Spine Disorders and their Treatment
The gradual deterioration of the disc between the vertebrae is referred to as Degenerative Disc Disease (DDD) or Spondylosis. Degenerative Disc Disease is very common affecting 40-50% of people over the age of 40 and becomes increasingly common as we age. It is a kind of wear and tear disease similar to osteoarthritis. Although it can occur at any spinal level, it is most common in the lumbar spine (low back). DDD can cause the discs to flatten losing their normal height. This disc height is important as it separates the disc above from the one below. When disc height is lost, the nerve pathways may become narrowed and cause nerve impingement, inflammation, and pain.
As the ‘discs’ degenerate, they become thinner. Sometimes the vertebrae develop small, rough areas which may irritate the nearby nerves. This causes troublesome symptoms like severe neck pain and stiffness and pain down the arms and hands.
Most patients tend to get better with medication and exercises. However occasionally the spondylotic changes can lead to compression of the spinal cord or the nerve roots and this may result in pain, numbness and weakness in the upper limbs (radiculopathy).
Cervical spondylosis is chronic degeneration of the bones of the neck (cervical spine) and the cushions between the vertebrae (inter vertebral disc). The treatment involves removal of worn out discs or bone spurs – depending on the underlying problem. If required the surgeon will fill the gap with a graft of bone or other implants made of metal combined with bone.
Patients have reported their symptoms as being as mild occasional backaches to chronic low back pain that is severe enough to limit their activities at work and play. The pain is typically mechanical in nature. This means the pain increases as more stress or load is placed on the low back. Bending, lifting, and twisting are the types of movement that may exacerbate DDD.
Rarely does DDD require surgery. There are several non-surgical treatments including anti-inflammatory medication, physical therapy and exercise programs. Surgery is only considered when the patient’s symptoms are debilitating; interfere with activities of daily living, and non-surgical treatment has failed after a reasonable period of time, usually at least six months.
Fusion permanently stops the motion of the spine at the level of the degenerated disc. This helps to relieve pain. Fusion for DDD is best when limited to one or two discs. Fortunately we have five discs in the lumbar spine. The un-fused discs take over to provide adequate function of the lower back.
An artificial disc can also be inserted into the space after removing the entire degenerated disc. This surgery is done from the front. This restores disc height, improves spine function, and helps to eliminate debilitating pain.
A prolapsed disc is a condition when the inner, softer part of the disc bulges out through a weakness in the outer part of the disc. This bulging disc may then press on nearby nerves which in turn causes discomfort and pain. The symptoms include – back pain, ache in the arm or leg and pinpricks felt in feet, toes and hands.
As a rule, surgery may be considered if the symptoms have not settled after about six weeks or so. At Apollo Hospitals, the spine surgeons may opt for:
Keyhole surgery – Also known as microdiscectomy spine surgery, it is typically performed when there is a prolapsed disc in the lumbar (lower back) region which is pressing against a nerve.
Disc replacement – An artificial disc is a device that is implanted into the spine to imitate the functions of a normal disc (carry load and allow motion). Artificial discs are usually made of metal or plastic-like (biopolymer) materials, or a combination of the two. The disc replacement for prolapsed disc is done in the cervical (neck) spine.
Spondylolisthesis is a Greek term meaning slipping of the spine. It is the abnormal forward movement of one vertebra over the vertebra below. Most often, this forward slip of the vertebra occurs in the lumbar area of the spine. This slippage and herniation of the disc causes pressure on the nerve roots associated with the affected vertebrae, causing pain and dysfunction. There are various types of spondylolisthesis.
Type 1 – Congenital spondylolisthesis
An individual is born with the abnormality of the posterior bony arch of the spine, which causes the slippage. This is usually seen at the L5-S1 level and often associated with abnormality of the facet joints. Patients usually present with back pain during the adolescent growth spurt. CT and MRI scans are required to diagnose the dysplasia (abnormal bone formation).
Type 2 – Isthmic spondylolisthesis
Isthmic spondylolisthesis is caused by a defect in a part of the bone called the pars interarticularis. The pars bone connects the upper joint of one vertebra to the lower joint. The defect is usually caused by a stress fracture in individuals with a hereditary predisposition (some minor abnormality or weakness of the pars at birth). In certain individuals a defect may exist without any forward slip, referred to as spondylolysis. This condition can be painful.
