The walls of the shower typically provide no help.  Unless you've put them there, there are no supports or railings you can use to catch yourself or prevent the hard fall that can cause so much harm.  There's often no way to "self-arrest" or stop your fall before it happens, and no way to break the impact of the fall before you hit the floor.

Second: Your physiology is against you!

Whether you are fit or frail, the process of getting in and out of that shower involves a bit of ballet that we aren't always careful about.  Stepping over the tub railing or the shower sill involves a bit of balance, particularly when going from dry ground to a wet, slippery surface.  Going too fast?  Carrying stuff with you?  Not paying attention?  This is often when patients - young and old - find themselves getting hurt.

But once in the shower, we tend to do crazy things, balance wise, and this is one thing I haven't seen mentioned in blogs or healthcare literature you may have read in the past:

The process of washing involves alot of bending and twisting.  We are particularly likely to lose our balance when trying to wash feet and toes or twisting to get to those hard-to-reach spots on our back side, BUT, most of us recognize that those are the situations where we need to be more cautious.  Where patients often get in trouble, in my experience at least, is when they go to wash their hair!

Think about it: what do you do when you wash your hair?

You close your eyes, tip your head way back, get your hands up where they can't help you balance, and then roll your head around in a random serious of oscillations that can make the surest of us a little unsteady. 

In anyone with a balance problem - like those with diabetes, Parkinsons, or history of a neurologic problem affecting their neck or back - closing your eyes and tipping your head back is the quickest way to throw your balance off.  That's what the police do when they want to see if someone is sober, and it's a test your neurologist will use to see if a person has a neurological disorder affecting their balance or coordination. 

And it's what my most recent, very healthy, shower-victim was doing just before he hit the floor!  Fortunately he just had bad strains and bruises, but it could have been worse.

Finally: Advanced age and illness don't help a bit.
​
Progressive weakness, stiffness of joints, poor balance all set us up for a fall and severely limit our ability to avoid a fall if we start to slip.  Osteoporosis and weaker bones set us up for fractures after even modest slips and falls.  Any condition that can cause black-outs - heart disease, diabetes, or neurological disorders - can lead to a hard fall in an unforgiving space.

What can you do to prevent a bad fall in the shower or bath?
There are a few simple precautions you can take, and a few pro-active home modifications anyone should consider:

Change that slippery floor to a non-slip surface.  Put down a non-slip tape or texture or change your tile to a non-slip product to limit the likelihood of that first slip.

Make sure that first step out of the tub or shower is also onto a non-slip mat or floor covering.

Install properly placed and designed hand rails that you can use when getting in and out, and when bending or twisting in the shower.  These should be professionally installed so they can hold your weight if you do start to fall.

Get a shower seat or stool that you can sit on while you tend to your toes and wash your hair without teetering.  Make sure it's a stool you easily get back up from, though!

Clean up after yourself or others - don't let soap or shampoo collect or drip onto the floor, don't let loose rugs present a trip hazard, and don't leave anything on the floor of the shower you might step on or slip on.

Design your bath area for safety and ease of use.  Plan ahead so that towels, or anything where you might be tempted to try and reach for, are in or right next to the shower.
​
And don't get in a hurry.  One of the joys of a nice hot shower or bath should be that it gives you a chance to relax a bit.  Don't rush to get in and out if that means you're going to get careless with your health!

​I hope you found this discussion helpful and interesting.  Please let me know if there are other topics you'd be interested in learning about, and check out my Facebook page for updates on future topics.

!  There are some things no back patient should ever do, but patients (and some soon-to-be patients) tend to try harmful activities every year anyway…So, how many are you guilty of?

1.   Shovel snow.  
This is one of the toughest activities any home-owner ever takes on, but every spring we get one last blast that blocks the walk or driveway, and - all across the Mid-West - back patients reach for that shovel.  If you've had recent back surgery, or you have a bad back for any reason, this is a job to avoid!  Forever!  

And if you absolutely have to move some snow, do it like your feeding a chipmunk - little, tiny bites, handled gently.
 
Snow is light when it's falling, but it gets very heavy when it hits the ground, particularly in spring when it tends to be wetter and denser.  And that snow shovel is a big clumsy spoon, designed to pick up a lot of material at once.  So each full shovel-full can easily exceed 20 lbs, which you're trying to pick up at an awkward angle while you're bending over, in the cold!  It will only take three or four big heaves to strain your back muscles and send you into spasm, so take little 1/3 shovels full, move them by stepping, not throwing, or better yet, get some help!

