscopy surgery (VATS)
fusion

Costotransversectomy

Surgeons use costotransversectomy to open a window through the bones that cover the injured disc. Operating from the back of the spine, the surgeon takes out a small section on the end of two or more ribs where they connect to the spine. (Costo means rib.) Then the bony knob on the side of the vertebra (the transverse process) is removed. (Ectomy means to remove.) This opens space for the surgeon to work. The injured portion of the disc that is pressing against the spinal cord is removed (discectomy) with small instruments. Surgeons take extreme care not to harm the spinal cord.

Transthoracic Decompression

Transthoracic describes the approach used by the surgeon. Trans means across or through. The thoracic region is the chest. So in transthoracic decompression, the surgeon operates through the chest cavity to reach the injured disc. This approach gives the surgeon a clear view of the disc.

With the patient on his or her side, the surgeon cuts a small opening through the ribs on the side of the thorax (the chest). Instruments are placed through the opening, and the herniated part of the disc is taken out. This takes pressure off the spinal cord (decompression).

Video Assisted Thoracoscopy Surgery (VATS)

Recent developments in thoracic surgery include video assisted thoracoscopy surgery (VATS). This procedure is done with a thoracoscope, a tiny television camera that can be inserted into the side of the thorax through a small incision. The camera allows the surgeon to see the area where he or she is working on a TV screen. Small incisions give passage for other instruments used during the surgery. The surgeon watches the TV screen while cutting and

removing damaged portions of the disc.

Categorized as minimally invasive surgery, VATS is thought to be less taxing on patients. Advocates also believe that this type of surgery is easier to perform, prevents scarring around the nerves and joints, and helps patients recover more quickly.

Fusion

After removing part or all of the disc, the spine may be loose and unstable. Fusion surgery may be needed immediately afterward. The medical term for fusion is arthrodesis. This procedure locks the vertebrae in place and stops movement between the vertebrae. This steadies the bones and can ease pain. Fusion surgery is not usually needed if only a small amount of bone and disc material was removed during surgery to fix a herniated thoracic disc.

In this procedure, the surgeon lays small grafts of bone over or between the loose spinal bones. Surgeons may use a combination of screws, cables, and rods to prevent the vertebrae from moving and allow the graft to heal.

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.

The first goals of treatment are to control symptoms, find positions that ease pain, and teach you how to keep your spine safe during routine activities.

As patients recover, they gradually advance in a series of strengthening exercises. Aerobic exercises, such as walking or swimming, can ease pain and improve endurance.

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 be visited by a physical therapist 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 calm pain and muscle spasm. Then they teach patients how to move safely with the least strain on the healing back.

As patients recover, they gradually begin doing flexibility exercises for the hips and shoulders. Mobility exercises are also started for the back. Strengthening exercises address the back muscles. Patients may work with the therapist in a pool. Patients progress with exercises to improve endurance, muscle strength, and body alignment.

As the rehabilitation program evolves, patients do more challenging exercises. The goal is to safely advance strength and function.

Ideally, patients are able to go back to their previous activities. However, some patients may need to modify their activities to avoid future problems.

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.

Kyphoplasty

A Patient’s Guide to Kyphoplasty

Introduction

Patients with osteoporosis are prone to compression fractures in the spine bones, or vertebrae. The bone cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States.

The fracture angles the spine forward and produces a hunchbacked appearance, called kyphosis. Patients with this condition are subject to debilitating pain, disturbed sleep, decreased lung and intestinal function, and difficulty completing routine activities.

Kyphoplasty restores the size and strength of the fractured vertebra. This realigns the spine and reduces pain. Nearly 95 percent of patients get immediate relief of pain with this procedure.

This guide will help you understand

why the procedure becomes necessary
what surgeons hope to achieve with kyphoplasty
what to expect during recovery

Anatomy

What parts of the spine are involved?

The main section of each spine vertebra is a large, round structure called a vertebral body. Compression fractures cause the front portion of this round bone to collapse in height. Because the back section of the bone stays intact, the damaged vertebral body becomes wedge-shaped.

It is this wedge shape that angles the spine forward into kyphosis. The vertebral body is the main structure treated in the kyphoplasty procedure.

Rationale

What do surgeons hope to achieve with this procedure?

In the past, surgeons used standard open surgical procedures to fix compression fractures from osteoporosis. Open procedures require larger incisions to give the surgeon more room to operate. The results of open surgery for this condition have generally been poor, mainly because operating on bones that are weak and soft from osteoporosis is difficult. In addition, some aging adults with fractures may not be physically able to tolerate such a surgery.

Kyphoplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, which involves an incision and the use of larger instruments, kyphoplasty is a minimally invasive procedure. It requires a small opening in the skin and small instruments. This lessens the chance of bleeding, infection, and injury to muscles and soft tissues.

The goal of kyphoplasty is to return the fractured vertebra as close as possible to its normal height. This is done by inflating a balloon inside the fractured bone to restore the vertebral body to its normal size. Special cement is then injected into the bone, fixing it in place. The cement strengthens the broken vertebra and stiffens it in its original height and position. This reduces pain and spine deformity (kyphosis), enabling patients to get back to normal activities.

Preparations

How will I prepare for the procedure?

The decision to proceed with kyphoplasty 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.

Kyphoplasty is normally done on an outpatient basis, meaning patients go home the same day as the surgery. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the procedure?

The patient lies on his or her stomach. To begin, the surgeon cleans the skin on the back with an antiseptic. Then the skin over the problem area is numbed using an anesthetic. Patients may also receive general anesthesia to put them to sleep during the procedure.

Two small openings are made in the skin on each side of the spinal column. Long needles are inserted through the openings. The needles are passed completely through the back of the spinal column into the fractured vertebral body. These needles serve as guides while the surgeon drills two holes into the vertebral body. The surgeon uses a fluoroscope to make sure the needles and drill holes are placed in the right spot. A fluoroscope is a special X-ray television that allows the surgeon to see your spine on a screen.

The device works like a video, though the images are in the form of an X-ray. Metal objects show up clearly on X-rays. The needle is easy for the surgeon to see on the fluoroscope screen. This helps the surgeon know the needle goes into the correct spot.

A hollow tube with a deflated balloon on the end is then slid through each drill hole. The balloons are inflated with air. This restores the height of the vertebral body and corrects the kyphosis deformity.

View animation

Next, the surgeon removes the balloon and injects bone cement into the hollow space formed by the balloon. A chemical reaction in the cement causes it to harden in about 15 minutes.

This fixes the bone in its corrected height and position. Bandages are then applied over the small incisions.

Complications

What might go wrong?

Serious complications from kyphoplasty are rare, involving less than five percent of cases. As with other procedures, however, complications can occur. Some of the most common complications of kyphoplasty include

problems with anesthesia
thrombophlebitis
infection
cement leakage
ongoing pain

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

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

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

Infection

Cement Leakage

The cement used in kyphoplasty is squeezed into the fractured vertebra in liquid form. Because it is injected at low pressure, cement leakage during kyphoplasty is rare. If some of the cement happens to leak out of the vertebra, it usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.

Ongoing Pain

Many patients get nearly complete relief of symptoms from kyphoplasty. As with any procedure, 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 monitored in the recovery room for two to three hours after the procedure before going home. You are instructed to move your back only carefully and comfortably. Some patients who are feeling extra pain or other problems after kyphoplasty may need to stay in the hospital overnight.

Patients rarely need to wear a brace after kyphoplasty, since bone cement immediately improves the strength and stiffness in the fractured vertebra.

Rehabilitation

What should I expect as I recover?

The cement used to fix the broken vertebra hardens quickly, within about 15 minutes. As a result, people often find it easier to do daily activities within one week. Pain also decreases rapidly, and most people require less pain medication within two weeks. Despite these improvements, most orthopedists consider that it takes about three months for the bone to heal after kyphoplasty.

Patients are encouraged to walk and do moderate activity as they recover. However, they should avoid strenuous exertion until their surgeon approves resuming normal levels of activity.

When the fracture was from osteoporosis, the doctor will suggest ways to prevent future problems. Patients may be prescribed medications and supplements (calcium and vitamin D) to maximize bone health. Lifestyle changes, such as quitting smoking and taking up exercising, may also be discussed.

Related Document: A Patient’s Guide to Osteoporosis

Patients who continue to have problems with posture and pain or who have lost muscle tone and strength may need the help of a physical therapist. These patients typically need to attend therapy sessions for four to six weeks.

The goal of therapy is to safely advance strength and function.
The therapist may use treatments such as heat or ice, electrical stimulation, and massage to help calm pain. Gentle exercise is used to improve strength of the spine and limbs. Patients begin learning how to move safely using healthy postures to reduce strain on the healing back. Exercises for the heart and lungs improve stamina and help with pain control.

As the therapy sessions come to an end, the therapist helps patients get back to the activities they enjoy. Ideally, patients are able to resume normal activities. They may need guidance on which activities are safe or how to change the way they go about their activities.

Scheuermann’s Disease

A Patient’s Guide to Scheuermann’s Disease

Introduction

The section of spine from below the neck to the bottom of the rib cage is called the thoracic spine. From the side, the thoracic spine appears slightly rounded. Its shape is like the letter “C” with the opening facing the front of the body. This normal curve is called kyphosis. With excessive kyphosis, the thoracic spine takes on a hunchbacked appearance.

Scheuermann’s disease (also called Scheuermann’s kyphosis) is a condition that starts in childhood. It affects less than one percent of the population and occurs mostly in children between the ages of 10 and 12. It affects boys and girls with a slightly higher number of boys affected. Those who do not get proper treatment for the condition during childhood often experience back pain from the spinal deformity as adults. Sometimes Scheuermann’s disease doesn’t develop until adulthood.

