Spine Disorders, Deformities & Diseases
Understanding Spine Disorders, Deformities & Diseases
Neurosurgical spine care at Advanced Neurosurgery Associates (ANA) focuses on all types of back, neck, spine, and spine-related disorders—from the more common to the most complex. Our surgical solutions address everything from disease to conditions causing recurring and often life-altering pain.
Back pain is ranked second only to headaches as the most frequent cause of pain among Americans. Eighty percent of the population experiences a bout of back pain at some time in their lives, and while fortunately the vast majority recover with no medical or surgical intervention, for others, back problems can interfere with everyday life.
Spinal injuries and diseases are among the most complex ailments encountered in a medical practice. Many of our patients suffer from the broad range of disease processes that can affect the spine, including degenerative conditions such as lumbar and cervical disc diseases and rheumatoid arthritis, compression syndromes, spinal cord and vertebral tumors, spinal cord malformations, trauma and infections.
Such problems may be the result of disease, abnormal development from birth (congenital), from aging or “wear and tear” (degenerative), trauma from an injury, from infection from a tumor (neoplastic) or perhaps even related to other medical conditions.
At ANA, we are experienced in a complete range of services for the diagnosis, treatment and rehabilitation of patients with spine and peripheral nerve disorders. Our expertise includes neurosurgical evaluation and surgical solutions for neck and back pain, nerve compression syndromes, herniated intervertebral discs, and spinal cord compression syndromes.
Neurosurgeons were among the first experts to operate on the spine, and their experience has resulted in the evolution of spinal surgery. At ANA, we believe that our training and experience in handling the delicate issues of the brain enhances our ability to effectively perform surgery on the spine and the nerves that are involved.
Read this guide Back and Neck Pain: Frequently Asked Questions for more information.
Anatomy of the Spine
It is helpful to have a basic understanding of the anatomy and function of the spine. The spinal column is made up of 33 vertebrae that are separated by spongy discs. The spine is divided into distinct areas: cervical, thoracic, lumbar and sacral. Ligaments and muscles connect the bones together and keep them aligned. The spinal column provides the main support for the body, allowing a person to stand upright, bend, and twist. The many muscles that connect to the spine help support the upright posture and movement of the spine. The normal spine has an “S”-like curve when looking at it from the side. This allows for an even distribution of weight. The “S” curve helps a healthy spine withstand all types of stress.
The spinal, or vertebral, column holds and protects the spinal cord, which is a bundle of nerves that sends signals to other parts of the body. The spinal cord is a major part of the central nervous system. It carries sensory and movement signals to and from the brain and controls many reflexes. The spine reaches from the base of the skull to the coccyx (tail bone). The bones of the spine and a sac containing cerebrospinal fluid surround the spinal cord.
Diagnosis of Spine Conditions
At ANA, we take advantage of a wide variety of diagnostic tools, working with patients to combine test results with their symptoms to come up with solutions for their care.
In addition to a medical history, at ANA we also perform a physical exam to evaluate spinal conditions. The physical exam is a means by which our doctor will learn about the pain and condition to provide an assessment. In this examination, he will feel the spine, check how well the joints move, and solicit information from the patient on pain and other symptoms. Specifically, an element of the physical exam is a neurological exam, which tests the reflexes, as well as muscle strength and other nerve changes. This is especially important in degenerative disc disease since that condition can affect the nerves or even the spinal cord.
The doctor will examine the areas in which a patient is experiencing pain or other symptoms. In a standard exam, a patient may be checked for:
- Pain – The doctor may try to determine if a patient is experiencing pain or tenderness in specific areas.
- Weakness – A patient might be asked to try to push or move against light resistance with the hand, arm or leg to test the muscles for strength.
- Sensory Changes – The patient may be tested to determine if he/she feels certain sensations in specific parts of the feet or hands.
- Changes in Reflexes – The ankle, below the kneecap or other reflexes may be tested.
- Range of Motion of Spine and Neck – The patient may be asked if and where there is pain or loss of flexibility when he/she moves, twists or bends.
- Motor Skills – The patient might be tested by being asked to walk on the toes or the heels.
- Other Signs – There are other measures which may indicate areas of concern, so the doctor may check for tenderness, abnormal pulse rate, fever, rapid weight loss, and the use of various drugs or medications.
