FAQ Category: General Spine

Thoracolumbar refers to the spot in the spine where the thoracic vertebrae end (T12) and the lumbar vertebrae begin (L1). That point (T12-L1) is called the thoracolumbar junction. Fractures affecting one level above (T11) and one level below (L2) are also included in this category.

Surgeons often use what’s called a classification system to help them identify the location and severity of spinal fractures. Some classification systems also include the mechanism of injury (how it happened). That information is what they use to determine the most appropriate treatment for each patient.

A new system called the Thoracolumbar Injury Classification and Severity Score (TLICS) has been proposed for fractures like you describe. Points are given for three basic characteristics of the injury: type of injury, neurologic status, and condition of the spinal ligaments. For example, a simple compression fracture would be assigned one point. A burst compression fracture would get an additional point for a subtotal of two points.

If the X-ray or other imaging studies show a rotation or translation of the segment, that’s another three points. Four points are added to the subtotal if the fracture has separated and the two ends of the fracture have moved apart.

Values ranging from zero to three are given based on morphology (type of injury: compression, burst) neurologic status (spinal cord or nerve root involvement), and ligament integrity (intact, torn).

The condition of thse soft tissues is important because they can create additional problems if not treated. For example, a distracted fracture with jagged edges increases the risk for nerve damage. A partially or fully torn ligament puts the patient at risk for instability.

The points are all totaled and the final value (indicating severity) guides treatment. Less than four points suggests a nonsurgical approach to treatment is possible. More than four points requires surgery. Patients with zero to four points fall in the middle: they could be candidates for surgical or nonsurgical treatment. In those middle-of-the-road patients, the surgeon must evaluate all factors before making the final treatment decision.

The United States leads the world in diagnostic technology yet for many patients, doctors can’t accurately diagnose their back pain. Relying on MRIs and/or surgery to help identify the problem isn’t working either. Half the patients with abnormal MRIs feel perfectly normal — no back pain at all. And for those with chronic back pain who have surgery the expected pain relief never comes. In fact, they may end up with worse pain than before.

Folks like yourself search for answers they can’t find. It turns out that the diagnosis of back pain IS complex and can be very challenging. Studies done so far show that in many cases, there isn’t just one single pain generator. The discs, ligaments, muscles, bone, nerve roots, and even the coverings and linings of these structures can all turn on a pain signal. When more than one area is affected, the pain messages can overlap, creating back pain that may not respond to one single treatment technique.

It can take a long time and a lot of patience on the part of the patient and the doctor when sorting out individual factors contributing to chronic pain. It can be a process of elimination trying first one treatment technique and then another.

Getting an accurate diagnosis is certainly an important first step. There is good evidence that nerve blocks can be used to diagnose and treat pain coming from spinal joints. Once the involved area has been identified, injections using a local anesthetic (numbing agent) can be given every two months for up to six months. Similar injections using steroid medication (antiinflammatory) can be given every two months for up to a year.

Studies have shown that the sacroiliac joint generates pain signals that can become chronic. Injecting the joint with a local anesthetic and/or steroid or using radiofrequency to stop nerve messages may confirm that area as the source of pain. In fact the diagnostic test is also a form of treatment. Short- to medium-term pain relief is possible. Evidence for the effectiveness of these treatments over a long period is very limited right now.

You are caught in a situation that reflects the current state of affairs when it comes to the diagnosis and treatment of chronic low back pain: there are more questions than answers! Don’t give up. Many patients are able to get the relief they want and need with time, persistence, and perserverance.

The type of system you are using is called an intrathecal (IT). Intrathecal means within the spinal canal. The spinal canal is the opening for the spinal cord to travel from the brain down to the bottom of the spine. Delivering pain medication through the spinal canal directly into the spinal fluid is a fast and effective way to override pain messages to the brain.

This type of pain control is done with a pump that can be implanted (placed) inside the body. The pump is usually placed in the abdomen with a catheter (tube) up into the spinal canal. When placed internally, the intrathecal pump provides a constant stream of pain relieving medications into the spinal fluid. Various medications can be used. They all have advantages and disadvantages. Opioids (narcotics) are commonly tried first.

