FAQ Category: General Spine

When patients have chronic pain that affects their quality of life, doctors do usually take this into consideration when suggesting treatment options. For example, a recent study was done to discover if one of two spinal fusion surgeries was more cost effective than the other in terms of the initial surgery and follow up care.

As the cost of health care rises everywhere, care is taken to understand the unseen costs involved in surgery, such as the rate of re-operation, post-surgery clinical visits, rehabilitation, and the patient’s ability to work.

Many times, there is more than one way to perform a certain procedure. While some may have a higher complication rate or a lower success rate, usually the different procedures are chosen for a variety of reasons.

While it may seem that both do the same thing, there may be issues with the patient and the problem that call for one approach over the other. Or, the surgeon may be more experienced with one procedure over the other.

If a patient is concerned about a surgeon’s approach, it’s best to speak with the surgeon in order to understand the reasoning behind the choice.

The spine, which is made up of several small bones called the vertebrae, can curve either from side to side (scoliosis), forward (kyphosis), or backward (lordosis, usually in the lower back).

The most common curvature is scoliosis; someone can have more than one curve, making an “S” shape with the spine. When the spine is curved, it affects other parts of the body. For example, there may be less room for the lungs to expand, making breathing a problem. A curve in the spine can also cause pain from both the curvature and from the body’s attempt at compensating for it.

Scoliosis can also affect the heart as well. By trying to stop the curve from getting worse or correcting it if it is severe, doctors are hoping to prevent such complications.

An artificial joint or disc is composed of a man-made polymer material that is made to retain its strength and shape as it is subjected to the body’s natural movements.

There are currently four subtypes of prosthesis being used in North America: composite, hydraulic, elastic, and mechanical discs. The type of disc chosen is up to the surgeon and his or her preferences.

A composite prosthesis is made of three parts, the two outer parts and the center that acts as a buffer, allowing the patient’s replacement to act as a lumbar disc. The hydraulic prosthesis contain a gel-like core, which is dehydrated and made as small as possible before it is implanted into the spine. After implantation, it reconstitutes itself with the spinal fluid. The elastic discs work with two titanium plates with an rubber or silicone substance in the middle. Finally, the mechanical disc is more like the traditional joint prosthesis and is composed of metal-hinged plates or a ball and socket design.

Artificial joints or discs are made in a few different ways, depending on the manufacturer. Which one your doctor chooses depends on preference and what is appropriate for each patient.

Although the surgery generally has a good outcome and patients are satisfied, some prosthesis do break down or cause problems. How this is treated depends on what the problem is and if it is fixable. The options include fixing or replacing the prosthesis, or removing it completely. If the prosthesis is removed completely, chances are the surgeon will fuse, or join together, that section of vertebrae.

Minor discomfort after a chiropractic manipulation is common. Some patients report increased symptoms such as pain, stiffness, and even headache or dizziness. Such symptoms usually resolve quickly. Patients often report their motion is better afterwards.

Any time you are having adverse effects from treatment, you should report this to your chiropractor. The treatment approach may need to be modified to reduce these side effects. The chiropractor may also want you to take some specific steps to manage these symptoms when they do occur.

The risk of serious effects of chiropractic spinal manipulation is reportedly low. There are no studies yet to show who might be at risk. It’s possible that those patients who experience minor side effects are at increased risk for a more serious reaction to treatment.

Until this is all sorted out, patients are encouraged to report all effects (both positive or negative).

It is common for patients receiving a manipulation of the cervical spine (neck) to experience some minor adverse effects. This can range from increase in neck pain, stiffness, and soreness to dizziness, fainting and headache.

Most of the time, these symptoms are temporary and go away within 24 to 48 hours. Many people have the opposite result. Their neck pain, stiffness, and numbness and tingling are gone or greatly reduced after chiropractic treatment.

In a small number of patients, more serious effects can occur. Stroke, blood vessel tears, and other neurologic problems have been reported. These occurences are estimated to be low to very low. The exact number or percentage of patients who have adverse responses to cervical spine manipulation remains unknown. More study is needed in this area.

Yes — much safer than relying on what the surgeon can see with the naked eye. Placement of screws is more accurate. And there’s less risk of screw perforation of important structures nearby. Insertion of screws always comes with a risk of damage to the blood vessels, nerves, or spinal cord.

Today’s technology continues to improve making this technique even safer and more accurate. Computer- and virtual-assisted navigation also allows the surgeon to confirm the correct placement of the screws before finishing the operation.

With some of the newest equipment, exposure to radiation is less for the surgeon. Patients can be assessed before the operation using the same imaging device. Surgery can be performed without changing the patient’s position.

Even with this updated technology, the surgeon’s knowledge of anatomy and technical skill are still important factors. Virtual imaging can’t replace experience and careful surgical technique. Surgeons don’t rely just on image guidance.