Type 3 – Degenerative spondylolisthesis
Degenerative spondylolisthesis is a forward slippage secondary to arthritis of the spine. Spinal stenosis is usually associated with this process. This is due to a long standing degenerative disc leading to weak facet joints in the back of the spine. This is usually seen at L4-L5 level.
In degenerative spondylolisthesis, surgery is indicated if slippage progressively worsens or if back pain does not respond to nonsurgical treatment and begins to interfere with activities of daily living. In the congenital and high dysplastic group, surgery is done at early stages to prevent neurological complications.
The spine has normal curves if seen from the sides and is seen as a straight column from the front. But in certain conditions the spine shows curvatures from the front and it is called scoliosis. The abnormal forward bending of the spine is called kyphosis.
Scoliosis is a term taken from a Greek word meaning curvature. During the 19th Century physicians thought poor posture was the primary cause of scoliosis. Today scoliosis is known to be either congenital (present at birth) or developmental and may be hereditary. The disease causes the spine to curve to the side usually in the shape of an “S” or “C”. The curvature is measured in degrees.
Adolescent Idiopathic Scoliosis is the most common type of spinal curvature. It occurs around the onset of puberty in otherwise healthy boys and girls. It is more common in girls. Physical signs may include uneven shoulders, one hip lower than the other, a rib hump when bent over at the waist and leaning to one side.
Whatever the patient’s age, the goal is to stabilize the spine to prevent additional curvature. Some patients with scoliosis are pain free and do not seek treatment until the deformity is noticed. Unfortunately, at that point it may be too late to treat the disease. The size of the curve is measured in degrees on an X-ray. The progression of scoliosis is monitored by periodic x-ray studies. When scoliosis is severe it may cause the spine to rotate, which can cause spinal spacing to narrow on the opposite side of the body.
While minor deformities may be treated non-operatively, more severe and progressive ones require surgery.
Surgical Management of Scoliosis
Surgical treatment of scoliosis is employed if the curvature at detection is of greater magnitude. The aim of surgical correction is to achieve a well-balanced spine in which the patient’s head, shoulders and trunk are centered over the pelvis. This is done by using instrumentation to reduce the magnitude of the deformity and obtaining fusion in order to prevent future curve progression.
Usage of Staple
A more recent development in the treatment of Scoliosis is the use of staples on the convex side of the curve, which correct and maintain the curve till the patient is skeletally mature. These staples allow differential growth to take place i.e. less growing speed on the stapled side than the concave side thereby correcting the curve as the child grows.
Special spinal implants made from Nitinol – a titanium based alloy has been studied extensively and is being employed clinically in a few centers in USA and Europe. The staples are in the shape of ‘C’ when they are manufactured at room temperature. When the staples are cooled to below freezing point the prongs become straight but clamp down into the bone in a ‘C’ shape when the staple returns to body temperature providing secure fixation. These are called Shape Memory Alloy (SMA) staples. As no fusion is done the child grows normally and even the residual deformity tends to improve with growth.
This novel procedure was performed for the first time in India at Apollo Hospitals, Chennai, on a 6-yr old girl, from a small town near Madurai, by the senior spine surgeon Dr. Sajan Hegde and his team.
A spinal tumor or a growth of any kind – whether cancerous or not, can impinge on nerves, leading to pain, neurological problems and sometimes paralysis. The symptoms include loss of sensation or muscle weakness, especially in the legs, difficulty in walking, sometimes leading to falls and loss of bowel or bladder function.
Newer techniques and instruments enable surgeons at Apollo Hospitals, India to reach tumors or treat delicate injuries even in the most inaccessible areas. High-powered microscopes are used during surgery and in some instances even intradural tumors are removed. In select patients, Total Spondylectomy – removal of the entire vertebra is done as a definitive cure.
A spinal cord injury occurs when there is damage to the spinal cord either from trauma, loss of its normal blood supply, or compression from tumor or infection. The injuries may be of two types – complete or incomplete. In complete injuries the body ceases to function below the level of injury. In incomplete injuries there is some function remaining below the level of injury.
Surgery is performed for spinal cord injury to stabilize the spine. If the vertebrae are weakened from fracture, tumor or infection, they may not be capable of supporting the normal weight from the body and protecting the spinal cord. A combination of metal screws, rods and plates may be necessary to help hold the vertebrae together and stabilize them until the bones heal. After surgery it is critical that patients undergo a thorough rehabilitation program. This may include methods to help the patient maximize their function through physical and occupational therapy and the use of assistive devices.