There are several types of intrathecal drug delivery systems. Some are totally implanted inside the body. Others have an external pump. The internal pumps are often placed in the abdomen. They have a catheter tube that goes into the spinal canal to deliver the drug.

Some units don’t have an actual pump. Instead, they have a catheter that goes from just under the skin to the spinal canal. A tiny opening under the skin (called the port) makes it possible to shoot an injection of medication from the outside into the catheter.

Newer pump models have programmable options for amount of drug delivered allowing preset times to be determined. Others make it possible to self-administer (the patient controls when and how much drug is delivered). Newer pumps have improved life — they are more durable and last longer. Some make it possible to use two different drugs administered without mixing them together.

It’s best to talk this over with your prescribing physician and/or the team members who are helping you manage your pain. Selection of devices depends on cost, features needed by the patient, drug doses and flow required for optimal pain control, and availability.

It may depend on the underlying cause of your problem and what type of treatment you have already received. Larger medical centers often have access to more of the newer treatment techniques. This is especially true for teaching hospitals associated with universities where research is carried out.

For example, interventional pain therapies that involve minimally invasive surgical procedures are often only offered by specialists who have advanced training in this area. Fluoroscopy-guided injections can be used to both diagnose and treat some patients.

Fluoroscopy is a type of real-time X-ray that allows the physician to see the location and pathway of the needle being used to inject the spine. Injecting the nerve, joint, disc, or other likely cause of the pain with a numbing and antiinflammatory agent helps confirm the diagnosis and treat the problem all at the same time.

Fluoroscopy has also made it possible to cut or heat the small sensory nerves that transmit pain signals in order to turn those signals off. The procedure is called a neurotomy. Other fluoroscopic-guided pain procedures include epidurals, adhesiolysis, nerve blocks, and intradiscal electrotherapy. These treatment methods all fall into a category called interventional pain procedures.

It’s possible that even where you are living these more advanced pain control techniques are available. Not everyone is a candidate for interventional pain therapy. Your doctor is the best one to advise you in this decision. It might be a good time to take a step back and review all that you have done to get control of your pain. Now might be a good time to look for additional ways to step up your pain management program that are available locally.

The bones in the spine, the vertebrae sometimes need to be fixed or stabilized and this often includes using screws. Through many years of research, doctors know which size screws work best in which circumstances. As well, the doctors must thoroughly evaluate the patients, taking into account their age, their size, and many other issues. It is with all this information together that the doctors make their decisions.

The spine is divided into different sections depending on how far from the skull it is. The very top of the spine – your neck and uppermost back – is the cervical spine. There are seven vertebrae, the bones that make up the spine, that make up this section. They all begin with C and are followed with the number that corresponds from the base of the skull down, from C1 to C7.

Below the cervical spine is the thoracic spine, where you will find the T1 to T12 vertebrae. Below that is the lumbar spine (L1 to L5) and then below that, the sacral (S1 to S5), which runs to your so-called tailbone.

There are different reasons to fuse the spine and different ways to do the fusion procedure. Surgeons are studying the results of fusion techniques to get an idea of which one works best for each problem. Fusing two or more vertebral bones together prevents motion at those segments and stabilizes the spine. Instrumentation such as screws or metal plates and screws may be used to perform the fusion. Bone grafting using the patient’s own harvested bone or bone from a bone bank (either without instrumentation) is another approach.

More recently, bone graft substitutes have come onto the scene. These materials made from bone are called recombinant human bone morphogenetic proteins (rhBMP). There are two types of recombinant BMPs available: rhBMP-2 and rhBMP-7. BMP bone graft materials rely on growth factors within the bone to do two things: make more bone cells (osteoinductive) and build a scaffold for the new bone cells to live (osteoconductive).

Bone graft materials are useful because they eliminate the risk of rejection with donor bone and the risk of infection at the donor site with patients who have donated their own bone. There are other potential problems with using patient-harvested bone for the graft. For example, the donor site can be very painful or sore for a long time. It takes time in the operating room to gain access and then remove the donor bone, which can increase the risk of complications. And then after all that, the bone graft may fail and the patient ends up with a nonunion fusion. In other words, the vertebral bones still move when they shouldn’t so the spine still isn’t stable.