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?

A healthy human spine has three gradual curves. From the side, the neck and low back curve gently inward. This is called lordosis. The thoracic kyphosis (outward curve) gives the mid back its slightly rounded appearance. These normal curves help the spine absorb forces from gravity and daily activities, such as lifting.

The angle of normal kyphosis in the thoracic spine varies. During the growth years of adolescence, a normal curve measures between 25 and 40 degrees. If the curve angles more than 40 degrees, doctors consider the kyphosis a deformity. In general, kyphosis tends to be more exaggerated in girls. The angle increases slightly throughout life both in women and men. Scheuermann’s disease causes the thoracic kyphosis to angle too far (more than 45 degrees).

The 12 thoracic vertebrae are known as T1 to T12. The main section of each thoracic vertebra is a round block of bone, called a vertebral body. A ring of bone attaches to the back of the vertebral body. This ring surrounds and protects the spinal cord.

In Scheuermann’s disease, the front of the vertebral body becomes wedge-shaped, possibly from abnormal growth. This produces a triangular-shaped vertebral body, with the narrow, wedged part closest to the front of the body. The wedge puts a bigger bend in the kyphosis of the thoracic spine.

The vertebral bodies are separated by a cushion, called an intervertebral disc. Between each disc and vertebral body is a vertebral end plate. Sometimes one or more discs in patients with Scheuermann’s disease squeeze through the vertebral end plate, which is often weaker in patients with Scheuermann’s disease. This forms pockets of disc material inside the vertebral body, a condition called Schmorl’s nodes.

A long ligament called the anterior longitudinal ligament connects on the front of the vertebral bodies. This ligament typically thickens in patients with Scheuermann’s disease. This adds to the forward pull on the spine, producing more wedging and kyphosis.

The disease usually produces kyphosis in the middle section of the thorax (the chest), between the shoulder blades. The condition sometimes causes kyphosis in the lower part of the thoracic spine, near the bottom of the rib cage.

Causes

Why do I have this problem?

Famed for discovering this disease, Scheuermann himself thought a lack of blood to the cartilage around the vertebral body caused the wedging. Though scientists have since disproved this theory, the root cause of the disease is still unknown.

View animation

Mounting evidence suggests wedging develops as a problem vertebral body grows. During normal growth, the cartilage around the vertebral body turns evenly and completely to bone. If the change from cartilage to bone doesn’t happen evenly, one side of the vertebral body grows at a faster rate. By the time the entire vertebral body turns to bone, one side is taller than the other. This is the wedge shape that leads to abnormal kyphosis.

Other theories of how Scheuermann’s kyphosis starts include

genetics
childhood osteoporosis
mechanical reasons

Genetics

Researchers have suggested that this disease can be passed down in families. Studies have shown multiple families who have passed the disease through inheritance of certain types of genes. The genetic link is uncommon but remains under investigation.

Childhood Osteoporosis

One medical study found that some patients with Scheuermann’s disease had mild osteoporosis (decreased bone mass) even though they were very young. Other studies did not show problems with osteoporosis. More research is needed to confirm the role of osteoporosis in Scheuermann’s disease.

Related Document: A Patient’s Guide to Osteoporosis

Mechanical Reasons

These include strains from bending, heavy lifting, and using poor posture. This theory makes sense because the back braces used in treating kyphosis work. If a back brace can straighten a bent spine, then perhaps mechanical forces could cause more kyphosis than naturally occurs in the spine. (Back braces are discussed in more detail later.) Some experts think that tight hamstring muscles (along the back of the thigh) pull on the pelvis contributing to spinal deformity.

Scientists are not convinced that mechanical reasons cause the disease; rather, these factors likely aggravate the condition. And in some cases, it is difficult to tell which came first: the mechanical changes causing the deformity or the deformity resulting in the anatomical and thus mechanical changes.

Other Reasons

Other theories put forth that might help explain the cause(s) of Scheuermann’s disease include biochemical changes in the collagen that make up the end-plates altering bone growth, above-average disc height, and increased levels of growth hormone.

Symptoms

What does the condition feel like?

Hunched posture or a round back in children usually alerts parents or teachers to the need for a doctor visit. Children don’t typically complain of back pain or other symptoms.

This is not the case in adolescents who are nearing puberty and have kyphosis in the lowest part of the thorax, near the bottom of the rib cage. In these patients, back pain is the overriding problem. This happens most often to young, active males. Doctors suspect this unique form of the disease occurs because the condition is overlooked during childhood, delaying treatment.

Adults who’ve lived with the hunched posture for many years may note worsening pain. They may be disturbed by the physical changes and deformity that develop.The pain and/or the physical changes typically causes them to seek medical help.

Besides having a forward curved spine, most people affected by Scheuermann’s report back pain, stiffness, and loss of flexibility. The neck and low back try to compensate by increasing the natural lordotic curves in these two areas. Since the person cannot straighten the thoracic spine, the cervical and lumbar spines increase their curves to compensate for the round back. All of these changes in posture are usually accompanied by tight shoulder, hip, and leg muscles.

Degenerative spondylosis is also reported as part of the natural history in middle-aged adults with Scheuermann’s kyphosis. Degenerative changes in the spine (usually from aging) can cause bone spurs to form around the spinal joints. The joint spaces start to narrow. This condition is called spondylosis, which can also contribute to pain and stiffness.

Patients of all ages who experience pain generally report feeling discomfort along the sides of the spine, slightly below the main part of the abnormal curve.

Exaggerated kyphosis can lead to an increased lordosis (inward curve) in the low back. This puts extra strain on the tissues of the low back. Over many years, this added wear and tear may produce low back pain. This mainly occurs in adults who have extra lumbar lordosis from years of untreated Scheuermann’s disease.

In rare cases, the spinal cord is affected. A severe kyphosis stretches the spinal cord over the top of the curve. This can injure the spinal cord. Also, patients with Scheuermann’s disease have a greater chance of having a herniated thoracic disc. This is where the disc material from inside the disc begins to squeeze out and press on the spinal cord. Spinal cord symptoms for both situations include sensations of pins and needles and numbness. The leg muscles may feel weak. Symptoms from an injured spinal cord can also include changes in bowel and bladder function.

When the kyphosis angle exceeds 100 degrees (rare), the sharply bent spine puts pressure on the heart, lungs, and intestines. When this occurs, patients may tire quickly, suffer shortness of breath, feel chest pain, and lose their appetite.

Diagnosis

How do doctors diagnose the problem?

Doctors start with a complete history and physical examination. However, X-rays are the main way to diagnose Scheuermann’s kyphosis. Taken from the side, an X-ray may show vertebral wedging, Schmorl’s nodes, and changes in the vertebral end plates. Doctors use X-ray images to measure the angle of kyphosis. Doctors diagnose Scheuermann’s disease when three vertebrae in a row wedge five degrees or more and when the kyphosis angle is greater than 45 degrees.

Scheuermann’s disease or kyphosis is diagnosed as either being typical (Type I) or atypical (Type II). These two forms of the disease affect different parts of the spine. The typical form (most common type) has the thoracic kyphotic pattern described in this section. The lower (lumbar) spine compensates by becoming hyperlordotic. Lordosis is the spinal curve exactly opposite of kyphosis. Hyperlordotic means the curve increases beyond what is considered “normal.”

The atypical form of Scheuermann’s (Type II) affects the low back known as the lumbar spine. The upper lumbar spine (where the thoracic spine transitions to become the lumbar spine) is involved. Type II is seen most often in young boys before puberty who are active in sports activities. They experience pain that goes away with rest and change in position or activity level.

A side-view X-ray can also show if the spine is flexible or rigid. Patients are asked to bend back and hold the position while an X-ray is taken. The spine straightens easily when it is flexible. In patients with Scheuermann’s disease, however, the curve stays rigid and does not improve by trying to straighten up.

From the front, X-rays show if the spine curves from side to side. This sideways curve is called scoliosis and occurs in about one-third of patients with Scheuermann’s kyphosis.

X-rays can show signs of wear and tear in adults who have extra lumbar lordosis from years of untreated Scheuermann’s disease.

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body’s tissue.

Myelography is a special kind of X-ray test. For this test, dye is injected into the space around the spinal canal. The dye shows up on an X-ray. This test is especially helpful if the doctor is concerned whether the spinal cord is being affected.

Magnetic resonance imaging (MRI) uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the area the doctor is interested in. The test does not require special dye or a needle.

Treatment

What treatment options are available?

Nonsurgical Treatment

A child or youth with mild kyphosis may simply need to be observed. Unless the curve or pain becomes worse, no other treatment may be needed. Some children who don’t require treatment eventually improve and have no long-term problems. Others may always have a mild thoracic kyphosis but are able to function normally without pain or other problems.

If the doctor is concerned that the curve will worsen, he or she may suggest bracing and exercise. A brace is most effective when used before the skeleton matures at about age 14. Doctors commonly chose a Milwaukee brace, which is designed to hold the shoulders back and gradually straighten the thoracic curve. The brace won’t reverse the curve in a fully developed spine. Nor is it helpful for rigid curves that angle more than 75 degrees.

The Milwaukee brace is made of molded plastic that conforms to the waist. On the back, two upright, padded bars line up along the sides of the spine. Pressure from the upright bars straightens the spine. Patients usually remove the brace to shower, but they keep it on at night.

Younger patients (under 15) generally wear the brace all the time. The doctor adjusts the brace regularly as the curve improves. When the thoracic curve has improved enough, the brace is worn part-time (eight to 12 hours per day) until the skeleton is done growing, typically around age 14 or 15.