2.   Drive to Florida…
Or embark on any long trip the week after back surgery or a recent back injury.  Many of my patients travel a distance to have their surgery with me, and they have to get home that next week. 

The trip is safe and works out fine if

1. someone else is driving/flying them home,
2. they get up or out and walk around a bit every two hours along the way, and
3. they plan to rest a lot once they get home. 

I've had a patient surreptitiously plan his post-op trip so he drove the family the whole way from Cleveland to South Beach 3 days after surgery!  Then called to say he was really sore, his wound was red and swollen, and he had drainage on his unchanged bandage. Obviously there's nothing your local doctor can do for you at that point except shake his/her head!

If you have to travel to get home after surgery, have a plan for someone to drive you or to accompany you on your flight.  You can't be handling the luggage or running for a taxi.  Even better, stay a few days in town and have a wound check before you make an extended trip by car or plane. 

And just don't decide you're still going to take that golf trip/cruise/motor home excursion just five days after your back or neck operation. Plan ahead and give it a little time!

3.  Try moving “that rock”…
This is the gardener’s favorite mistake. Sure….it looked like such a little rock… But that was before you started digging!!!

​Every gardener knows this, but - for some reason - lots of gardeners can't stop themselves even though they know better.  Every little rock is just the top of a much bigger rock!

​It's probably a good idea to stay out of the garden for a couple of weeks after surgery or injury in any event, but I've had a number of patients that "just couldn't".  So, if that describes you, you should at least follow a couple of rules.

If you are recovering from any kind of fusion surgery for the neck or back, you may sit in your garden and enjoy it.  And that's IT!

If you've had a discectomy or decompression surgery you still need to take it easy for 3 - 6 weeks before you start doing anything very vigorous.

And, if you've had previous surgery, or you've had a back or neck injury in the past, you need to use good, common sense:

• Avoid repetitive bending and lifting. 
• Kneel or sit and work for a little while then get up and walk around. 
• Work for about 30 minutes at a time, then rest and reassess.
• If your back or neck starts to tighten up stop for the day. 
• And feel free to pick up the occasional stick or pebble, but do not start digging up tarps, pipes, roots, or rocks!  Know when to quit.

4.   Walking the dog(s) before you’re ready…
​Yes, you love your dogs and they LOVE you!  They’re glad to have you home and can't wait to get out and go for their walk!!!  But it doesn't matter if they are big or small, they’re going to try to kill you!  

​The big ones will bolt and drag you across the yard, which is disastrous if you've just had anything like back, shoulder or knee surgery, and the little ones will wrap that leash around your feet and trip you, which is just as bad or worse. 

​If you are recovering from a back or neck injury or from any kind of back, neck, or Orthopaedic surgery, be careful!  Share the dog-walking chore with someone who can help you, or have someone else give them a walk ‘til you're good on your feet.  

5.   Hosting that big Holiday, Thanksgiving, or any kind of affair involving lots of food, decorations, and furniture arranging too soon after surgery! Like the driving to Florida thing, you need to give yourself a little time to recuperate!  If you do have surgery around the time of a big important event, make sure everyone knows you are now the spectator, not the chef d'cuisine.  

Whether it's a family get-together, a wedding, or some other once in a life-time event, you will be much happier and the family will be much happier if you watch - or, at most, point to stuff for younger hands to carry - than if you aggravate your back or neck and end up miserable or worse.

Remember, that turkey weighed between 20 - 30 lbs before it was stuffed, and those big crocks, pans, and kettles - they're heavy when they're full.  If you're the only one that knows the recipe, that's fine, but you need to recruit good helpers any time you're trying to protect your back at the holidays.

6.   Anything involving a horse, a motorcycle, or an ATV -
Let's just say any non-standard form of transportation that you have to feed, hold upright, or try not to bounce out of or off of! 

If you've had a recent back or neck injury or you are less than 6 weeks out from surgery, this is a good time to groom the horse, rebuild the bike, or polish the ATV.  And any attempt to cut corners and get back to riding before you are ready will result in back and neck pain and spasm, at the least. 

Getting back to riding and back on the trail will be most successful if you take it in stages, build your strength up first, and then go back to activity a bit at a time. And when it comes to horses you can love them, comb them, watch them.  But no riding and no chores that’re measured in buckets, bales, or bags! 