Bone cells from a bone bank are really only osteoconductive — they provide a framework for the body to fill in with its own live bone cells. The donated bone is no longer alive, so it is not osteoinductive (able to make new bone cells). That’s where bone substitutes like bone morphogenetic proteins (BMPs) come in handy. BMPs contain both the bone mineral matrix and growth factors, which makes them osteoconductive (provides a scaffold) AND osteoinductive (helps fill the scaffold in with new bone).

You may be observing something doctors call response shift phenomena. It happens to many, many patients before and after surgery (or other treatment). They have less pain and better function, but they rate their progress as worse than before treatment. They seem to see themselves as more disabled even though tests show they are stronger and more active.

The patient has adapted to the new level of ability and then his or her expectations change. It’s a bit like a moving goal post or using a shorter yardstick for measuring desired outcomes. Showing the benefit of treatment becomes a challenge because patients change their internal standards for how they view their pain or other symptoms. They may reassign importance of one symptom over another.

Your father’s example is a good one. Someone with back and leg pain from degenerative disc disease has surgery to remove the disc. After surgery, the leg pain is gone but the back pain is still there. Even though half the pain is gone, the patient rates pain-related disability as much worse than before surgery when there was back AND leg pain.

This patient has had more than just one type of response-shift phenomena. Besides changing internal standards of pain, now he or she has reprioritized the relative value of pain severity. In the absence of leg pain, suddenly the same level of back pain is much worse and more disabling.

It may take some time before things settle out and your father recognizes the improvement in his function and quality of life. At the same time, the doctors and therapists can now address the back pain and see if additional treatment can help. It is possible that gently pointing out the changes you have observed may help your father take a step back and re-evaluate his own situation. This may or may not help create a better appreciation for the results of treatment so far. After all, pain is pain and it has a way of getting our full attention!

It’s not uncommon for patients to experience a change in perception(s) following treatment for a chronic problem like low back pain. It’s good you recognize that you really got better as a result of the surgery. But you may be experiencing a shift in the meaning or impact pain has had on daily activities and function.

The change in health status wasn’t what you were expecting. You were hoping for a complete cure but what you got was a partial cure. This type of treatment response can shift how you view the results you did get. Social scientists call this the response shift phenomena. The response shift occurs in all kinds of patients whether the health condition is multiple sclerosis, diabetes, dental disorders, joint replacements, cancer, or back pain.

Efforts are underway to look at different types of patients and compare their response shifts. For example, Worker’s Compensation patients may have a very different response shift compared with non-Worker’s Comp patients. It’s possible that patients like yourself who have a partial cure are more likely to develop a response shift.

Knowing there is such a thing as the response shift phenomena may help you understand your own situation. You are asking good questions that will help guide you through the recovery process. A successful return-to-work plan should take into account both your reality and your perception of reality. Vocational counseling may help you sort through all the ifs, ands, and buts you might put up subconsciously as you move toward a full return-to-work status.

Nerve blocks to reduce low back pain caused by spinal nerve impingement or compression is a fairly common way to treat this problem. But the nerve root is usually located deep in the spine and it is underneath a tough ligament called the lumbosacral ligament. Getting to the nerve with a long, thin needle is essential.

In some people, there is an arch of bone that is wider than normal. It covers the nerve enough that the needle can’t pass through to the nerve without puncturing it. Ultrasound-guided treatment can help guide the surgeon. The multibeam technology allows the surgeon to see as he or she tilts and/or rotates the needle. By slowly pushing forward into the soft tissues and seeing the probe on the ultrasound monitor, accurate placement of the needle is possible.

Anatomical variations like this can prevent the needle from reaching its desired location. That’s one reason you might not qualify for this procedure. Obesity and osteoporosis (brittle bones in danger of breaking with needle puncture) are two other risk factors for an unsuccessful attempt at a nerve block.

Surgeons are advised to use fluoroscopy (real-time 3-D X-rays) before attempting a nerve block. Fluoroscopy provides a pre-scan before ultrasound-guided injection. The surgeon uses these X-rays to look for any anatomical variations in form or structure of the spine that could prevent accurate probe/needle placement. And the X-rays help the surgeon find the best spot for probe/needle advancement and placement.