A physical therapist may show the patient recommended exercises. When used in combination with a brace, exercises appear to maximize the effect of the brace by strengthening muscles that help align the spine. Certain exercises, such as general conditioning and stretching, are also worthwhile for helping patients control pain. Core training for spinal stabilzation is an important part of the pain management program. However, exercises alone don’t reduce kyphosis in Scheuermann’s disease.

Doctors may prescribe anti-inflammatory medication for pain. Younger patients generally use this medicine on a short-term basis, in combination with other treatments. Adults who have ongoing pain sometimes require long-term use of anti-inflammatory medication. Sometimes adults obtain partial correction of the kyphosis and pain relief with bracing even though they have reached full bone growth. Bracing for pain relief in adults is also considered when surgery is not an option.

Surgery

Surgeons rarely recommend fusion surgery for Scheuermann’s disease. Certain situations may require it, however. For example, surgery may be needed if pain becomes severe and doesn’t go away with nonoperative treatment or if pressure on the spinal cord or spinal nerves is causing problems. Some people request surgery if the deformity is severe enough that their appearance causes them considerable psychologic and/or emotional distress.

Patients whose skeletons are done growing may require surgery. Patients with a rigid kyphosis that angles more than 75 degrees may also need surgery. The entire length of the kyphosis is fused.

Two procedures commonly used to treat thoracic kyphosis are

posterior fusion
combined fusion

Posterior Fusion

In a fusion operation, two or more bones are joined into one solid bone. Surgeons perform posterior fusion for Scheuermann’s disease on the rare patient who prefers not to use a brace and whose spine is still growing, is mildly flexible, and has a kyphosis of less than 65 degrees.

This surgery is done through the back (posterior) of the spine. After making an incision in the back, the surgeon applies pressure to straighten the kyphosis. Small strips of bone graft are then laid over the back of the spinal column. These strips encourage the bones to grow together. Metal rods are attached along the spine to prevent the vertebrae from moving. The rods hold the spine in better alignment and protect the bone graft so it can heal better and faster.

The posterior-only approach has the advantage of less blood loss than an anterior approach and does not interfere with major anterior blood supply to the spinal cord. Surgical time is shorter with the posterior-only method. Improved instrumentation and surgical technique has improved results for posterior-only fusions. Many more surgeons are using this approach with fewer problems even with more rigid curves.

Combined Fusion

Combined fusion is actually two fusion surgeries, one from the back (posterior) and one from the front (anterior) of the spine. In the past, two separate operations were needed, but now some surgeons do both fusions in the same operation. This surgery is commonly used if the spine is finished growing and the kyphosis angle is more than 75 degrees.

The surgeon starts with anterior fusion. With the patient on his or her side, the surgeon cuts away a piece of rib to make a small opening on the side of the thorax. The rib opening is spread apart so the surgeon can reach the spine better. The surgeon operates on the front of the spine through the chest cavity.

A section of the anterior longitudinal ligament is cut. This makes it easier to straighten the hunched spine. The intervertebral discs in the problem area are taken out, and the spaces between the wedged vertebrae are filled with bone graft. One method is to take a graft of bone from the pelvis and tamp it into the place of each removed disc. This requires another incision over one side of the pelvis. A second method is to grind up the piece of rib that was removed and place it in the disc spaces. As the grafts heal, the vertebrae become fused into solid bone.

The second part of surgery is an involved form of posterior fusion using special rods and hooks. This part of the operation can be done right after the anterior fusion or scheduled for one week later.

First, the surgeon makes an incision over the back of the spine. The skin and muscles are spread apart.

Then strips of bone graft are laid across each vertebra to be fused. Long rods are inserted along the sides of the spine. The rods have hooks attached on both ends. Wire is wrapped between the top and bottom hooks. Tightening the wires causes the spine to straighten. The rods help hold the spine steady as the bone grafts heal. The rods are usually left in permanently.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Children and adolescents treated nonsurgically sometimes work with a physical therapist. Certain exercises are beneficial when used in combination with a brace. Upper back exercises, such as gentle back bends (extension) can improve posture and prevent the spine from slouching forward. Hamstring stretches and pelvis exercises improve posture by preventing extra lordosis in the low back. Aerobic exercise improves heart and lung health and combats pain.

Pain is also addressed by the physical therapist. The therapist may apply heat, cold, ultrasound, and massage treatments. Adults who’ve had kyphosis for many years (and the resulting low back pain from too much lordosis) benefit from postural exercises to reduce the lumbar curve, followed by stabilization exercises to help them keep better posture. Patients benefit most when these exercises are done regularly and for a lifetime.

After Surgery

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

Many surgical patients also need physical therapy outside of the hospital. Patients normally wait up to three months before beginning a rehabilitation program after fusion surgery for Scheuermann’s disease. They typically need to attend therapy sessions for eight to 12 weeks. Full recovery may take up to eight months.

Upon completing physical therapy, patients are in charge of doing their exercises as part of an ongoing home program. Final results are overall favorable following surgery. The majority of patients report being satisfied with their cosmetic appearance. Some patients even experience complete relief from their pain. There may be some low back pain or discomfort with strenuous activity. Complications are rare but can include infection, loss of correction, spinal cord injury or other neurologic problems. In a small number of cases, a second surgical procedure may be required.

Cervical Spine Anatomy

A Patient’s Guide to Cervical Spine Anatomy

Introduction

Knowing the main parts of your neck and how these parts work is important as you learn to care for your neck problem.

Two common anatomic terms are useful as they relate to the neck. The term anterior refers to the front of the neck. The term posterior refers to the back of the neck. The part of the spine that moves through the neck is called the cervical spine. The front of the neck is therefore called the anterior cervical area. The back of the neck is called the posterior cervical area.

In addition to reading this article, be sure to watch our Cervical Spine Anatomy Animated Tutorial Video.

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

what parts make up the neck
how these parts work

Important Structures

The important parts of the cervical spine include

bones and joints
nerves
connective tissues
muscles
spinal segments

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 form the spinal column. The spinal column is the body’s main upright support.

The first seven vertebrae make up the cervical spine. Doctors often refer to these vertebrae as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine (the chest area).

The base of the skull sits on top of C1, also called the atlas. Two thickened bony arches form a large hole through the center of the atlas. The opening is large because the spinal cord is wider where it first exits the brain and skull. Compared to other vertebrae, the atlas also has much wider bony projections pointing out to each side.

The atlas sits on top of the C2 vertebra. The C2 is called the axis. The axis has a large bony knob on top, called the dens. The dens points up and fits through a hole in the atlas. The joints of the axis give the neck most of its ability to turn to the left and right.

Each vertebra is made of the same parts. The main section of each cervical vertebra, from C2 to C7, is formed by a round block of bone, called the vertebral body. A bony ring attaches to the back of the vertebral body. This ring has two parts. 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. The laminae provide a protective roof over the spinal cord.

A bony knob projects out at the point where the two lamina bones join together at the back of the spine. These projections, called spinous processes, can be felt as you rub your fingers up and down the back of your spine. The largest bump near the top of your spine is the spinous process of C2. At the base of the neck where the cervical and thoracic spines join together, you’ll feel another large spinous process. That’s C7.

Each vertebra in the spine has two bony knobs that point out to the side, one on the left and one on the right. These bony projections are called transverse processes. The atlas has the widest transverse processes of all the cervical vertebrae. Unlike the rest of the spine, the neck vertebrae have a hole that passes down through each transverse process. This hole, called the transverse foramen, provides a passageway for arteries that run up each side of the neck to supply the back of the brain with blood.

Between each pair of vertebrae are two joints called facet joints. These joints connect the vertebrae together in a chain but slide against one another to allow the neck to move in many directions. Except for the very top and bottom of the spinal column, each vertebra has two facet joints on each side. The ones on top connect to the vertebra above; the ones below join with the vertebra below.

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 ends of bones to move against each other smoothly, without friction.

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

The hollow tube formed by the bony ring on the back of the spinal column surrounds the spinal cord as it passes through the spine. The spinal cord is a similar to 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. Two large nerves branch off the spinal cord from each vertebra, one on the left and one on the right. The nerves pass through the neural foramina. These spinal nerves group together to form the main nerves that go to the limbs and organs. The nerves that come out of the cervical spine go to the arms and hands.

Connective Tissues

Ligaments are strong connective tissues that attach bones to other bones. (Connective tissues are networks of fiber that hold the cells of the body together.) 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.

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.

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.

Muscles

The anterior cervical area is covered with muscles that run from the rib cage and collar bone to the cervical vertebrae, jaw, and skull. The posterior cervical muscles cover the bones along the back of the spine and make up the bulk of the tissues on the back of the neck.

Spinal Segment

A good way to understand the anatomy of the cervical 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 cord at each vertebra, and the small facet joints that link each level of the spinal column.

The intervertebral disc separates the two vertebral bodies of the spinal segment. 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.

The spinal segment is connected by a facet joint, described earlier. When the facet joints of the cervical spine move together, they bend and turn the neck.

Summary

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

Anterior Cervical Discectomy and Fusion

A Patient’s Guide to Anterior Cervical Discectomy and Fusion

Introduction

Anterior cervical discectomy and fusion (ACDF) is a procedure used to treat neck problems such as cervical radiculopathy, disc herniations, fractures, and spinal instability. In this procedure, the surgeon enters the neck from the front (the anterior region) and removes a spinal disc (discectomy). The vertebrae above and below the disc are then held in place with bone graft and sometimes metal hardware. The goal is to help the bones to grow together into one solid bone. This is known as fusion. The medical term for fusion is arthrodesis.

Operating on the back of the neck is more commonly used for neck fractures. That procedure is called a posterior cervical fusion.

This guide will help you understand

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

Anatomy

What parts of the neck are involved?

Surgeons perform this surgery through the front part of the neck. Key structures include the ligaments and bones, intervertebral discs, the spinal cord and spinal nerves, and the neural foramina.

