FAQ Category: General Spine

Sometimes scoliosis in the older adult can be managed with nonoperative care such as physical therapy and medications. If the pain isn’t severe or disabling, then conservative care is always advised. A three to six month course of treatment is encouraged.

Drugs such as nonsteroidal antiinflammatories or pain relievers can help with the painful symptoms. Therapy can improve motion, strength, and function. Addressing issues such as deconditioning can be very helpful. Bracing is not usually beneficial. It reduces movement and puts the patient at increased risk for osteoporosis and falls from loss of balance.

But failure to reduce pain, deformity, weakness, and bowel/bladder problems is an indication that surgery may be needed. The decision to have surgery should not be taken lightly. Complications from this type of surgery can be serious in this age group. Patients and surgeons talk together at length before taking this step.

Patients are advised that surgery can provide about a 50 per cent improvement. In other words, it’s not a cure, and it doesn’t result in a 100 per cent reduction of pain. There’s no way to predict how much bowel or bladder function will improve (or if it will even improve at all).

Pain, neurologic symptoms, and the loss of function that occurs because of these problems are the most common reasons to pursue surgery. Patients who opt for surgery often have much greater disability. They are more likely to have severe back and/or leg pain, leg weakness, and loss of normal bowel and bladder function.

Older adults should be encouraged to try an adequate course of nonoperative care before considering surgery. All the pros and cons of surgery should be discussed. The patient makes the final decision, but the surgeon plays an important role in the counseling and management portion of treatment. It’s a difficult and complex decision that must take many factors into consideration.

We are assuming by saying you had a long fusion that there were several spinal segments fused. Most of the time using this term means that fusion occurred within the lumbar spine and that the lumbar spine was fused with the sacrum.

Since you had a long fusion, it’s possible you had bone grafts (bone harvested for use in fusions), graft extenders (materials used to increase the amount of graft available), and instrumentation (metal rods, plates, and/or screws to hold the bones in place until fusion occurs).

With long spine fusions, there is always a risk of fusion failure. The instrumentation may loosen, shift, pullout, or break. Pseudoarthrosis (formation of a false joint with movement at the fusion site) can occur.

Mesh cages are used to fill in the space where the disc material is removed. The cages are filled with bone graft material to help local bone incorporation. But sometimes the cage gets in the way of seeing the fusion site.

If that’s the case, it may be possible to get a better view using a CT scan. But the scans are more expensive and expose the patient to more radiation, so they are not used routinely. You can discuss your concerns with the surgeon and see if a CT scan is advised.

In the future, this problem may be eliminated. There is a new type of cage called a PEEK cage. PEEK refers to polyetheretherketone. It’s a plastic substance with biomechanical properties similar to those of cortical bone. It doesn’t show up on plain X-rays. Small metallic markers are placed on the front and back of the device to help the physician monitor its position.

People who have surgery for back pain often have had the pain for quite a while before the surgery is done. This means, that people experience a lot of pain and it affects their life significantly for a long period of time – long enough to feel angry, frustrated, or even depressed over how pain has changed what things can be done and how they are done.

It’s not uncommon for someone to be depressed following back surgery, much like your mother seems to be. The problem is, research has shown that people who are depressed tend to participate less in their recovery and, therefore, the chances of a full recovery are compromised. Although it is painful to go for physiotherapy, your mother has to take charge of her own health care. Doctors can prescribe medications and treatments, but patients are responsible for following up and actually participating. Most often, the patients who are active in their recovery, participating in treatments and following up, do much better than patients who sit back and wait for things to happen for them and to them.

If you can’t encourage your mother to look at the situation in a more positive light, sometimes counseling can help in this regard. In the meantime, her doctor has to understand why your mother isn’t participating and perhaps he can offer some suggestions.

Physical therapy can leave you sore after a work out, but it isn’t supposed to cause pain. If you are experiencing pain with your physical therapy, you should speak to your therapist about where the pain is, what seems to be causing it, and what type of pain it is. This is essential because if your therapist doesn’t know that you are hurting, you could be doing more harm than good.

On the other hand, if you are talking about soreness from using the muscles and stretching, this isn’t unusual. Most people have waited quite a while before going for back surgery. During that time, by adjusting your posture and how you do things, you most likely put as little stress on the affected muscles as you could. As a result, they weakened and now need to be strengthened again.

Again, speak with your physical therapist as any pain or discomfort could mean that you may need to have your exercises changed a bit.

When bone grafts are used, the patient donates slivers of bone taken from his or her own ilium (pelvic bone). Bone from a bone bank can also be used. The bone in the bone bank is donated by others, but this occurs after the donor’s death.

The problems and complications that can arise after bone harvest make it difficult for people to donate bone for their own use (much less taking bone from a family member). As a result, scientists are working hard to come up with synthetic (manmade) materials that can be used to help local bone grow.