Using metal plates and screws to help stabilize the spine is called spinal instrumentation. Rigid fixation of the spine through this type of fusion is often needed after trauma. Degenerative disease and tumors can also result in spinal instability requiring this type of fixation.

The placement of the screws varies depending on the problem. Inserting the screws into the pedicles is a common way to stabilize the vertebrae. The pedicles are part of the vertebral segment where the bony ring attaches to the main body of the vertebra.

Perforations of the screw can occur when the size of the screw is larger than the diameter of the bone. Problems can occur if the screw pushes into a blood vessel, nerve, or the spinal cord.

But surgeons often use a technique called the in-and-out to avoid this problem. The screw is threaded in and out of the bone to avoid hitting the wall of the pedicle. The threads of the screw might be exposed but there’s no danger to the nerves or vessels.

Fusion of the spine has been around for many, many years now. For a long time, bone graft was used along with plates and screws. More recently, the development of titanium cages has changed this feature.

Now, after the surgeon removes the disc, a device called a cage (often made of titanium) is inserted in place of the disc. The cages usually come in different heights. This is to make it possible to match each patient’s anatomy as closely as possible.

The titanium mesh cages are usually cylindrical in shape. They provide support for the spine while the bone graft fills in and the spine fuses at that level. There are also different sizes and shapes depending on whether the implant is going in the cervical (neck) or lumbar (low back) spine.

Biofeedback is a way to help people learn to control their own body responses. It can be used to help improve body functions that aren’t under our normal (voluntary) control. This includes things like heart rate, blood pressure, and skin temperature.

But it can also be used to help train or retrain the muscles. Injury, disease, or surgery can get the sensory-motor loops out of balance. Biofeedback helps restore messages between the nervous system and the musculoskeletal system.

A new type of noninvasive feedback is available now to rehab specialists. It’s called rehabilitative ultrasound imaging (RUSI). The therapist uses a transducer or soundhead over the skin. Using sound waves, an image of the deep muscles of the trunk is projected onto a screen or monitor. By seeing this image, the patient is able to contract and hold the muscle. This is done during specific activities or movements.

Over time, the goal is to be able to control the muscle without relying on the RUSI to show that the muscle is contracting. Feedback of this type can help improve motor control and motor performance.

Studies show that biofeedback with selected deep muscles of the trunk and spine can decrease pain. Patients who have participated in this type of rehab program have fewer repeat episodes of low back pain, too.

Core training or spinal stabilization is not a new concept but it has really caught on in the last few years. The idea is to contract the deep muscles of the trunk such as the lumbar multifidus (LM) and the transverse abdominis. This has the effect of increasing the stiffness around the spine and reducing painful motion at the spinal joints.

The first exercise taught in spinal stabilization is the abdominal drawing-in maneuver (ADIM). The patient pulls the belly-button in toward the spine while still breathing in and out. This exercise teaches the patient how to activate these two deep trunk muscles. It’s done without contracting the other abdominal or trunk muscles.

This exercise helps you become more aware of your own control over selected muscles. Improving control of muscle activation has been shown to reduce low back pain (LBP). Following this program consistently has also been proven to reduce future episodes or recurrence of LBP.

Research is uncovering more and more ways to predict who will improve with treatment.This is true for a wide range of medical or health problems. These are called predictive factors of outcome.

In the case of chronic pain affecting the back and/or neck, several predictive factors have been identified. Having both back AND neck pain present at the same time is the first prognostic indicator. These patients are less likely to improve or get better compared to patients who only have neck OR back pain.

Older age (65 years or older) and a previous history of neck or back pain are also included as negative predictive factors. In other words, the presence of either of these is linked with a poor outcome.

Patients who have low expectations of treatment or who do not think they will ever get better often don’t improve. And a recent study from England confirmed that physical therapists are in fact aware of these types of psychosocial factors being strongly linked with poor treatment results.

If you haven’t seen a physician, you might want to consider making an appointment. You may just have a soft tissue injury. But your slower than usual recovery and high pain level may be a sign of a more serious injury. For example, an X-ray may be needed to rule out a bone fracture.

Today’s guidelines for the management of pain associated with acute low back pain is to use acetaminophen (Tylenol) as prescribed by your doctor. Dosage and duration may need to be adjusted for you. An anti-inflammatory drug may also be appropriate.

Narcotics (also referred to as opioids) are usually reserved for people with more severe pain. Their side effects and negative effects from long-term use keep these drugs from being the first line of treatment choice.

Very often patients who are given opioids within the first 15 days of an acute injury end up with more severe, longer lasting pain later. This is when compared to people who have similar injuries who do not take opioids. Early opioid users are more likely to have surgery later.

Given the information here, a medical consultation seems advised. An accurate diagnosis is first. Then the most appropriate treatment can be prescribed. Pain management without the use of opioids may be best. Your doctor will know what to suggest for you.