Rationale

What do surgeons hope to achieve?

In most cases, ACDF is used to stop symptoms from cervical disc disease. Discs start to degenerate as a natural part of aging and also from stress and strain in the structures of the neck. Over time, the disc begins to collapse, and the space decreases between the vertebrae.

When this happens, the openings (the neural foramina) around the spinal nerves narrow 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 cord. The outer rings of the disc, the annulus, weaken and develop small cracks. The nucleus in the center of the disc may press on the weakened annulus and actually squeeze out of the annulus. This is called a herniated disc. The herniated disc may press on ligaments, nerves, or even the spinal cord. Fragments of the disc that press against the outer annulus, spinal nerves, or spinal cord can be a source of pain, numbness, and weakness. Pressure on the spinal cord, called myelopathy, can also produce problems with the bowels and bladder, changes in the way you walk, and trouble with fine motor skills in the hands.

Discectomy is the removal of the disc (and any fragments) between the vertebrae that are to be fused. When symptoms are coming from the disc, it is hoped that this stops the symptoms.

View animation of distraction

View animation of enlarging the space

Once the disc is removed, surgeons spread the bones of the spine apart slightly (distraction) to make room for the bone graft. This is bone material that can be taken from the top of the pelvis bone (autograft) or from a natural substitute (allograft). The bone graft separates and holds the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through them. Also, the ligaments inside the spinal canal are pulled taut so they don’t buckle into the spinal canal.

No movement occurs between the bones that are fused together. By holding the sore part of the neck steady, the fusion helps relieve pain. And it prevents additional wear and tear on the structures inside the section that was fused. This keeps bone spurs from forming, and it has been shown that fusion causes existing bone spurs to shrink. By fusing the bones together, surgeons hope that patients won’t have future pain and problems from cervical disc disease.

Preparations

How will I prepare for surgery?

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.

The patient’s neck is positioned facing the ceiling with the head bent back and slightly to the right. A two-inch incision is made two to three fingers’ width above the collar bone across the left-hand side of the neck. Surgeons often choose the left side to avoid injuring the nerve going to the voice box. Retractors are used to gently separate and hold the neck muscles and soft tissues apart so the surgeon can work on the front of the spine.

A needle is inserted into the disc, and an X-ray is taken to identify the correct disc. A long strip of muscle and part of the long ligament that covers the front of the vertebral bodies are carefully pulled to the side. Forceps are used to take out the front half of the disc. Next, a tool is attached to the vertebrae to spread them apart. This makes it easier for the surgeon to see between the two vertebrae. A small rotary cutting tool (a burr) is used to carefully remove the back half of the disc. A special microscope is used to help the surgeon see and remove pieces of disc material and bone spurs near the spinal cord.

A layer of bone is shaved off the flat surfaces of the two vertebrae. This causes the surfaces to bleed. This is necessary to help the bone graft heal and join the bones together.

The surgeon measures the depth and height between the two vertebrae. A section of bone is grafted from the top part of the pelvis. It is measured to fit snugly in the space where the disc was taken out. The surgeon increases the traction pull to separate the two vertebrae, and the graft is tamped into place.

The traction pull is released. Then the surgeon tests the graft by bending and turning the neck to make sure it is in the right spot and is locked in place. Another X-ray may be taken to double check the location of the graft.

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 your neck in a rigid collar.

Complications

What might go wrong?

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

anesthesia
thrombophlebitis
infection
nerve damage
problems with the graft
nonunion
ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most common.

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

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 and may require additional surgery to treat the infected portion of the spine.

Nerve Damage

The nerve to the voice box is sometimes injured during surgery on the front of the neck. Surgeons usually prefer to do surgery on the left side of the neck where the path of the nerve is more predictable than on the right side. During surgery, the nerve may be stretched too far when retractors are used to hold the muscles and soft tissues apart. When this happens, patients may be hoarse for a few days or weeks after surgery. In rare cases in which the nerve is actually cut, patients may end up with ongoing minor problems of hoarseness, voice fatigue, or difficulty making high tones.

Problems with the Graft

Fusion surgery requires bone to be grafted into the spinal column. The graft is commonly taken from the top rim of the pelvis. There is a risk of having pain, infection, or weakness in the area where the graft is taken.

After the graft is placed, the surgeon checks the position of the graft before completing the surgery. However, the graft may shift slightly soon after surgery to the point it is no longer able to hold the spine stable. When the graft migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align the graft and to apply metal plates and screws to hold it firmly in place.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (The term pseudarthrosis means false joint.) If the joint motion from a nonunion continues to cause pain, you may need a second operation. In the second procedure, the surgeon usually adds more bone graft. Metal plates and screws may also be added to rigidly secure the bones so they will fuse together.

Ongoing Pain

ACDF 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?

After ACDF, patients usually wear a special neck brace for several months. These neck braces are often bulky and restrictive. However, the bone graft needs time to heal in order for the fusion to succeed. This requires the neck to be held still.

Recently, surgeons have begun using metal hardware, called instrumentation to lock the bones in place. This hardware includes metal plates and screws that are fastened to the neck bones. They hold the neck bones still so the graft can heal, replacing the need for a rigid neck brace.

Patients may stay in the hospital for one to two days after surgery. When the surgery is done on an outpatient basis, patients may even go home the same day of surgery. Patients can get out of bed as soon as they feel up to it. They are watched carefully when they begin eating to make sure they don’t have problems swallowing. They usually drink liquids at first, and if they are not having problems, they can start eating solid food.

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.

Rehabilitation

What should I expect as I recover?

Rehabilitation after ACDF can be a slow process. 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.

Many surgeons prescribe outpatient physical therapy beginning a minimum of four weeks after surgery. At first, treatments are used to 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 treatments to ease muscle spasm and pain.

Active treatments are slowly added. These include exercises for improving heart and lung function. Walking and stationary cycling are ideal cardiovascular exercises. Therapists also teach specific exercises to help tone and control the muscles that stabilize the neck and upper back.

Your therapist also 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 neck 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’ll learn how to keep your neck safe while you lift and carry items and as you begin to do other heavier activities.

As your condition improves, your therapist will begin tailoring 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 heavy and 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 ways that keep your neck safe and free of extra strain.

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

Cervical Corpectomy and Strut Graft

A Patient’s Guide to Cervical Corpectomy and Strut Graft

Introduction

A corpectomy is surgery to relieve pressure on the spinal cord due to spinal stenosis. In spinal stenosis, bone spurs press against the spinal cord, leading to a condition called myelopathy. This can produce problems with the bowels and bladder and disrupt the way you walk. Fine motor skills of the hand may also be impaired. In a corpectomy, the front part of the spinal column is removed. (Corpus means body, and ectomy means remove.) Bone grafts are used to fill in the space. This procedure is used when bone spurs have developed in more than one vertebra.

This guide will help you understand

what part of the spinal column is affected
why the procedure becomes necessary
what happens before and during the operation
what to expect as you recover

Anatomy

What parts of the neck are involved?

Surgeons perform this procedure through the front of the neck. This is known as the anterior neck region. Key structures include ligaments, bones, intervertebral discs, the spinal cord and spinal nerves.

Rationale

What do surgeons hope to achieve?

Spinal stenosis occurs when bone spurs project into the spinal column and press against the spinal cord. Removing the vertebral bodies along the front section of the spinal column gives surgeons a way to relieve pressure on the front surface of the spinal cord, reducing or eliminating the symptoms caused by the bone spurs.

Preparations

How will I prepare for surgery?

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?

The surgeon starts by making an incision up the left side of the neck to the ear and then under the jaw to the bottom of the chin. The skin flap is opened to expose the structures of the neck. Retractors are used to separate and hold the muscles and soft tissues apart so the surgeon can work on the front of the spine.

Special instruments are attached either to the skull or the spinal bones to stretch the neck with mild traction. The traction pull spreads the neck joints apart to give the surgeon more room to work. It also takes additional pressure off the spinal cord. Then the surgeon inserts a needle into the disc and does an X-ray to locate the exact sections where the bones are to be removed.

The surgeon carefully cuts part of the anterior longitudinal ligament away from the front section of the spinal column. Instruments are then used to take out the front half of the discs that lie between the vertebral bodies. Next, a small rotary cutting tool (a burr) is used to carefully remove the back half of the discs (called discectomy) and a row of vertebral bodies (called corpectomy). The ring of bone that surrounds and protects the spinal column isn’t touched.

When the discs and vertebral bodies are out of the way, the posterior longitudinal ligament can be seen where it covers the front of the spinal cord. This thin ligament is shaved to remove areas that have hardened or buckled, as these areas are known to add pressure to the spinal cord.

The surgeon then prepares a bone graft that will fill in the space where the discs and vertebral bodies have been removed. A section of bone is taken from the fibula, the thin bone that runs along the outside of the lower leg. (The main bone of the lower leg is called the tibia.) Some surgeons prefer to take bone from the pelvis instead of the fibula.

Before inserting the bone graft, the surgeon increases the traction pull on the neck to help separate the space even more. The bone graft is sized to fill the full length of the removed section of bone and discs from one end to the other.

The section of bone is grafted into the space where the vertebral bones have been taken out. The graft acts like a supportive column, or strut, to support the elongated space and to prevent the neck from buckling forward. Your surgeon may attach a metal plate along the front of the spine to help lock the new graft in place.

Another X-ray is taken to check the position of the graft. Then the muscles and soft tissues are put back in place, and the skin is stitched together. Patients are often placed in a rigid neck brace for at least three months to hold the neck still while the bones grow together, or fuse.

Complications

What might go wrong?

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

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

This is not intended to be a complete list of the possible complications, but these are the most common.