In 2002, the FDA approved the use of bone graft substitutes. Bone graft substitutes replace bone harvested from the patient or from a donor. Bone morphogenetic protein referred to as rhBMP-2 is an example of a bone graft substitute. At first, BMP was just used for single level spinal fusions.

But results with rhBMP-2 have been so good, its uses have expanded. Surgeons can now use smaller amounts of BMP to get the same results. They can use it in anterior spinal fusions, posterior spinal fusions, and for two-level lumbar spinal fusions. Surgery time is less, blood loss is reduced, and hospital stay is shorter.

The rhBMP-2 sends out signals to attract stem cells that can form bone cells. Graft extenders and bone graft substitutes can be used together. Bone fillers or graft extenders include demineralized bone matrix, TCP-HA (tricalcium phosphate/hydroxyapatite) granules, local bone, and donated bone chips. These biomaterials serve as a three-dimensional scaffold. Stem cells and bone cells can attach here and multiply. Bone tissue engineering eliminates the need for family donors.

A recent Japanese study evaluated several factors that could be associated with acquired risk factors for the development of disc degeneration among an older population. Among the most likely risk factors, all of which are modifiable, are high BMI, high LDL cholesterol, occupational lifting, and sports activities.

A fragility fracture is a broken bone that has occurred from a minor accident that would not usually break a bone. The most common cause is loss of bone strength from osteoporosis.

Yes, a recent study evaluated available literature. The authors found that the mortality rate ranged between 23 and 67 percent.

The usual two options are conservative care and kyphoplasty. An orthopedic surgeon who recently authored an article, compared the mortality between these two treatment options. Kyphoplasty is the placement of bone cement into the vertebral body using a needle that is guided by x-ray. Conservative care usually involves the use of oral analgesics, activity restriction, and bracing.

It is estimated that twelve to 25 percent of men and women will have compression fracture. Interestingly, sustaining a second vertebral fracture within twelve months is four times greater.

With improved technology and surgical technique, percutaneous biopsy of bone lesions are starting to replace the more traditional open-incision biopsy. Percutaneous means through the skin.

During a percutaneous biopsy, a very long, thin needle is inserted through the skin and soft tissues and then into the bone. A sample of the suspicious tissue is removed and sent to the lab. An accurate diagnosis is the best way to determine the most effective treatment.

In order to guide the needle to the right spot, the surgeon uses an X-ray device called fluoroscopy. This type of imaging allows the surgeon to see while moving the needle. The advantage of this type of biopsy is that the muscles aren’t cut open and the surgeon can avoid damaging nearby nerves. The disadvantage is that it is less accurate than an open biopsy.

The percutaneous technique has advanced so much that studies are now being done to refine the procedure. Researchers are looking at the effect of needle size and type of imaging used (fluoroscopy versus CT scans) on accuracy. Other factors under study include the location of the lesions, expertise of the surgeon, and complication rate.

Biopsy of the spine may be needed when a suspicious lesion appears on X-ray, CT scan, or MRI. Although these imaging studies help identify the location, shape, and effect of lesions on the surrounding soft tissues, only by removing the pathologic tissue can a positive identification be made.

The most common lesions of the vertebrae are infections and tumors. Tumors can be primary (first developed at that site) or metastasized (spread from a tumor somewhere else in the body). Sometimes what look like lesions are really artifacts from the imaging. This means a shadow or distortion gives the impression of a true lesion.

There are other possible explanations for your situation. Sometimes the biopsy needle misses the lesion or fails to collect enough of the pathologic tissue to show up in the lab analysis. And there can be false negatives. This means the test came back negative when there really was something there.

And finally, it’s entirely possible that whatever was there has resolved. If that’s the case, then your symptoms should also slowly disappear. However, if there has been no change (improvement) in your weakness or you have developed other symptoms, a follow-up appointment is needed as soon as possible.

Your concern is justified and should be explained. Don’t hesitate to contact your physician and ask some questions. No one likes the idea of a second biopsy, but it may be necessary.

The authors of a recent study evaluated several different factors. They concluded that cement leakage into the intradiscal region, lower body mass index and weight were risk factors for adjacent level subsequent fracture. Heavier patients with osteoporotic bone, as well as motion gradient appear to be risk factors for nonadjacent level subsequent fracture.

A recent study illustrated a case report of a patient who had a coronal plane subluxation of the spinal cord. Initially, the patient had partial paralysis. After surgery to fixate the spine, there was improvement in neurological function. The authors found other case reports of similar improvement in patients with total subluxation of the spinal column in the coronal plane. Patients with total subluxation in the sagittal plane showed no improvement in neurological function following surgery.

High energy injuries are the cause of complete subluxation of the spinal column. This is also called spondyloptosis. Motor vehicle crashes, structural collapse are examples of the more common causes for spondyloptosis.

Achondroplasia is often accompanied by several deformities of the spine. One of these is thoracolumbar kyphosis. This is a forward curve of the spine in the mid-to-lower back.