I used to tell my post-op patients who were ready for normal, unrestricted activity that they could go back to "everything but rugby and rodeo!" and everyone would chuckle.  Until one day when the young woman I was so happy with started to tear up and sniffle. 

I had just one question - "You're a Barrel racer aren't you?".  "Yes sir" she replied tearfully.  So we had a nice long talk about sports rehab, and conditioning, and muscle strengthening to get ready to go back to her sport.

And I learned never to tease my patients who have horses!

7.   Deciding a tall stack of books will make an excellent step-ladder.  I've had a patient decide this was a sound strategy.  And at the age of 80 you'd think anyone would know better.  Any time you have any kind of idea like this, go sit down for a while until the impulse passes.  Please!!

8.    General Gardening. 
Of course – no bending, lifting, or twisting for 8 weeks after surgery! “But it’s spring and those roses won’t plant themselves!”  Again, find a helper, pay the gardener a little more, or enjoy last year's garden for a second season. 

If you are going to be "the muscle" in your yard then remember - nothing for 3-6 weeks after surgery, no lifting over 20 lbs until 6 weeks after surgery AND permission from your surgeon, and work in short stints - 30 minutes at a time, with a little walk about and rest to make sure your back or neck isn't tightening up.

And, please, if you do over-do it - ice, anti-inflammatories and rest are the only thing for it.  You won't need to call your doctor just to say you chopped wood all weekend and now your back is sore!  He/she won't be able to do anything but offer sympathy...

9.   Anything involving a chainsaw, engine hoist, or a bungee cord.  
Does anyone actually need say this…?  As with Holiday dinners, the person recovering from a recent back or neck injury, or recent back or neck surgery can watch heavy operations.  You can even point to stuff for younger folks to do.  You can display your wisdom and experience for all to marvel at.  

But don't try to pick up, twist, or torque anything that would make someone else grunt!
​
10.   Losing your pain medications –
Whether it's down the sink, down the toilet, off the front seat of the car – it doesn’t matter.  Now-a-days you can’t just call in for a refill. 

Your pharmacist likely won’t refill it no matter what your doctor says, because - by law - they have to keep track of how many prescriptions you fill in how many days.  And recently, it hasn't mattered if this is your first pain prescription in decades or one of a number you've gotten over the years, your pharmacist can simply refuse to refill your refill.  So take care of those pain  medications the way you really ought to - very carefully.…

As always…I want my patients to be active, and get back to full fitness and recreation when they've healed up.  But that always means taking care of your back and using good common sense at home and at work!
 
I hope you find this discussion interesting and useful.  If you have other questions that I can answer for you, please leave a comment below.  And feel free to like and follow my Facebook page to find more content that you and others might find helpful!

Cervical disc replacement - or disc arthroplasty - represents a powerful, well-established tool for treating herniated discs and degenerative disc disease in patients who have persistent pain and impaired function due to neck and arm pain, and who want to avoid a spine fusion if they can.

So, what’s the role of Disc Replacement Surgery in 2023?  There’s more good news and no bad news…
 
Good news!! Most patients with neck pain can recover without surgery:  80-90% will get better, and get back to normal activity with physical therapy, anti-inflammatory meds, rest, activity modifications, chiropractic manipulation…or, in some cases with nothing but time and TLC!
 
For the 10-15% of patients with a serious neck problem that just doesn't respond to time and supportive therapy, many will need an operation.  Many of these patients will need a discectomy - a removal of the cervical disc through the front of the neck - to relieve the neck pain and spasm, and the persistent arm pain, numbness, and weakness caused when a spinal nerve root is compressed by a degenerated or herniated cervical disc.
​

This is not a minor surgery, and rarely the first choice in a patient's care, but when pain is bad enough that it interferes with daily function, employment, fitness, and/or sleep…surgery starts to make sense.
 
Who needs spine surgery?
​
​We consider surgery the first choice for patients who have more serious issues such as fracture, infection, or tumor.  

​These conditions are relatively rare, often emergencies, and not the sort of thing we usually see in patients with persistent and long-standing neck pain problems.  
 
More commonly we are considering surgery for patients with wear and tear and degenerative neck pain problems, or those with a disc herniation related to repetitive trauma or a sudden accident.  