Evidently something in the pre-procedure work-up placed you in an at-risk category for a nerve block. You’ll need to discuss the particulars with your surgeon to find out why you aren’t a good candidate for this treatment and what your other options might be at this point.

According to a recent study involving 78 patients who had an ultrasound-guided nerve block for L5 radicular syndrome, the procedure is painless. They all reported a tapping sensation but no pain and no muscle contraction. L5 radicular syndrome refers to pressure on the spinal nerve root located at the bottom of the lumbar spine causing back and buttock and/or leg pain.

The reason for the difference in patient response between X-ray and ultrasound-guided techniques has to do with the way the procedure is done. The X-ray guided approach uses a contrast dye that is injected into the nerve. The dye makes the nerve visible on X-rays. This allows the surgeon to confirm correct placement of the needle delivering the numbing agent. The ultrasound method uses a very low intensity electrical stimulation. The electrical pulses create the tapping sensation when the needle is close to (but not inside) the nerve.

Not only is the ultrasound-guided procedure more comfortable for the patient, it is safer. That’s because once the nerve has been located, a numbing solution is injected around the nerve to block pain messages from traveling to the spinal cord up to the brain. The nerve isn’t punctured, which then prevents further damage to the already compromised nerve tissue. And the patient is exposed to less radiation, another bonus of the ultrasound method.

The McKenzie method is one particular testing and treatment approach for neck and back pain. Robin McKenzie’s idea is that if neck or back pain location or intensity level can be changed with some simple repeated movements, then it is possible to predict a favorable or unfavorable response to treatment using McKenzie principles.

McKenzie’s movement testing called centralization requires the patient to move in a prescribed direction repeatedly. If the pain retreats from down the arm or down the leg to a central spot in the spine, this is a sign that specific movements can be used to treat the problem.

Rehabilitation specialists look to see if there’s any evidence that the examiner can predict the final outcome based on symptoms observed during the exam. And secondly, they ask the question: is it possible to tell how well patients will respond to treatment based on how their pain responds to conservative (nonoperative) care?

Many physical therapists subscribe to this theory and are trained in the McKenzie technique. But there hasn’t been enough evidence so far to prove the technique is a reliable predictor of long-term results. A recent review of all studies published to date confirmed that evidence is still very limited to support the idea that symptoms changed by repeated spinal movements point to a positive prognosis.

These results don’t necessarily mean the McKenzie principles are NOT predictive. It’s more the case that better research with high quality methods are needed to investigate this approach. Finding patient factors that can predict what will happen is a high priority among neck and back pain researchers.

Understandably, patients would like to know: How serious is my condition? What do my symptoms mean? How soon can I get back to work? Finding ways to predict the answers to these questions and figuring out what kind of treatment works best for each type of problem remains to be discovered.

Only your doctor can help you decide when you are ready to return to work, so the first thing to do – if you’ve not done it already – is have a talk with him or her. Discuss your pain, the type of work you do, and your fears about re-injuring yourself.

Something that is important to understand though, is that often the fear of hurting yourself again or more actually can work against your back healing properly. This fear of pain, often called fear avoidance, is not uncommon and has been studied by researchers. If this is what is holding you back, your doctor may be able to recommend a rehabilitation program that can help your back get better and help the way you think about your back and pain at the same time.

Spinal fusion is aided by the placement of bone chips placed alongside and between the vertebral bodies. These bone graft materials help jump start the healing process and foster a successful fusion.

There are two basic bone grafts: autografts (harvested from the patient) or allografts (obtained from a donor bank). Donor bank bone comes from cadavers (bone preserved after death for use in studies or surgery). Live donors (other than the patient himself) are not used because of what’s referred to as donor site morbidity and the risk of tissue rejection. Patients donating bone would be at risk for post-collection infection, pain, and disability at the donor site.

Autografts are really still considered the gold standard (the best choice). Using your own bone means there won’t be any issues with tissue rejection. And since it’s live bone when it’s harvested, it helps stimulate new bone growth at the surgical site much faster and more efficiently than allografts.

The major disadvantage of autografts is persistent and sometimes disabling pain at the donor site. As your own donor, you may suffer more from the donor location than from the main area of surgery. A minor inconvenience is the extra time during surgery to collect the bone from some other site. Autografts for spinal fusion usually come from bone removed from the spine (e.g., laminae or spinous process) or from the crest of the pelvic bone.