Typically traditional x-rays are the first imaging test done to evaluate a condition. This test provides information on the bones in the spine. An x-ray is often used to check for spinal instability (such as spondylolisthesis), tumors, fractures, osteoarthritis, bone spurs and narrowed spinal canals (spinal stenosis). Although not effective for showing much of the soft tissue, x-rays do show bones, and thus are used for evaluation of suspected fractures, infections, or tumors (tumors, which are denser than soft tissue, appear white on the x-ray).
An MRI is able to show any abnormality of soft tissues, such as nerves and ligaments, cartilage of the joints, muscles and spinal cord. This test can be used to evaluate disc height and hydration, enlargement of facet joints (hypertrophy), spinal stenosis, or a herniated disc. It can also show spinal cord or nerve root compression, and pinched or inflamed nerves. It can reveal any abnormalities in the spine or spinal cord that may be causing spinal pain.
An MRI does not use radiation (unlike x-ray and CT scans), but rather produces images through magnetic forces which act on the atoms that comprise the body’s tissues and organs by penetrating multiple layers of the spine.
Because it shows both bones and soft tissue, the CT scan is an x-ray image that is similar to both the MRI and a regular x-ray. CT scans are able to produce x-ray “slices” taken of the spine (slices refer to horizontal, or axial, images). This facilitates separate examination of each section of the spine.
The x-ray beam moves in a circle around the body in CT scans. This allows many different views of the same organ or structure. The x-ray information is sent to a computer that interprets the data and displays it in a two-dimensional (2D) form on a monitor.
This scan provides details about the bones in the spine and is effective at showing such conditions as degeneration of bones. It may also be used to check for specific conditions, and like an MRI, can show conditions such as a herniated disc or spinal stenosis.
A CT (or MRI) scan is more effective than x-rays at showing the soft tissues in the spine. With a CT scan, it is easier to see the bones and nerves, and a CT scan more easily reveals problematic structures, such as a bone spur pressing on a nerve.
A myelogram, also called myelography, may be performed to assess any abnormalities in the spinal cord, subarachnoid space (the space between the arachnoid membrane and pia mater), nerve roots and other tissues. It is often indicated when other imaging tests are inconclusive. It is used to check for a spinal canal or a spinal cord disorder, such as nerve compression causing pain and weakness, tumors or infections. In this test, a special dye is injected into the area around the spinal cord and nerves. Administration of the dye is followed by an x-ray or a CT scan. The contrast dye appears on an x-ray screen, allowing for a clearer view of the structures the doctor is seeking to evaluate and assess.
Nerve Conduction Study and Electromyogram (EMG)
The purpose of a nerve conduction study is to help diagnose nerve disorders and pinpoint the location of abnormal sensations, such as numbness, tingling or pain. It is done to find and assess damage to the nerve that leads away from the brain and spinal cord to the smaller nerves that branch out from them. In this test, electrodes are placed over the nerve to be studied. Brief electrical pulses are sent to the nerve. This is done to measure the electrical pulse in order to show whether the nerves are transmitting electrical impulses to the muscles, or through the sensory nerves, in normal fashion.
A nerve conduction study is usually done in conjunction with an electromyogram (EMG). An EMG evaluates the function of the nerve roots leaving the spine. The test is done by inserting tiny electrodes into the muscles of the lower extremity. By looking for abnormal electrical signals in the muscles, the EMG can show if a nerve is being irritated, or pinched, as it leaves the spine. If the EMG machine finds that the muscles are not working properly, the doctor can assume there is impingement (pinched) somewhere along the nerve or nerves in question. In addition, if the doctor suspects nerve damage from degenerative changes in the spine, this test will also measure the speed at which the nerves respond, and aid in this diagnosis.
When an MRI fails to confirm the source of lower back pain and there is a suspicion of disc malfunction, a discogram may be ordered. Discography entails inserting a thin needle into the back muscles directly into the intervertebral disc. The needle placement is then verified by an x-ray. A small amount of contrast dye is then injected into the disc. If there is a problem with the disc, such as herniation, the dye will leak out of the disc. The doctor will be able to see that on an x-ray, which is taken as part of the process. A discogram is also an anatomical test, the result of which depends on a patient’s response. If injecting the dye recreates the pain the patient has been experiencing, it indicates to the doctor that the specific disc being tested is the source of that pain. If the pain is unlike the patient’s normal pain, however, although it may be determined that the disc appears to be degenerative, that disc may not be the cause of the patient’s pain.
Is spinal or back surgery necessary? While it is true that a number of back conditions resolve on their own, some more serious conditions, as well as those that cause unresolved pain, can be dealt with by a variety of surgical methods. At ANA, we first exhaust the most conservative treatments to solve spine problems. However, when surgery is indicated, we have the knowledge of and experience with the most cutting-edge procedures, including the latest minimally invasive surgical techniques.