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

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 very 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 and may require additional surgery to treat the infected portion of the spine. Your surgeon may give you antibiotics before spine surgery when the procedure requires bone grafts or hardware (plates, rods, or screws).

Nerve Damage

Problems with the Graft or Hardware

Corpectomy surgery requires bone to be grafted into the spinal column. The graft is taken from either the top rim of the pelvis or, more commonly, from the fibula bone along the outside of the lower leg. There is a risk of having pain, infection, or weakness in the area where the graft is taken.

After the graft is placed, the surgeon checks the position of the graft before completing the surgery. However, the graft may shift slightly soon after surgery to the point it is no longer able to hold the spine stable. When the graft migrates out of position, it may cause injury to the nearby tissues. When the graft shifts out of place, a second surgery may be needed to align the graft and apply more hardware to hold it 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. The surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem.

Nonunion

In the second procedure, the surgeon usually adds more bone graft. If hardware was used in the first surgery, the surgeon will check to make sure it is attached firmly. Hardware may also be added to secure the bones so they will fuse together.

Ongoing Pain

Corpectomy is a complex surgery. Not all patients feel complete pain relief with this procedure. The main goal of this surgery is to get pressure off the spinal cord and to try and prevent further problems. 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?

Most patients are placed in a rigid neck brace or a halo vest, for a minimum of three months after surgery. These restrictive measures 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 will schedule daily sessions to help patients learn safe ways to move, dress, and do activities without putting extra strain on the neck.

Rehabilitation

What should I expect during my recovery?

Rehabilitation after corpectomy surgery can be a slow process. You will probably need to attend therapy sessions for two to three months, and you should expect full recovery to take up to one year.

Many surgeons prescribe outpatient physical therapy beginning a minimum of five weeks after surgery. At first, treatments are used to 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 treatments to ease muscle spasm and pain.

Active treatments are slowly added. These include exercises for improving heart and lung function. Walking, stationary cycling, and arm cycling are ideal cardiovascular exercises. Therapists also teach specific exercises to help tone and control the muscles that stabilize the neck and upper back.

Your therapist also 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 neck 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’ll learn how to keep your neck safe while you lift and carry items and as you begin to do other heavier activities.

As your condition improves, your therapist will tailor 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 heavy and strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job. You’ll learn new ways to do these tasks to keep your neck safe and free of extra strain.

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

Cervical Discectomy

A Patient’s Guide to Cervical Discectomy

Introduction

Cervical discectomy is surgery to remove one or more discs from the neck. The disc is the pad that separates the neck vertebrae; ectomy means to take out. Usually a discectomy is combined with a fusion of the two vertebrae that are separated by the disc. In some cases, this procedure is done without a fusion. A cervical discectomy without a fusion may be suggested for younger patients between 20 and 45 years old who have symptoms due to a herniated disc.

This guide will help you understand

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

Anatomy

What parts of the neck are involved?

Surgeons usually perform this procedure through the front of the neck. This is called the anterior neck region. Key structures include ligaments, bones, intervertebral discs, spinal cord, spinal nerves and the neural foramina.

Surgery is occasionally done through the back, or posterior region, of the neck. Important structures in this area include the ligaments and bones, especially the lamina bones.

Rationale

What do surgeons hope to achieve?

Discectomy is used to alleviate symptoms of a herniated disc. A disc herniation happens when the nucleus inside the center of the disc pushes through the annulus, the ligaments surrounding the nucleus. The herniated disc material may push outward, causing pain. Numbness or weakness in the arm occurs when the nucleus pushes on the spinal nerve root. Of greater concern is a condition in which the nucleus herniates straight backward into the spinal cord, called a central herniation. Discectomy relieves pressure on the ligaments, nerves, or spinal cord.

Discectomy is also commonly used when the surgeon plans to fuse the bones of two neck vertebrae into one solid bone. Most surgeons will take the disc out and replace the empty space with a block of bone graft, a procedure called cervical fusion.

Discectomy alone is usually only used for younger patients (20 to 45 years old) whose symptoms are from herniation of the disc. But some surgeons think discectomy should always be combined with fusion of the bones above and below. They are concerned that the empty space where the disc was removed may eventually collapse and fill in with bone. Inserting a bone block during fusion surgery helps keep pressure off the spinal nerves because the graft widens the neural foramina. The neural foramina are openings on each side of the vertebrae where nerves exit the spinal canal. Most research on discectomy by itself shows good short-term benefits compared to discectomy with fusion. But more information is needed about whether the long-term results are equally as good.

Preparations

How will I prepare for surgery?

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?

Cervical discectomy is commonly done through the anterior (front) of the neck. This is called an anterior cervical discectomy. However, when many pieces of the herniated disc have squeezed into the posterior (back) of the spine, surgeons may need to operate through the back of the neck using a procedure called a posterior cervical discectomy.

Anterior Discectomy

The patient’s neck is positioned facing the ceiling with the head bent back and turned slightly to the right. A two-inch incision is made two to three fingers’ width above the collar bone across the left-hand side of the neck. The left side is chosen to avoid injuring the nerve going to the voice box. Retractors are used to gently separate and hold the neck muscles and soft tissues apart so the surgeon can work on the front of the spine.

A needle is inserted into the herniated disc, and an X-ray is taken to identify and confirm it is the correct disc. A long strip of muscle and the anterior longitudinal ligament that cover the front of the vertebral bodies are carefully pulled to the side. Forceps are used to take out the front half of the disc. Next a small rotary cutting tool (a burr) is used to carefully remove the back half of the disc. A surgical microscope is used to help the surgeon see and remove pieces of disc material and any bone spurs that are near the spinal cord.

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

Posterior Discectomy

This method is used when the herniated disc has fragmented into small pieces near the spinal nerve.

The operation is usually done with the patient lying face down with the neck bent forward and held in a headrest. The surgeon makes a short incision down the center of the back of the neck. The skin and soft tissues are separated to expose the bones along the back of the spine.

Then the surgeon may use an X-ray to identify the injured disc. A burr is used to shave the edge off the lamina bones, the back part of the ring over the spinal cord. When the disc has jutted straight backward into the spinal cord (central herniation), surgeons may need to completely remove both lamina bones in order to see better and to be able to clear all the pieces of the disc near the spinal cord.

After shaving the lamina bone, the surgeon cuts a small opening in the ligamentum flavum, a ligament within the spinal canal and in front of the lamina bone. By removing part of this ligament, the surgeon exposes the spot where the disc fragments are pressed against the spinal nerve. Next, the spinal nerve is gently moved upward. Using a surgical microscope, the surgeon magnifies the area in order to carefully remove the disc fragments and any bone spurs.

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 discectomy include

problems with anesthesia
thrombophlebitis
infection
nerve damage
ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most common.

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

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 and may require additional surgery to treat the infected portion of the spine.

Nerve Damage

The nerve to the voice box is sometimes injured during surgery on the front of the neck. When doing anterior neck surgery, surgeons prefer to go through the left side of the neck where the path of the nerve to the voice box is more predictable than on the right side. During surgery, the nerve may get stretched too far when retractors are used to hold the muscles and soft tissues apart. When this happens, patients may be hoarse for a few days or weeks after surgery. In rare cases where the nerve is actually cut, patients may end up with ongoing minor problems of hoarseness, voice fatigue, or difficulty making high tones.

Ongoing Pain

Many patients get nearly complete relief of symptoms from the discectomy 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 an hour or two after surgery. Your surgeon may have you wear a hard or soft neck collar. If not, you will be instructed to move your neck only carefully and comfortably.

Most patients leave the hospital the day after surgery and are safe to drive within a week or two. People generally get back to light work by four weeks and can do heavier work and sports within two to three months.

Outpatient physical therapy is usually prescribed only for patients who have extra pain or show significant muscle weakness and deconditioning.

Rehabilitation

What should I expect as I recover?

Patients usually don’t require formal rehabilitation after routine cervical discectomy surgery. Surgeons may prescribe a short period of physical therapy when patients have lost muscle tone in the shoulder or arm, when they have problems controlling pain, or when they need guidance about returning to heavier types of work.

If you require outpatient physical therapy, you will probably only need to attend therapy sessions for two to four weeks. You should expect full recovery to take up to three months.

At first, therapy treatments are used to 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 treatments to ease muscle spasm and pain.

Active treatments are added slowly. These include exercises for improving heart and lung function. Walking, stationary cycling, and arm cycling are ideal cardiovascular exercises. Therapists also teach specific exercises to help tone and control the muscles that stabilize the neck and upper back.

As your condition improves, your therapist will begin tailoring 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 heavy and strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job. Your therapist can also provide ideas for alternate forms of work. You’ll learn to do your tasks in ways that keep your neck safe and free of extra strain.

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

Cervical Foraminotomy

A Patient’s Guide to Cervical Foraminotomy

Introduction

Foraminotomy is a surgical procedure for widening the area where the spinal nerve roots exit the spinal column. A foramen is the opening around the nerve root, and otomy refers to the medical procedure for enlarging the opening. In this procedure, surgeons widen the passageway to relieve pressure where the spinal nerve is being squeezed in the foramen.

This guide will help you understand

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

Anatomy

What parts of the neck are affected?

The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. The spinal canal is a hollow tube formed by the bony rings of all the vertebrae. The spinal canal surrounds and protects the spinal cord within the spine. There are seven vertebrae in the neck that form the area known as the cervical spine. The vertebrae are separated by intervertebral discs.

Traveling from the brain down through the spinal column, the spinal cord sends out nerve branches through openings on both sides of each vertebra. These openings are called the neural foramina. (The term used to describe a single opening is foramen.)

The intervertebral disc 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.

Rationale

What do surgeons hope to achieve?