Allografts on the other hand create no donor site problems, but fusion takes longer and there is a risk of transferring an infection from the donor tissue to the recipient. That’s why donors are screened very carefully before being accepted and the donor tissue is sterilized with gamma irradiation techniques. Advantages of allografts include shorter surgical time, availability of preformed shapes and sizes of donor tissue, and as mentioned, there’s no pain from bone collection.

The two basic bone grafts used in spinal fusion are either autografts (harvested from the patient) or allografts (obtained from a donor bank). Each type of grafting material has its own advantages and disadvantages. But apparently, infection based on bone graft type isn’t one of them.

Bone used from a bone bank comes from donors who have been screened very carefully. The tissue may be irradiated to reduce the risk of transmitting any diseases or infections from the donor to the recipient. Bone banks have strict procedures that also involve quarantine of the donated tissue for a certain length of time to watch for any potential problems. Surgeons are careful to use bone banks with an excellent track record for preparation of donor bone with minimal risks and rates of infection.

According to a recent study from the Mayo Clinic in Rochester, Minnesota there is no difference in postoperative infection rates based on type of bone graft used. That means the surgeon can choose the type of bone graft based on the patient’s needs, availability of autograft versus allograft, and what’s needed for the particular surgical procedure planned. Patients were followed for at least one full year after surgery. The overall infection rate for all three types of grafts was only five per cent. Most of the infections that did occur developed within the first 60 days.

Post-operative infection in the early days, weeks, and months after spinal fusion is a major concern. That’s because it isn’t just an isolated problem. With it can come osteomyelitis (infection enters the bone), failure of getting a solid fusion, and pseudoarthrosis (movement at the fusion site). Potential risk factors for infection include patient age (older than 60 years old), tobacco use, diabetes, obesity, and alcohol abuse. Length of surgery and surgical technique can also add to the risk of infection postoperatively.

A synovial cyst is a mass linked with a joint. It is formed when leakage of synovial fluid from inside the joint forms a gel-filled pouch lined withepithelial cells or cells that are epithelial-like. Epithelial cells are special cells that line cells the cavities and surfaces of structures throughout the body, including cysts. In the case of these cysts, there is a channel connecting joint to cyst. The channel may be long enough that the cyst isn’t even next to the joint.

Studies show there are different types of spinal synovial cysts based on form and structure. Some have no lining and are very inflexible (lacking elasticity). Those that have a lining vary from having a very thin to a very thick lining made of synovial cells. Some of the cysts have walls that are calcified or hardened. Others have new formation of tissue with a good blood supply that turned clots into fibrous scar tissue.

Arthritic changes or trauma seem to be the first step in the formation of these cysts. One study showed that in about three-fourths of cysts examined, a channel formed between the cyst and the joint. Fluid from the damaged joint leaked out, traveled down the channel and filled the cyst with fluid from the joint. The channel is what is called the intraligamentous bursal communicating channel mentioned in your father’s pathology report.

As a result of this direct connection, a large percentage of these cysts have bone and cartilage debris from the osteoarthritic process embedded in the cyst wall. Some of the cysts can be pressed up against osteophytes (bone spurs) that have formed around the joints. The cysts are filled with blood and scar tissue and surrounded by a layer of additional scar tissue. It appears that the risk of synovial cysts is greatest in the lower lumbar spine where the arthritic changes are the most severe. It is here that debris collects and blocks the channels.

Spinal stenosis refers to a narrowing of the spinal canal where the spinal cord is located. Many things can contribute to stenosis but the most common are the degenerative changes that occur with aging. One of the major causes of synovial cysts in the spine is degenerative spondylolisthesis.

Spondylolisthesis is the forward slippage of one vertebral body over the one below it. As the vertebra moves forward, the spinal canal narrows. Anything that narrows the spinal canal can cause pinching (impingement) or compression of soft tissue structures such as the spinal cord and spinal nerve roots.