A microdiscectomy and discectomy both refer to the surgical removal of an entire or partial intervertebral disc. Discectomy is often done as a microdiscectomy, a minimally invasive procedure using a microscope. Minimally invasive surgical techniques utilize tiny incisions (or portals) made in the skin through which small, specialized instruments are inserted.
This procedure is typically performed when non-operative measures have not been successful on a herniated lumbar disc. In microdiscectomy spine surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve impingement and pain. The objective is to remove the herniated portions that are compressing the exiting spinal nerve but not necessarily remove the entire disc. The procedure also enables more room for the nerve to heal.
A special microscope to view the disc and nerves is used in a microdiscectomy. This magnified view allows the surgeon to make a smaller incision, and thus, the procedure results in less damage to surrounding tissue. Minimally invasive techniques also allow access to the herniated disc fragment with a reduced amount of muscle and soft tissue disruption. This innovative technique also reduces post-operative pain and discomfort, and significantly reduces recovery time.
Laminectomy is surgery to remove the lamina, which is a portion of the vertebral bone that covers the spinal canal. Also known as decompression surgery, a laminectomy enlarges the spinal canal to relieve pressure on the spinal cord or nerves. A laminectomy is also done to create a better view of a herniated disc, and most commonly, a laminectomy is performed to treat spinal stenosis.
Fusion creates a solid connection between bones, such as vertebral segments in the spine, to halt movement in that section of the spine. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
At the time of the fusion surgery, instrumentation (e.g. screws and rods) typically provides stability for several months following surgery. Over time, the bone heals, creating a solid fusion, and thus, providing stability.
A bone graft and/or bone graft substitute is needed to create the elements of fusion. The bone graft does not form a fusion at the time of the surgery. Instead, the bone graft provides the foundation to allow the body to grow new bone into the desired bond, or shape.
There are several methods of bone graft: an autograft bone graft (when the patient’s own bone is used, usually taken from the pelvis), an allograft bone graft (bone obtained from cadavers via a bone bank), and bone graft substitutes (products that either assist or replace the need for autograft or allograft bone).
The cervical spine is comprised of the first seven spinal vertebrae. It starts just below the skull and ends just above the thoracic spine (located in the upper back). The cervical spine has a lordotic curve, resembling a backward C-shape. The cervical spine, much less fixed than the other areas, allows for the wide range of motion in the neck.
The neck, or cervical spine, consists of bones, nerves, muscles, ligaments and tendons. In addition, the cervical spine is a unique structure which houses the spinal cord. Though the cervical spine is very flexible, its location and function makes it at high risk for conditions such as herniation, stenosis, degenerative disc disease and osteoarthritis. It is vulnerable to injury due to its limited muscle support, as well as the fact that it must support the weight of the head. Thus, sudden, strong head movements, such as from whiplash, can cause significant injury.
The purpose of a cervical fusion is to connect damaged vertebral column segments in the neck. Injury or chronic wear-and-tear can damage the cervical vertebrae as well as the discs that lie between each vertebrae. During surgery, the disc(s) (or disc fragments) between the vertebrae are removed, and the adjacent vertebra are linked together by a process which stimulates bone growth following surgery. Often, metal instrumentation is utilized to stabilize the fusion until the bone growth is solid and functional.
Anterior Cervical Fusion
Most neck pain is due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints between each vertebra. If non-operative treatments fail to control neck pain, an anterior cervical fusion may be suggested in the hope it will reduce neck pain.
An anterior cervical fusion, performed from the lower front of the neck, is done for two reasons: to remove pressure on the nerve roots caused by bone spurs or herniated disc material, and to stop the motion between two cervical vertebrae.
First, the disc is removed between the vertebrae. Then, a cervical fusion is performed by using a bone graft to fill the space left by the disc removal. Placing a bone graft between two or more vertebrae causes the vertebrae to fuse together.
The goal of spinal fusion is to stop the motion caused by the instability of the segments in the spine. This reduces the mechanical neck pain caused from excess motion in the spinal segment. Anterior cervical fusion may also be done in a way that slightly spreads the vertebrae apart in an attempt to restore the space between them.