Without a brace or support of some kind, the child ends up slump-sitting. Prolonged slumping puts pressure on the front of the vertebrae. Over time, the bones start to assume a wedge-shape. If not prevented, the deformity can become permanent.

Studies show that with bracing and sitting prevention, children can come through this without spinal deformity. There are some potential problems with the bracing. In very young children, it can prevent mobility. Developing the skills needed to pull up to a standing position and start walking can be delayed.

The brace can also reduce pulmonary (lung) function. This puts the child at risk for upper respiratory infections. Because of the potential problems, parents are informed of the risks and benefits of bracing. Most parents won’t go ahead with the expense and bother of bracing if they don’t understand the importance of this kind of prevention.

It may be helpful if you ask your daughter what she has been told are the benefits and reasons for bracing. It may be a lack of understanding of the importance of this important tool.

A basic health plan for any condition consists of staying adequately hydrated (clear liquids such as water, herbal teas), taking in good nutrition, and exercising daily. Your exercise program should include core (abdominal and trunk) strengthening. Stretching to maintain flexibility is important. And getting your heart rate up to improve cardiovascular endurance is advised.

If your physician has approved going ahead with an exercise program, seek the help of a physical therapist. He or she can get you started and guide you through the process. An aquatics (pool) program can be especially helpful. You’ll be able to work on all these components of exercise at the same time in a safe environment.

The therapist will also evaluate you for a lumbar support (brace or corset). Supportive bracing can offer temporary relief from symptoms until you are able to build up your core muscles to stabilize your spine.

If your pain and limitations are extreme, then surgery may be needed. Most physicians would recommend following a three-to-six month program of conservative (nonoperative) care first before considering surgery.

When surgery is indicated, a decompressive laminectomy is performed. The piece of bone that is pressing on the spinal nerve is removed. Usually more than one level is done at a time. Spinal fusion is carried out at the same time. This restores stability while taking pressure off the nerve roots.

The use of metal rods helps stabilize the spine and reduce or correct spinal deformity from the scoliosis. There are many factors to consider when doing this type of complex surgical procedure. And since most patients are 65 years old or older, there are often additional health concerns. The risk of complications, failed surgery, and need for a revision procedure make surgical treatment a distant second choice after nonoperative care.

There are several possible reasons for this. Generalized back pain can occur just related to muscle fatigue. In adult-onset scoliosis, there are disc degeneration, bone spur formation, and facet (spinal) joint changes that contribute to muscle imbalance and deformity. The imbalance of muscle pull from spinal deformity can cause pain.

Often in older adults, there are other problems at the same time that make the symptoms of scoliosis worse. For example, spinal stenosis (narrowing of the spinal canal) is a common cause of back and leg pain in this age group. When you combine the changes caused by scoliosis along with the changes from spinal stenosis, the symptoms of back and leg pain can escalate.

Another problem encountered by this age group is peripheral vascular disease (PVD). Arteries and veins get clogged up with atherosclerotic plaques resulting in diminished blood supply to the legs. This is another potential cause of leg pain with walking.

Fragile bones from osteoporosis is common in postmenopausal women. This condition affects men, too but about 10 years later. Insuffiency or vertebral compression fractures are a potential source of pain in an older adult with scoliosis.

If your mother hasn’t been evaluated by her physician, now would be a good time to update her medical exam and find out what’s going on. There are many ways to treat this problem and bring about pain relief and improved function.

The authors of a recent study were able to conclude that more extensive involvement in the peripheral joints seemed to correlate with more extensive involvement in the lumbar spine. Radiographs and MRI were used in this study to evaluate lumbar vertebral bodies and discs. Sixty one percent of patients with the most severe classification of their rheumatoid arthritis had grade II or grade III lesions, number III being the most severe on a grading scale from zero to III.

Surgery is a big decision. Many things can go right. But many things can also go wrong. Fast relief of sciatica and low back pain is the usual reason for early surgical intervention. But pain relief is not guaranteed. Just as many patients feel better as don’t.

For those who do get relief, function improves and the time to recovery and return to work is much shorter. Certainly, in dollars and cents, this makes sense! And your productivity will be greater. This is a big factor for you if you are the business owner or self-employed. Otherwise, the boon goes to the owner of your company and to society.

Studies show that in the long-run, patients with low back pain and leg pain from disc protrusion will get better. Conservative (nonoperative) care often helps but also costs money. For those who are insured, there’s a cost to the insurer and usually a smaller cost to you, the patient.

So, if you don’t want to wait or can’t cope with the pain, then surgery may be advised. If there are signs of permanent motor damage (e.g., muscle weakness, foot drop), then surgery is often considered an emergency procedure. It must be done as soon as possible.

If you really just don’t want to have surgery, then there are some other alternatives. Acupuncture, chiropractic, nonsteroidal antiinflammatory drugs (NSAIDs), and physical therapy all have some potential for improving your symptoms without surgery.