The shift in the bodies of the vertebral bones also changes the normal alignment of the spinal (facet) joints. Any change in joint alignment can contribute to uneven wear and tear. Eventually, bone spurs form, joint integrity is disrupted, and joint fluids escape, leading to cyst formation. So you can see, one thing leads to another and another and another.

The incidence of synovial cysts within the spine hasn’t been calculated but reports that it is linked with degenerative spondylolisthesis suggest it is more common in older adults. Recurrence rates are also unreported. Since this occurs as a result of osteoarthritis, which doesn’t go away when the cysts are removed, it’s possible that the cysts can reform or more likely, new cysts can develop.

A recent finding has opened up discussion around this topic. It appears that there are channels leading from the spinal joints called facet joints that are present even in the normal spine without stenosis and in the absence of any cysts. The purpose of these channels remains a mystery. Clearly, they are used to transport synovial fluid out of joints damaged by osteoarthritis because that’s how these cysts form. Now that these channels have been identified, researchers will study them more closely.

Surgery for degenerative disc disease has traditionally been discectomy (removal of the disc) and spinal fusion. But with the new total disc replacement procedure, more patients are opting for this motion sparing technique. Fusion limits motion at the fused vertebral segments, whereas disc replacement tries to keep as much of the natural motion as possible.

With the removal of the herniated or destroyed disc, pressure is removed from the spinal nerve roots and irritation reduced. The resulting reduction of pain makes it easier to move once again. Studies show that disc replacement patients may lose a little motion at the replacement site but total lumbar spine motion is not always lost because it is made up by the level above. It is somewhat dependent on the level of the disc replacement. So for example, in someone who has an L45 disc replacement, there’s a compensatory increase in motion at the L34 segment. This make-up in motion is not as likely to occur when the replacement is done at the L5S1 level.

In most cases, if the implant is placed with good alignment, then normal biomechanical motion at that level is preserved. This reduces the risk of uneven stresses and evens out the load transmitted to adjacent vertebral segments above. The goal of total disc replacement is to preserve spine motion and normal patterns of movement. The result is prevention of biomechanical strain on the rest of the spine. All indications are that disc replacement to manage degenerative disc disease in the lumbar spine is safe and effective. Long-term results are still as yet undetermined.

Surgeons want the best for their patients. And they pride themselves on obtaining the best results for each patient no matter what kind of surgery is being done. Having said that, they also are very careful in what is referred to as patient selection to assure those good results.

Studies are done that show which patients have the best results for each type of surgery being done. This kind of information helps surgeons with patient selection that will lead to the most excellent results.

Risk factors such as age, general health, and past medical history are reviewed. The presence of other serious conditions such as heart disease, high blood pressure, or diabetes is always a consideration in patient selection. If the patient is at risk, the surgeon may not even suggest surgery as an option. If the patient is particularly interested in a surgical approach to his or her problem, then the surgeon will review any concerns or precautions to be considered.

Studies show that patients in good health having spinal fusion have low rates of complications such as infection, blood loss, or poor fusion rates. Selecting healthy patients for spinal fusion who can benefit from pain relief and reduced disability is the goal. The mortality (death) rate is very low for the average healthy adult having spinal fusion.

Decompression is a surgical procedure designed to take pressure off the spinal cord and/or spinal nerve roots. The surgeon removes a portion of the bone called the lamina. The lamina forms part of back/leg pain associated with spinal stenosis (narrowing of the spinal canal) or degenerative disc disease.

The use of a preoperative prophylactic (preventive) antibiotics is standard procedure. Studies show at least a 50 per cent reduction in infection with the use of this single-dose antibiotic. Surgeons also rely on sterile technique to prevent skin and deep wound infections.

The use of minimally invasive spinal surgery (MISS) has also decreased the number and severity of infections. In minimally invasive spinal surgery, a tubular retractor type system is used to pass surgical instruments through a small opening in the skin. With this approach, there’s less risk of transporting bacteria into the surgical site. With a smaller incision, there is less chance of wound drainage or blood pooling where infection can form.

Before you cancel the surgery, talk with the surgical nurse and/or the surgeon about your concerns. Studies show the risk of infection is fairly low — less than one per cent with minimally invasive surgery. Unless you have specific risk factors such as diabetes, obesity, or incontinence (dribbling urine), there’s not much chance of an infection developing.