Posterior Cervical Fusion
Posterior cervical fusion, done through the back of the neck, consists of joining together the bones in the back of the cervical spine. During the healing process, the vertebrae grow together, creating a solid piece of bone out of the two vertebrae. Posterior cervical fusion is most commonly used to treat neck fractures and dislocations and to fix deformities in the curve of the neck. A serious fracture or dislocation of the neck vertebrae poses a risk to the spinal cord. The goal in this case is to protect the spinal cord from additional injury by fusing these bones together. Surgeons also use posterior cervical fusion to help patients who have mechanical neck pain (pain in the spine or its supporting structures). Extra movement within the parts of the cervical spine can be a source of this type of neck pain. Fusing these bones together prevents the extra movement, easing pain.
Spinal (Lumbar) Fusion
An unstable spine can result from an injury, disease, infection, tumor, fracture, scoliosis, other deformity or the natural aging process. When these conditions cause abnormal movement of the vertebrae to rub against or compress one another, back, leg, or arm pain may result. Lumbar fusion is a surgical procedure performed to permanently join together two or more bony vertebrae of the spine. Fusing bones together can prevent painful motion and provide stability. Metal plates, screws and rods may be used to hold the vertebrae together, so the vertebrae can heal into one solid unit. Bone graft material may also be used. Fusing the vertebrae stabilizes and aligns the spine, maintains the normal disc space between the vertebrae, and prevents further damage to the spinal nerves and cord. Spinal fusion may be indicated for a broken vertebrae (when it causes spinal instability, spinal deformities (scoliosis or kyphosis), spinal weakness or instability (such as resulting from severe arthritis), spondylolisthesis, or herniated disc(s). Unresolved chronic lower back pain may also be addressed by spinal fusion.
Spinal Cord Stimulation (SCS)
In spinal cord stimulation, soft, thin wires tipped with electrical leads are placed through a needle in the back near the spinal column. A small incision is then made and a tiny, programmable generator is placed under the skin in the upper buttock or abdomen which emits electrical currents to the spinal column. This electrical current treats chronic pain as these pulses interfere with the nerve impulses that cause that pain.
Nerve stimulation is done in two steps. A trial is first conducted to see if a SCS is effective in relieving a patient’s pain. The doctor inserts a temporary electrode through the skin connected to a stimulator controlled by the patient. If this experimental stimulation by the patient is successful, the doctor can implant a stimulator. With the feedback of the patient, the doctor then determines the most optimum pulse strength. The patient is then instructed in the use of the device independently at home.
Since its approval by the FDA in 1989, SCS has become a standard treatment for patients with chronic back or limb pain who have not found relief from other treatments. Most patients who receive spinal cord stimulation report a 50% to 70% reduction in overall pain, as well as an increased ability to participate in normal daily activities.
Pain Pumps/Intrathecal Drug Delivery
A pain pump, technically called intrathecal drug delivery, is a surgically implanted device in the lower abdomen that provides a steady stream of medication through a catheter leading directly to the spinal cord. It is similar to an epidural that a woman may have during childbirth. Because the medication is delivered directly to the spinal cord, the symptoms can be controlled with a much smaller dose than is needed with oral medication.
A pain pump may be used if all other traditional methods have failed to relieve long-term symptoms, oral pain medication has proved successful, and when no further surgeries are indicated. The goal of a pain pump is to better control symptoms and to reduce oral medications and their potential side effects. In fact, a patient generally needs about 1/300th of the amount of medication (typically morphine for pain, or baclofen for spasticity) with a pump than when taken orally.
Baclofen Pumps for Treatment of Spasticity
When tight, stiff muscles make movements difficult, it can make everyday life a challenge. This condition is called severe spasticity and can be caused by stroke, cerebral palsy, multiple sclerosis, brain injury, or spinal cord injury.
Electrical signals come from the spinal cord through the nerves and then to the muscles. These signals tell the muscles when to contract and relax. Spasticity is a result, causing an imbalance of these electrical signals, hyperactivity in the muscles, and resulting in involuntary spasms. Baclofen, a medication commonly used to decrease this spasticity, works by restoring the normal balance and reducing muscle hyperactivity, allowing for more normal muscle movements.
Baclofen is delivered via a surgically implanted pump, consisting of a round metal disc, about one inch thick and three inches in diameter, and a catheter placed under the skin of the abdomen near the waistline. The catheter is the tube that delivers the drug from the pump to the fluid around the spinal cord.
Lumbar disc replacement, which is widely seen as an alternative to spinal fusion surgery, is a relatively new procedure to relieve back pain. It gained FDA approval in 2004. It may also be performed on the cervical spine (neck).