Foraminotomy alleviates the symptoms of foraminal stenosis. In foraminal stenosis, a nerve root is compressed inside the neural foramen. This compression is usually the result of degenerative (or wear and tear) changes in the spine.

View animation of disc collapse

Wear and tear from repeated stresses and strains on the neck can cause a spinal disc to begin to collapse. As the space between the vertebral bodies shrinks, the opening around the nerve root narrows. This squeezes the nerve. The nerve root is further squeezed in the foramen when the facet joint lining the outer edge of the foramen becomes inflamed and enlarged as a result of the same degenerative changes.

The degenerative process can also cause bone spurs to develop and point into the foramen, causing further irritation. In a foraminotomy, the surgeon removes the tissues around the edges of the foramen, essentially widening the opening in order to take pressure off the nerve root.

Preparations

How will I prepare for surgery?

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. For shorter procedures such as foraminotomy, patients are usually given a gas form of anesthesia through a mask. 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.

This surgery is usually done with the patient lying face down on the operating table. The surgeon makes an incision down the middle of the back of the neck. The skin and soft tissues are separated on the side where the spinal nerves are compressed. Some surgeons use a surgical microscope during the procedure to magnify the area they’ll be working on.

The surgeon may use a small, rotary cutting tool (a burr) to shave the inside edge of the facet joint. This opens up the outer rim of the neural foramen. The burr is sometimes used to shave a small section of the bony ring on the back of the vertebra above and below the affected nerve root.

Small cutting instruments are used to carefully remove soft tissues within the neural foramen. The surgeon takes out any small disc fragments that are present and scrapes off nearby bone spurs. In this way, tension and pressure are taken off the nerve root.

The muscles and soft tissues are put back in place, and the skin is stitched together. Patients are sometimes placed in a soft collar after surgery to keep the neck positioned comfortably.

Complications

What might go wrong?

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

problems with anesthesia
thrombophlebitis
infection
nerve damage
ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most common.

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

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 and may require additional surgery to treat the infected portion of the spine.

Nerve Damage

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 these structures can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Ongoing Pain

Many patients get nearly complete pain relief from the foraminotomy 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 an hour or two after surgery. Your surgeon may have you wear a soft neck collar. If not, you will be instructed to move your neck only carefully and comfortably.

Outpatient physical therapy is usually prescribed when patients have extra pain or show significant muscle weakness and deconditioning.

Rehabilitation

What should I expect during my recovery?

Rehabilitation after foraminotomy surgery is generally needed for only a short period of time. If you require outpatient physical therapy, you will probably need to attend therapy sessions for two to four weeks. You should expect full recovery to take up to two or three months.

Many surgeons prescribe outpatient physical therapy within four weeks after surgery. At first, treatments are used to 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 treatments to ease muscle spasm and pain.

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 neck 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’ll learn how to keep your neck safe while you lift and carry items and as you begin to do heavier activities.

As your condition improves, your therapist will begin tailoring 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 heavy and strenuous tasks. Therapists may suggest changes in job tasks that enable you to go back to your previous job. They may also provide ideas for alternate forms of work. You’ll learn to do your tasks in ways that keep your neck safe and free of extra strain.

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

Shoulder Instability

A Patient’s Guide to Shoulder Instability

Introduction

Shoulder instability means that the shoulder joint is too loose and is able to slide around too much in the socket. In some cases, the unstable shoulder actually slips out of the socket. If the shoulder slips completely out of the socket, it has become dislocated. If not treated, instability can lead to arthritis of the shoulder joint.

This guide will help you understand

what parts of the shoulder are involved
what causes shoulder instability
what treatments are available

Anatomy

What parts of the shoulder are involved?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone,) and the clavicle (collarbone).

The rotator cuffconnects the humerus to the scapula. The rotator cuff is actually made up of the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move bones by pulling on tendons. The muscles of the rotator cuff also keep the humerus tightly in the socket. A part of the scapula, called the glenoid, makes up the socket of the shoulder.

The glenoid is very shallow and flat. A rim of soft tissue, called the labrum, surrounds the edge of the glenoid, making the socket more like a cup. The labrum turns the flat surface of the glenoid into a deeper socket that molds to fit the head of the humerus.

Surrounding the shoulder joint is a watertight sac called the joint capsule. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are soft connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so that the shoulder is unrestricted as it moves through its large range of motion. If the shoulder moves too far, the ligaments become tight and stop any further motion, sort of like a dog coming to the end of its leash.

Dislocations happen when a force overcomes the strength of the rotator cuff muscles and the ligaments of the shoulder. Nearly all dislocations are anterior dislocations, meaning that the humerus slips out of the front of the glenoid. Only three percent of dislocations are posterior dislocations, or out the back.

Sometimes the shoulder does not come completely out of the socket. It slips only partially out and then returns to its normal position. This is called subluxation.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What makes a shoulder become unstable?

Shoulder instability often follows an injury that caused the shoulder to dislocate. This initial injury is usually fairly significant, and the shoulder must be reduced. To reduce a shoulder means it must be manually put back into the socket. The shoulder may seem to return to normal, but the joint often remains unstable. The ligaments that hold the shoulder in the socket, along with the labrum (the cartilage rim around the glenoid), may have become stretched or torn. This makes them too loose to keep the shoulder in the socket when it moves in certain positions. An unstable shoulder can result in repeated episodes of dislocation, even during normal activities. Instability can also follow less severe shoulder injuries.

Related Document: A Patient’s Guide to Labral Tears

In some cases, shoulder instability can happen without a previous dislocation. People who do repeated shoulder motions may gradually stretch out the joint capsule. This is especially common in athletes such as baseball pitchers, volleyball players, and swimmers. If the joint capsule gets stretched out and the shoulder muscles become weak, the ball of the humerus begins to slip around too much within the shoulder. Eventually this can cause irritation and pain in the shoulder.

A genetic problem with the connective tissues of the body can lead to ligaments that are too elastic. When ligaments stretch too easily, they may not be able to hold the joints in place. All the joints of the body may be too loose. Some joints, such as the shoulder, may be easily dislocated. People with this condition are sometimes referred to as double-jointed.

Symptoms

What problems does an unstable shoulder cause?

Chronic instability causes several symptoms. Frequent subluxation is one. In subluxation, the shoulder may slip (sublux) in certain positions, and the shoulder may actually feel loose. This commonly happens when the hand is raised above the head, for example while throwing. Subluxation of the shoulder usually causes a quick feeling of pain, like something is slipping or pinching in the shoulder. Over time, you may stop using the shoulder in ways that cause subluxation.

The shoulder may become so loose that it starts to dislocate frequently. This can be a real problem, especially if you can’t get it back in the socket and must go to the emergency room every time. A shoulder dislocation is usually very obvious. The injury is very painful, and the shoulder looks abnormal. Any attempted shoulder movements cause extreme pain. A dislocated shoulder can damage the nerves around the shoulder joint.

If the nerves have been stretched, a numb spot may develop on the outside of the arm, just below the top point of the shoulder. Several of the shoulder muscles may become slightly weak until the nerve recovers. But the weakness is usually temporary.

Diagnosis

What tests will my doctor run?

Your doctor will diagnose shoulder instability primarily through your medical history and physical exam. The medical history will include many questions about past shoulder injuries, your pain, and the ways your symptoms are affecting your activities.

In the physical exam, your doctor will feel and move your shoulder, checking it for strength and mobility. Your doctor will stress the shoulder to test the ligaments. When the shoulder is stretched in certain directions, you may get the feeling that the shoulder is going to dislocate. This is a very important sign of instability. It is called an apprehension sign. (Don’t worry. Unless your shoulder is extremely loose, it will not dislocate.)

Your doctor may order an X-ray. X-rays can help confirm that your shoulder was dislocated or injured in the past.

If your doctor is unsure about the diagnosis, you may need to undergo further tests. A surgeon may need to examine your shoulder using an arthroscope while you are under general anesthesia, which puts you to sleep. An arthroscope is a tiny TV camera inserted into the shoulder through a small incision. This allows a good look at the muscles and ligaments of the shoulder. When you are awake, it is hard to test the ligaments because you automatically tighten the muscles during the exam.

When you go to the doctor with a dislocated shoulder, X-rays are necessary to rule out a fracture. X-rays are usually done after the shoulder is put back into joint. This allows your doctor to make sure the joint is back in place.

Treatment

What treatment options are available?

Nonsurgical Treatment

Your doctor’s first goal will be to help you control your pain and inflammation. Initial treatment to control pain is usually rest and anti-inflammatory medication, such as aspirin or ibuprofen. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone is a strong anti-inflammatory medication.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, patients are shown ways to avoid positions and activities that put the shoulder at further risk of injury or dislocation. Overhand athletes may be issued a special shoulder strap or sleeve to stop the shoulder from moving in ways that strain it.

Your therapist may use heat or ice treatments to ease pain and inflammation. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder and nearby joints and muscles. Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This will improve the stability of the shoulder and help your shoulder joint move smoothly.

You may need therapy treatments for six to eight weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgery

If your therapy program doesn’t stabilize your shoulder after a period of time, you may need surgery. There are many different types of shoulder operations that have been developed and used in the past to stabilize the shoulder. Almost all of these operations attempt to tighten the ligaments that are loose. The loose ligaments are usually along the front or bottom part of the shoulder capsule.

Surgery on the shoulder has improved dramatically over the past two decades. many of the procedures that have been developed in the past have been abandoned altogether. Today, surgery that is performed for stabilizing an unstable shoulder is most commonly done using the arthroscope.