While we think of surgery as the ultimate treatment for neck pain that won't respond to anything else, we know that surgery is the most reliable solution for most causes of arm pain or weakness (radiculopathy) including disc herniation, cervical stenosis, or spinal instability.
 
Not every type of operation works for every type of spine problems, though, and while disc replacement surgery is an excellent treatment for disc herniations and disc degeneration, it is not a treatment for spinal instability or deformity, and not at all useful for treating tumors, infections, or fractures and dislocations of the cervical spine.  Cervical fusion remains the very best solution for each of those problems.
 
For those patients who do suffer neck and arm pain due to disc degeneration or herniation, though, disc replacement – or cervical arthroplasty – is an important option.
 
What is disc replacement surgery?

​Disc replacement surgery and disc arthroplasty surgery are the same thing.

​Also referred to as an “artificial disc” the implants used in these surgeries are designed to preserve motion in the spine after a discectomy (removal of the disc) and they have been shown to maintain motion and reduce the likelihood of degeneration at adjacent levels of the spine, something that often occurs in the years following a fusion. They are recommended for patients aged 18 – 70 years, but I, and other surgeons, have had excellent success in selected patients over the age of seventy years.
 
Artificial discs are placed in the neck through the front of the spine (an anterior approach) after a damaged disc has been surgically removed to treat neck pain associated with radicular pain – the arm pain caused by a “pinched” nerve.

​In the neck, this is exactly the same approach we use for most disc surgeries and all anterior cervical fusions.
 
Disc arthroplasty implants are not experimental or untested.  The implants we have now have been in development for over 40 years and similar designs have been available for patient care for nearly 2 decades.  There are disc replacement implants specifically designed for the cervical spine (neck) and for the lumbar spine (lower back).  

​They are specifically intended for treatment of degenerated or herniated discs in otherwise healthy patients.  There are no discs designed for the thoracic spine, and they are not intended to treat fractures, infections, scoliosis, or spondylolisthesis.

​And, to answer a pretty common question - you can’t undo an old fusion and put in an artificial disc later!
 
Artificial disc replacement can be carried out as an outpatient surgery, and utilizes many minimally invasive techniques, but it is not “minor surgery”.  When it comes to the spine, there is no such thing!  The importance of surgeon experience and skill is reflected in the careful diagnosis and plan for treatment, and the skillful approach and placement of the implant.

Surgeon experience with disc replacement procedures is important to the outcome here.  Ask your doctor what their experience level is and whether they've treated cases like yours before.
 
Disc replacements last a long time. How long? We don’t really know, because – unlike artificial hips and knees – we haven’t seen any of the ones we use today wear out.  We have had the opportunity to observe patients from Europe who have had disc implants in place for up to 35 years without failures. 

​As an investigator for early trials of two-level disc replacements, I have followed my own patients for more than 18 years without seeing any cases where the disc has worn out or deteriorated.
 
Who needs disc surgery?
Disc degeneration is a process that occurs over time, with wear and tear, age, and physical and environmental stress that causes changes in disc that separates each of the vertebral bodies in our spinal column.

Each disc acts as a shock absorber and a slightly flexible joint that allows the spine to move, but only so much.  As we age, the molecular components of the disc change, resulting in a loss of water content.  The disc loses height, becomes tougher and harder, and becomes a less successful shock-absorber. 

​As this happens, the disc may bulge or protrude into the canal where it can press on the spinal cord or nerve roots, causing arm pain, and it can lose its ability to control neck motion or cushion the small joints during motion, resulting in neck pain

​As these changes progress we see:

Axial neck pain – pain in the joints, muscles, and ligaments of the neck, causing focal pain and stiffness;

Referred pain - symptoms over the shoulder girdle muscles that support the neck - the trapezius, rhomboids, and paraspinous muscles
​
and Radicular pain - pain running down the arm and into the hand and fingers in a pattern or distribution typical of a specific nerve level, caused by pressure on the spinal nerve at that level.
 
Radicular arm pain can be uniquely intense and is the symptom that drives most patients to ask for surgery.

When these symptoms fail to improve after a trial of non-operative care, that’s when we consider surgery.
 
We generally consider surgery for patients with:

• Arm pain that has not responded to a good trial (6 weeks) of non-operative therapy
• Any progressive neurological deficit - increasing numbness or weakness
• A persistent neurological deficit with persistent radicular pain
• A surgically correctable lesion documented on imaging studies - MRI confirms a problem that can be corrected; or
• Any progressive instability or deformity, though these patients will more often require fusion than disc replacement.