Artificial discs are structurally similar and perform similar functions to the damaged discs that are being replaced, including allowing motion and weight-bearing load. The goal of using an artificial disc is to provide pain relief without compromising the spine’s natural anatomical structure.
The recommendation for disc replacement may vary for each type of situation or symptoms. Pain arising from the disc that has not resolved with non-operative care such as medication, injections, chiropractic care and/or physical therapy may be resolved with this procedure. Other indications are that the source of the pain is limited to one or two discs, that there is no significant joint disease or nerve compression, or no spinal deformity such as scoliosis. Finally, disc replacement is also an option if there is no history of spinal surgery, and the patient is not excessively overweight.
Surgery for adults with scoliosis is generally determined by the presence of pain. In fact, about 85 percent of adult scoliosis surgeries are done to relieve severe pain. Pain may be related to the actual curve of the spine or to the compression on the nerves of the spine, resulting in spinal stenosis.
Scoliosis surgery is generally recommended for those with pain and spinal curvatures greater than 50 degrees. If the curvature is over 60 degrees, surgery is almost always indicated because this deformity of the torso can lead to serious lung and heart conditions. Other indications for surgery include significant disfigurement, difficulty breathing or continued progression of the spinal curve.
Surgery for adult scoliosis includes decompression and fusion procedures. Posterior cervical fusion with instrumentation is most commonly indicated. Some candidates are eligible for minimally invasive procedures. Minimally invasive surgery for scoliosis, done through an endoscope, allows for a few small incisions rather than one long one. It is usually done when the scoliosis curvature is present in the thoracic spine.
Although corrective spinal surgery is much more complicated in adults than adolescents, a new study shows surgical treatment can improve function and the quality of life for older people with scoliosis. Advances in instrumentation have resulted in an increase in success rates in adults. In a recent study, for example, adults who underwent anterior fusion and instrumentation had excellent results. In another study of newer generation instrumentation, 87% of adult patients reported satisfaction.*
When adult scoliosis requires surgery, many different procedures may be suggested. At ANA, we recognize that each case of scoliosis is somewhat different and may require its own highly specialized approach for optimal results. It should be emphasized that surgery is suggested not simply to straighten the spine, but to solve the problems brought on by the scoliosis.
Back surgery is complicated, and can therefore create mixed results. It may take a few months to assess the success of a back procedure. Recurrent lumbar disc herniations happen to about 5% to 10% of patients. Decompression of a nerve root with back surgery is not always successful, such as if a portion of the nerve root is still pinched after the back surgery and can cause continued pain. At ANA, we are experienced in the complications of back surgery, and the possible need for revision surgery.
Often, the reason for continued pain after surgery is that either the patient has a secondary problem that needs to be addressed, or the lesion operated on was not, in fact, the source of the patient’s pain. (A lesion is the term used for any abnormal change involving any tissue or organ due to disease or injury.) Finally, improper and/or inadequate postoperative patient rehabilitation is probably one of the most common causes of continued back pain after surgery.
Unfortunately, back or spine surgery in and of itself cannot end someone’s pain. It is only able to alter the anatomy. In order to ensure success to the greatest degree possible, the actual injury, which is the probable cause of back pain, must be identified prior to, rather than after, back or spine surgery.
In most cases, the above reasons are why revision surgery, while it may be necessary, is often not technically due to an error from a prior surgery. However, there are other factors, such as a condition called pseudarthrosis (failure to achieve solid fusion) that may be a related factor to the need for revision surgery. This condition can lead to poor tissue healing and subsequent results. Another factor to consider is that the spine is ever-changing. Even after successful surgery, it can continue to deteriorate or develop other problems.
Spinal reconstruction involves any or all parts of the spine and is used to correct significant deformities (scoliosis, spondylolisthesis, kyphosis), disc herniations, traumatic injuries to the spine, degenerative or congenital conditions, and tumor removal. These can result in an unstable and weakened spinal column or significant neurological defects. This surgery stabilizes the newly shaped spine with rods and pins, and fuses the vertebrae together. In some cases, entire vertebrae are removed and replaced with artificial components to replace the diseased segment.
Reconstructive spine surgery is different from other types of spine surgery, such as decompressive spine surgery and spinal fusion performed following decompression. Modern reconstructive spine surgery focuses on restoring the anatomy to the degree possible to its pre-trauma or pre-degenerative state.
For more information about our Neuro-Spine Center, its specialists and any additional questions you may have please contact us at: (201) 457-0044.