Bankart Repair

The most common method for surgically stabilizing a shoulder that is prone to anterior dislocations is the Bankart repair. In the past, the Bankart repair was done through a large incision made in the front (anterior) shoulder joint. This required damage to a great deal of normal tissue in order for the surgeon to be able to see the damaged portion of the joint capsule. The procedure was difficult and usually involved an attempt to sew or staple the ligaments on the front side of the joint back into their original position.

The arthroscope has changed all that.

An arthroscope is a special type instrument designed to look into a joint, or other space, inside the body. The arthroscope itself is a slender metal tube smaller than a pencil. Inside the metal tube are special strands of glass called fiberoptics. These small strands of glass form a lens that allows one to look into the tube on one end and see what is on the other side – inside the space. This is similar to a microscope or telescope. In the early days of arthroscopy, the surgeon actually looked into one end of the tube. Today, the arthroscope is attached to a small TV camera. The surgeon can watch the TV screen while the arthroscope is moved around in the joint. Using the ability to see inside the joint, the surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.

The arthroscope lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery. If your surgery is done with the arthroscope, you may be able to go home the same day.

To perform the Bankart type repair using the arthroscope, several small incisions are made to insert the arthroscope and special instruments needed to complete the procedure. These incisions are small, usually about one-quarter inch long. It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations to see different areas of the shoulder.

A small plastic, or metal, tube is inserted into the shoulder and connected with sterile plastic tubing to a special pump. Another small tube allows the fluid to be removed from the joint. This pump continuously fills the shoulder joint with sterile saline (salt water) fluid. This constant flow of fluid through the joint inflates the joint and washes any blood and debris from the joint as the surgery is performed.

There are many small instruments that have been specially designed to perform surgery in the joint. Some of these instruments are used to remove torn and degenerative tissue. Some of these instruments nibble away bits of tissue and then vacuum them up from out of the joint. Others are designed to burr away bone tissue and vacuum it out of the joint. These instruments are used to remove any bone spurs that are rubbing on the tendons of the shoulder and smooth the under surface of the acromion and AC joint.

Once any degenerative tissue and bone spurs are removed, the torn ligaments that stabilize the shoulder are reattached to the bone around the socket of the shoulder, the glenoid. Special devices have been designed to reattach these ligaments. These devices are called suture anchors.

Suture anchors are special devices that have been designed to attach tissue to bone.In the past, many different ways were used to attach soft tissue (such as ligaments and tendons) to bone. The usual methods have included placing stitches through drill holes in the bone, special staples and screws with special washers – all designed to hold the tissue against the bone until healing occurred. Most of these techniques required larger incisions to be able to see what was going on and to get the hardware and soft tissue in the right location.

Today, suture anchors have simplified the process and created a much stronger way of attaching soft tissue to bone. These devices are small enough that the can be placed into the appropriate place in the bone through a small incision using the arthroscope. Most of these devices are made of either metal or a special plastic-like material that dissolves over time. This is the “anchor” portion of the device. The anchor is drilled into the bone where the surgeon wished to attach the soft tissue. Sutures are attached to the anchor and threaded through the soft tissue and tied down against the bone.

Capsular Shift

Another surgery to tighten a loose shoulder joint is a procedure called a capsular shift. The lining of any joint is called the joint capsule. The joint capsule forms a pocket, or bag that is made up of the ligaments and connective tissue around the joint. The shoulder joint has a fairly large joint capsule that is necessary to allow the joint to move in such a wide range.

Sometimes the problem causing the shoulder instability is because the joint capsule is simply too large. This is sometimes referred to as a redundant, or patulous joint capsule. This may cause shoulder instability in multiple directions. This is sometimes referred to as multi-directional instability. In order to fix this type of instability, the joint capsule needs to be made smaller and tightened.

This procedure also can be performed using the arthroscope. The surgeon pulls the flap of tissue over the front of the capsule and connects it together. This is similar to when a tailor tucks loose fabric by overlapping and sewing the two parts together. Once the appropriate degree of tightness is achieved, the surgeon uses a combination of sutures and suture anchors to hold the joint capsule in this position until healing occurs.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even nonsurgical treatment for shoulder instability usually requires a rehabilitation program. The goal of therapy will be to strengthen the rotator cuff and shoulder blade muscles to make the shoulder more stable. At first you will do exercises with a therapist. Eventually you will be put on a home program of exercise to keep the muscles strong and flexible. This should help you avoid future problems.

After Surgery

Rehabilitation after surgery is more complex. You will likely wear a sling to support and protect the shoulder for one to four weeks. A physical or occupational therapist may direct your recovery program. Depending on the surgical procedure, you will probably need to attend therapy sessions for two to four months. You should expect full recovery to take up to six months.

The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy after Bankart surgery proceeds slowly. Range-of-motion exercises begin soon after surgery, but therapists are cautious about doing stretches on the front part of the capsule for the first six to eight weeks. The program gradually works into active stretching and strengthening.

Therapy goes even slower after surgeries where the front shoulder muscles have been cut. Exercises begin with passive movements. During passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts three to four weeks after surgery. You use your own muscle power in active range-of-motion exercises. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.

At about six weeks you start doing more active strengthening. Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities.

By about the tenth week, you will start more active strengthening. These exercises focus on improving strength and control of the rotator cuff muscles. Strong rotator cuff muscles help hold the ball of the humerus tightly in the glenoid to improve shoulder stability.

Overhand athletes (such as those who throw baseballs or footballs) start gradually in their sport activity about three months after surgery. They can usually return to competition within four to six months.

Some of the exercises you’ll do are designed to get your shoulder 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 shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Thoracic Outlet Syndrome

A Patient’s Guide to Thoracic Outlet Syndrome

Introduction

Thoracic outlet syndrome (TOS) can cause pain and numbness in the shoulder, arm, and hand. Testing for TOS is difficult. There is no one test to accurately diagnose TOS, and other conditions can have similar symptoms. You will need to go through several tests to find out if TOS is actually the cause of your pain. Making the right diagnosis often takes time and can be a cause of frustration, both for you and your doctor.

This guide will help you understand

what happens to cause TOS
what tests will be used to diagnose the condition
what can be done to relieve your pain

Anatomy

What is the thoracic outlet?

The nerves and blood vessels that go into the arm and hand start at the side of the neck. Nerves come out of the spine through small openings along the side of each vertebra. These openings are called neural foramina.

The nerves and vessels travel between muscles in the neck called the scalene muscles and over the top of the rib cage. The thoracic outlet is this opening between the scalene muscles and the rib cage. The nerves and blood vessels then go under the collarbone (also known as the clavicle), through the armpit (the axilla), and down the arm to the hand.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes TOS problems?

The main cause of TOS is that the nerves and blood vessels going to the arm and hand get squeezed near the thoracic outlet. This can occur for many reasons.

Pressure on nerves and vessels can happen in people who have fractured their clavicle. It can also happen in people who have an extra first rib, although this doesn’t always result in TOS.

Extra muscle or scar tissues in the scalene muscles can put extra pressure on the nerves and arteries. Heavy lifting and carrying can bulk up the scalenus muscles to the point where the nerve and arteries get squeezed.

Traumatic injury from a car accident can also cause problems that lead to TOS. In an accident, the shoulder harness of the seat belt can strain or tear the muscles. As they heal, scar tissue can build up, putting pressure on the nerves and blood vessels at the thoracic outlet.

Neck and arm positions used at work and home may contribute to TOS. People who have to hold their neck and shoulders in awkward alignment sometimes develop TOS symptoms. TOS symptoms are also reported by people who have to hold their arms up or out for long periods of time.

People with TOS often slouch their shoulders, giving them a drooped appearance. The poor body alignment of slouching can compress the nerves and arteries near the thoracic outlet. Being overweight can cause problems with posture, and women who have very large breasts may also have a droopy posture. For some reason, TOS affects three times as many women as men.

Symptoms

What symptoms does TOS cause?

TOS causes pain along the top of the clavicle and shoulder. The pain may spread along the inside edge of the arm. Occasionally pain spreads into the hand, mostly into the ring and pinky fingers. Numbness and tingling, called paresthesia, may accompany the pain, especially in the early hours of the morning before it’s time to wake up. Symptoms tend to get worse when driving, lifting, carrying, and writing. The arms may also feel tired when held overhead, as when using a blow dryer. It may be harder to hold and grip things, and the hand may feel clumsy.

Symptoms related to the blood vessels are less common. If the blood vessels are causing symptoms, the arm and shoulder may feel heavy and cold. The arm may become somewhat blue (cyanotic), and the constriction of vessels can cause the arm and hand to swell. Problems with the blood vessels that go to the arm are serious. If you experience these symptoms, you should call your doctor right away.

TOS symptoms are similar to the symptoms of many other conditions. A herniated disc in the neck, carpal tunnel syndrome in the hand, and bursitis of the shoulder can all cause symptoms very much like those of TOS.

Diagnosis

How will my doctor know that I have TOS?

Because TOS doesn’t have any unique symptoms, it can be difficult to diagnose. The diagnosis of TOS involves getting as much information as possible to eliminate other possible causes of your pain.

First, your doctor will take your medical history and do a thorough physical examination. Because TOS is so difficult to diagnose, your doctor will rely heavily on what you report about your symptoms and medical history.

You may need to get an X-ray. The X-ray could show an extra cervical rib or other problems with the bones and joints, such as arthritis. Your doctor may also ask you to get an magnetic resonance imaging (MRI) scan or other imaging tests. MRI scans use magnetic waves to show pictures of the bones and soft tissues of your body in slices. X-rays and other imaging tests are mostly used to rule out other problems.

Your doctor may recommend electrical tests, called electromyography, of the nerves in the arm. These tests are used to find out if the nerves between the neck and hand are being pinched.

To confirm the diagnosis, doctors may do special tests of the blood vessels that run along the nerves. These tests are frequently negative, but it is important that your doctor rule out other causes of your pain.