 
​The traditional treatment for cervical disc herniation has been fusion, typically described as an "anterior cervical discectomy and fusion" (ACDF).  

​That’s a surgery through the front of the neck, with complete removal of the disc back to the spinal canal and removal of disc or bone spurs that may be pressing on the nerves. 
 
But, why fuse the spine after we get the disc out?
 
The interbody fusion is performed by placing a cage or bone spacer between the endplates of the adjacent vertebrae to restore the intervertebral and foraminal height, immobilize the painful segment, and provide permanent stability.

Fusion does all of these things reliably and well!
 
But fusion eliminates motion at the treated level and increases stresses in the adjacent levels above or below, and that can lead to breakdown at that adjacent level, (adjacent level degeneration) sometimes just a year or two after the initial surgery.

​What does the Artificial Disc do that’s different?
 
The cervical disc arthroplasty or disc replacement is intended for the patient who:
-   needs the discectomy and would otherwise need a fusion, but
-  still has motion at the injured level and wants to avoid the down-time required for a cervical fusion to heal,
-  wants to avoid the risk of non-union (fusion failure) that might require another surgery, and
-  wants to avoid the risk of adjacent level disease down the road.
 
The approach for the disc arthroplasty, and the removal of the damaged or herniated disc during disc replacement surgery is exactly the same as in the ACDF, but instead of placing the bone or a fusion cage in the empty disc space, disc replacement surgery fills the space with an artificial device that restores disc height and alignment and preserves the motion of the original disc.  

​This allows the treated spinal level to move more naturally, reducing the risk of adjacent level degeneration down the road.  And there is no need for prolonged immobilization or restricted activity, as we don't need to "wait for fusion".

Who is the best candidate for a disc replacement surgery?

• Patients with at least 6-12 weeks of pain that hasn’t responded to a good trial of conservative therapy
• Patients with radicular arm pain or weakness causing serious functional impairment
• Patients whose surgical problem is limited to one or two disc-levels
• Patients with disc disease at one or two-levels between the C2-3 to C6-7 levels
• Patients with good bone quality and fitness
• Patients who demonstrate adequate residual motion at the treatment levels on flexion and extension x-rays.

 
 
Where will disc arthroplasty work well?
 
Success has been unequivocally demonstrated in the well-maintained but painful disc, in the young and active patients.

​There are over 150 peer-reviewed publications analyzing investigational FDA trials, long-term follow-up studies, and large multicenter studies to ensure the safety and effectiveness of these implants.  These studies have shown that, when used for the correct indications in the properly selected patients, disc arthroplasty provides significant advantages over traditional fusion procedures.  They are not "experimental or investigational", and their effectiveness is proven.
 
Do they work in everyone?
As we noted at the top of the page, these implants are not intended to treat problems like infections, tumors, or fractures, and they can't undo what has already been done.
 
But they can be considered in almost every patient who would be a candidate for a one or two-level ACDF, so long as the patient has good bone quality and still has motion left at the level to be treated

​Severe osteoporosis makes any sort of stabilization difficult, and disc replacement is as likely to fail as a simple fusion, but would require a more complex revision that a failing fusion might.  And, a patient with no remaining motion at an arthritic level has already started to fuse naturally, and is unlikely to get good motion back  with any operation.  The disc arthroplasty is a motion-preserving procedure, but it can't undo a solid fusion.
 
What about age?

​If patients are reasonably fit and bone quality is good, age isn’t a big problem!  Large studies and FDA trials of disc replacement have included patients up to age 69, and my experience with patients older than this suggests disc replacements are actually better tolerated than the traditional fusion.

At age eighty, some of my fit patients do very well with outpatient disc replacement surgery, returning home within a few hours of their operation, with a soft collar, and no restrictions of daily activity.  There has to be good bone quality and good residual disc motion, however.

What about activity level?  

​Patients who are athletic or hard working can depend on disc replacements to hold up to their physical demands – the discs are not fragile and the patients don't need to feel fragile either.  Patients don't have to restrict their fitness or work activities beyond what makes sense for normal people.
 
What about smokers?

Well , first off – stop ! It’s not good for you.  However, smoking does not affect the fixation of the disc replacement implant the way it can impede bone formation needed for fusion.  Studies to date have not shown smokers to have any poorer outcome after disc replacement surgery than nonsmokers.  That's just not the case with fusion, so disc replacement is probably a better choice for you too.