Bone graft substitute is a fairly new material on the market. There are five basic types but many products within those five types. The composition of each product varies. Some are incorporated into a sponge, which is then pushed into place where needed.

Some bone graft substitutes are injected whereas others are in paste or strip form and applied directly to the surface of the bone defect. They also come in pellet, block, or granular form.

Besides differences in composition, there are also differences in the strength of these materials. How fast or slow they are absorbed by the body is also important. Too fast or too slow can affect the final results.

The FDA must approve bone graft substitutes. However, studies to back up how well they work by patient type or bone location are very limited. The same is true for identifying which type (paste, chips, pellets, etc.) works best. More studies are needed to compare each type.

Scoliosis or curvature of the spine in older adults can present with some unique kinds of problems. For some patients, the aging process affects bone quality. Degenerative effects in the bones can make her scoliosis worse.

As the spine twists and rotates, the soft tissues must change to conform to the new spine position. This can cause painful muscle spasms. Some people have trouble finding a comfortable position. They may have trouble sleeping at night. If the curve is severe enough, the heart, lungs, and other organs start to get pulled or compressed.

Surgery can be done to stabilize the spine but it is not the first line of treatment. Surgeons tend to be very conservative when it comes to the treatment of adult scoliosis. Complication rates are higher for patients having this type of operation.

Bone quality is often marginal at best. Operating on bones with poor quality can cause more problems than it solves. Conservative care may be helpful. Your mother-in-law may be a good candidate for a brace to help support her spine. Physical therapy to strengthen the muscles and improve posture can also help.

With your mother-in-law’s permission, you can discuss all available options with her doctor. He or she may already have in mind the best approach for the specific problem, age of the patient, and functional status.

Conservative care for degenerative spinal deformities is definitely the first approach most doctors recommend. Bracing, physical therapy, and chiropractic care are tried first before surgery is ever considered.

Studies comparing different treatment methods for adult spinal deformities have not been able to identify one approach that works better than another. In general, there’s only weak evidence that bracing works.

For some patients, bracing helps reduce the pain (if they are having any pain). Sometimes function is improved. For example, walking distance increases. If the person has other problems such as arthritis in the hands and/or shoulders, it can be very difficult getting the brace off and on.

Many older adults try a brace for awhile but eventually stop wearing it. They give different reasons for this such as forgetfullness, uncomfortable fit, difficulty putting it on and off, and so on.

It might be helpful to go with your father to his next doctor’s appointment. Let him or her know your concerns. Find out what your father’s options are and what the physician advises. You may have to try one or more approaches before you find something that works for him.

The use of donated human discs is very cutting edge. Only one study has been done so far. It was performed by spine surgeons from Hong Kong and Beijing.

There were only five patients in the study. Although the results were moderately successful, this procedure is not available for everyone just yet. Much more study is needed. But scientists are cautiously optimistic that this type of transplantation is possible.

The patients receiving donor tissue were followed for up to five years. X-rays at the end of that time showed some mild loss of disc space. This suggests there are some degenerative changes occurring in the donated segments.

One patient had a natural neck fusion. The two vertebrae adjacent (next to) the transplanted disc formed a solid union. MRI showed the disc signal was still preserved but there was no movement at that level.

It’s still too early to tell what the long-term effects of transplanted discs may be. Animal studies have been successful enough to conduct trials in humans. There are still many questions about how long the discs will remain alive and if the mechanical stability will last.

Human-to-human disc transplantation has only been done in five adults so far. The results after five years have been very encouraging, but there remain some unknown factors.

So far, animal studies have led scientists to believe that 70 to 80 per cent of the transplanted disc cells survive. This means the majority of disc cells remain to preserve disc function.

Based on animal studies, we also know the recipient (person receiving the disc) won’t experience a rejection reaction like with so many other types of transplanted tissue.

The adult disc has special immune status. This is because it doesn’t have a blood supply. The blood is needed to deliver cells from the immune system that create an immune reaction.

Disc transplantation can be revised. If the disc degenerates or prolapses or fails for any reason, the spine can still be fused. If the patient is eligible, a total disc replacement may also be possible.

Your surgeon is the best one to advise you. Obviously you have had some imaging studies done (such as an X-ray) to know about the rod breakage.

Implant damage does not always mean revision surgery is needed. The surgeon will review your symptoms and function along with measurements taken from the X-rays. If the spine has remained stable, then no further surgery may be needed.

Many spinal fusion operations for scoliosis involve a large number of vertebral bones. In fact, according to a recent study at the Children’s Hospital in Boston, an average of seven segments are fused this way.

If the bones have fused well and there’s no problem with the fractured rod, then the treatment may be just careful watching. If the spine has continued to progress and the scoliosis is getting worse, then a second surgery may be needed.

If the rod is pressing on a nerve or the spinal cord, then serious neurologic problems can develop. In such a case, the rod would be removed. Many times, implant fracture occurs but the instrumentation does not move or shift. It can be left alone.