Treatment

What treatment options are available?

Nonsurgical Treatment

Doctors begin treating your pain conservatively, without surgery or other invasive procedures. Your doctor can prescribe some types of medicine to ease your discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, can relieve pain and inflammation, and muscle relaxants can relieve muscle spasm. Some patients who experience chronic pain, such as the pain of TOS, end up battling depression. In these cases, anti-depressants can be very helpful.

Your doctor may recommend some simple ways to help you combat TOS. For example, decrease the tension of the shoulder strap of your seat belt. Take rest periods to avoid fatigue. Overweight patients should seek help with weight loss, and women with especially large breasts may benefit from using a strapless long-line bra. Avoid heavy lifting, pulling, or pushing. Rapid breathing and stress can worsen symptoms. Avoid looking up, bending the neck back, or holding your arms up for long periods of time. And don’t carry a purse or bag on the affected shoulder.

Your doctor may start you on some basic exercises. If you have done them for some time and your symptoms aren’t getting much better, you may need to work with a physical or occupational therapist.

In most cases therapy can be very effective. However, therapy may not help much if your symptoms are so severe that the muscles of the hand or forearm have atrophied (shrunk).

Surgery

Surgery for TOS is usually a last resort. The surgery is directed at removing the source of compression on the nerves of the brachial plexus. The brachial plexus is the network of nerves that go to the hand and forearm. If there is an extra rib, it is usually removed. Otherwise, surgery consists of simply releasing the constricting elements and scar tissue around the nerves.

Surgery is usually done through an incision under the arm. The surgery will require a general anesthetic, which will put you to sleep. You will probably need to spend at least one night in the hospital.

Rehabilitation

What can I expect after treatment?

Nonsurgical Rehabilitation

If you are getting nonsurgical treatments, a home exercise program is essential to the treatment of TOS. This is true even if the cause of your TOS is an abnormality in the bones and muscles. You must consistently do your exercises to get the most benefit.

Usually a physical or occupational therapist will direct your exercise program. Rehabilitation may begin with a few exercises to loosen up tight muscles and joints around the compressed nerves and blood vessels. To help restore normal mobility, your therapist may prescribe stretching for the joints, muscles, and nerves. Your therapist can also help you find ways to manage your pain and avoid future problems.

You will be given exercises to strengthen the muscles of your shoulder and upper back and to stretch the muscles in the front of the chest and shoulders. Swimming can help some patients, but the backstroke and full breaststroke may worsen the condition. Your exercise program will focus on helping you sit and stand with good posture. Good posture is critical to managing TOS symptoms.

Your therapist can also give you tips to help avoid TOS pain. For example, you should limit the length of time the arms are used in outstretched or overhead positions, and don’t do heavy carrying and lifting. Simple things like taking frequent breaks, changing positions, stretching, or using a hand truck or cart can bring relief. Your doctor or therapist can help you with any specific tasks that cause you pain.

After Surgery

Your rehabilitation will likely be more complex after surgery. Patients wear a sling after surgery to support the shoulder and arm. Passive movements can begin soon after surgery. But there should be no active motion for about two weeks, to allow the soft tissues time to heal.

Patients usually start doing resistive exercise and activities after three to four weeks. Therapy treatments help improve motion in the shoulder blade and arm. Posture and strengthening exercises help prevent future TOS problems.

Your surgeon and therapist will give special attention to the type of work you do. They may have suggestions to help you avoid work postures and activities that could cause problems. You’ll be shown strategies to take care of any future symptoms and avoid further problems.

Anterior Lumbar Interbody Fusion

A Patient’s Guide to Anterior Lumbar Interbody Fusion

Introduction

Anterior lumbar interbody fusion (ALIF) is a procedure used to treat problems such as disc degeneration, spine instability, and deformities in the curve of the spine. In this procedure, the surgeon works on the spine from the front (anterior) and removes a spinal disc in the lower (lumbar) spine. The surgeon inserts a bone graft into the space between the two vertebrae where the disc was removed (the interbody space). The goal of the procedure is to stimulate the vertebrae to grow together into one solid bone (known as fusion). Fusion creates a rigid and immovable column of bone in the problem section of the spine. This type of procedure is used to try and reduce back pain and other symptoms.

This guide will help you understand

what surgeons hope to achieve
what happens during surgery
what to expect as you recover

Anatomy

What parts of the spine and low back are involved?

ALIF surgery is performed through the front (anterior). The structures in this area include the anterior longitudinal ligament, the vertebral bodies, and the intervertebral discs. The anterior longitudinal ligament attaches along the front of the spinal column. 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.

Rationale

What do surgeons hope to achieve?

This procedure is often used to stop symptoms from lumbar disc disease. Discs degenerate, or wear out, as a natural part of aging and also from stress and strain on the back. Over time, the disc begins to collapse, and the space decreases between the vertebrae.

When this happens, the openings around the spinal nerves (the neural foramina) narrow and may put pressure on the nerves. The long ligaments in the spine slacken due to the collapse in vertebral height. These ligaments may buckle and put pressure on the spinal nerves.

View animation of degeneration

Also, the outer rings of the disc, the annulus, weaken and develop small cracks. Tears in the outer annulus are painful because these tissues are rich with pain sensors. The nucleus in the center of the disc may press on the weakened annulus and actually squeeze out of the annulus (herniate). Inflammation from the nucleus as it escapes the annulus also causes pain. 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.

If the nucleus presses against the spinal nerves, symptoms of pain, numbness, and weakness may occur where the nerve travels. Pressure on the spinal nerves inside the spinal canal can also produce problems with the bowels and bladder, requiring emergency surgery.

Discectomy is the removal of the disc (and any fragments) between the vertebrae that are to be fused. Taking out the painful disc is intended to alleviate symptoms. It also provides room for placing the bone graft that will allow the two vertebrae to fuse together. The medical term for fusion is arthrodesis.

Once the disc is removed, the surgeon spreads the bones of the spine apart slightly to make more room for the bone graft. The bone graft separates and holds the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through these openings. Also, the long ligaments that run up and down inside the spinal canal are pulled taut so they don’t buckle into the spinal canal.

View animation of spreading vertebrae apart

View animation of graft fusion

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 helps relieve the mechanical pain, which occurs in the moving parts of the back. Fusion also prevents additional wear and tear on the spinal segment 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?

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.

The patient is positioned on his or her back with a pad placed under the low back. An incision is made through one side of the abdomen. The large blood vessels that lie in front of the spine are gently moved aside. Retractors are used to gently separate and hold the soft tissues apart so the surgeon has room to work.

The surgeon inserts a needle into the disc. By taking an X-ray with the needle in place, the correct disc is identified. Forceps are used to open the front of the disc. Next, a tool is attached to the vertebrae to spread them apart. This makes it easier for the surgeon to see between the two vertebrae. A small cutting tool (a burr) is used to carefully remove the front half of the disc. A special surgical microscope may be used to help the surgeon see while removing pieces of disc material near the back of the disc space.

The surgeon shaves a layer of bone off the flat surfaces of the two vertebrae. This causes the surfaces to bleed. Bleeding stimulates the bone graft to heal and join the bones together.

The surgeon measures the depth and height between the two vertebrae. Making a separate incision, the surgeon takes a section of bone from the top of the pelvis to use as a graft. The graft is measured to fit snugly in the space where the disc was taken out. The surgeon uses a traction device to spread the two vertebrae apart, and the graft is tamped into place.

Traction is released. Then the surgeon tests the graft by bending and turning the spine to make sure the graft is in the right spot and is locked in place. Another X-ray may be taken to double check the location and fit of the graft.

Most surgeons apply some form of metal hardware, called instrumentation, to prevent movement between the vertebrae. Instrumentation protects the graft so it can heal better and faster. One option involves screwing a strap of metal across the front surface of the spine over the area where the graft rests. A second method involves additional surgery through the low back, either on the same day or during a later surgery. In this operation, metal plates and screws are applied through the back of the spine, locking the two vertebrae and preventing them from moving.

A drainage tube may be placed in the wound. The muscles and soft tissues are then put back in place. The skin is stitched together. The surgeon may place you in a rigid brace that straps across the chest, pelvis, and low back to support the spine while it heals.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following ALIF 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 possible complications.

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

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

Infection

Nerve Damage

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 is the largest artery in the body. This major artery and the large veins that accompany it pass in front of the spine and split to go into each leg. The surgeon has to move these vessels aside to perform the anterior interbody procedure. The vessels can be injured, causing internal bleeding.

Problems with the Graft or Hardware

After the graft is placed, the surgeon checks the position of the graft before completing the surgery. However, the graft may shift slightly soon after surgery to the point that it is no longer able to hold the spine stable. If the graft migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align or replace the graft and to apply metal plates and screws to hold it firmly in place.

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

Nonunion

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 continues to cause pain, the patient may need a second operation.

In the second procedure, the surgeon usually adds more bone graft. Metal plates and screws may also be added to rigidly secure the bones so they will fuse together.

Ongoing Pain

ALIF is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, patients 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 may not be necessary 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, patients work daily with a physical therapist. The therapist demonstrates safe ways to move, dress, and do activities without putting extra strain on the back. The therapist may recommend that the patient use a walker for the first day or two. Before going home, patients are shown ways to help 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 should avoid activities that cause the spine to bend back for at least six weeks. Patients are also cautioned against bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient physical therapy is usually started a minimum of six weeks after the date of surgery.

Rehabilitation

What should I expect as I recover?

Rehabilitation after ALIF 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 graft has time to fuse. You will probably need to attend therapy sessions for two to three months. You should expect full recovery to take up to eight months. However, therapy can usually progress faster in patients who had fusion with instrumentation.

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