​With all that in mind, cervical disc arthroplasty continues to offer an attractive and valuable option for most patients otherwise indicated for cervical fusion to treat their neck and arm pain. 

​If you’ve been offered a fusion surgery, ask your surgeon if you’re a candidate for disc replacement!
 

​As always, I hope you find this discussion interesting and useful.  If you have other questions that I can answer for you, please comment below.  If you want more updates on blog posts please like and follow me on my Facebook page.
 
And feel free to like and share this content with others that might find it beneficial!
 
Thanks for reading.

​who have now developed new neck pain or a new disc herniation at the level above or level below their fusion.  

​This is called Adjacent Segment or Adjacent Level Degeneration, and it is a well known and common complication of cervical fusion surgery.  And, until recently, it has almost always been treated with another fusion.

​That treatment strategy was the only one available up until ten or fifteen years ago, and it would, as you might guess, tended to start a vicious cycle of fusion and adjacent level herniation that often lead to multiple surgeries and multilevel fusions in many other wise fit and active patients.  Even today there are many spine surgeons who will advise their patients in this situation that there is nothing for it, they're going to need another fusion.

I've treated enough patients over the years to know that an active, young patient with a 4-level fusion is not often happy with their result.  Neck pain is constant, stiffness and limitations in motion are inevitable, and there is always the likelihood that any level that's still mobile is going to degenerate, become painful and require another round of surgery.  Again, up until ten or fifteen years ago there really wasn't much else that could be done.
​ 
That vicious cycle was one reason surgeons and non-surgeons alike would advise their patients to avoid surgery until they just couldn't take it anymore.

​That approach to neck pain and disc disease is changing, largely due to the advent of disc replacement surgery as an alternative to fusion.

​Disc replacement surgery is  growing in popularity, both because of the interest of patients, but also because of the growing number of surgeons who have been trained in these surgical techniques and who have become familiar with the vast experience of other surgeons who have preformed large clinical trials and extensive peer-reviewed studies to document the advantages and safety of the devices we now have available to us.

​However, there is still a lot of misinformation out there, and it’s sometimes hard to figure out what facts are important to your individual condition!  And that's particularly true when it comes to patients who have an adjacent level disc herniation or degeneration adjacent to a previous fusion.
Here are five points that are particularly important for these patients and their care-givers to know:

1. Disc replacement surgery (also called disc arthroplasty) has been available for roughly two decades now, and has an extensive background of supportive research and surgical experience.  Use of an “artificial disc” to preserve motion in the spine after a discectomy (removal of the disc) has been shown to maintain motion and reduce the likelihood of degeneration at adjacent levels of the spine, which often occurs in the years following a fusion surgery.  

​Disc replacements have been widely studied in a number of controlled, FDA approved trials, and have proven safety and effectiveness in all of those studies.  For those studies, the patients included were very specifically selected, however. Disc replacements were recommended for patients aged 18 – 70 years, typically, but were not allowed for any older patients, patients with other illnesses, and - importantly - patient who had had a previous cervical fusion.  

​It wasn't that they were not expected to work for those patients.  Instead, it was known that including patients with too many variables in their background would make the analysis of all of data much more difficult, and could confuse the study.  Comparing patients who had had a previous neck surgery to patients who had had no previous surgery would have made these early studies impossibly complicated and could have made it impossible to reasonably document their safety and efficacy for any patient. 

​2. Artificial discs are placed in the neck using exactly the same surgical technique used for anterior discectomy and fusion surgery, the commonly recommended treatment for adjacent level disease.  The surgical approach is through the front of the neck (an anterior approach), and the damaged disc above or below the previous fusion is surgically removed to treat neck pain and the associated radicular pain – the arm pain caused by a “pinched” nerve - in exactly the same way whether a fusion is planned or a disc replacement performed.

​In the neck, this is the same approach we use for most disc surgeries, but it has to be carried out with added care when a previous surgery has created scarring in the vicinity.  That said, there is no greater difficulty with this approach when an arthroplasty is planned than for fusion.  In fact, revision surgery for fusion often requires removal of the old plate and screws before the next level can be fused, while this is not usually necessary for an arthroplasty operation.

​3. Disc arthroplasty implants have been in development for over 40 years and have been available for patient care for nearly 2 decades.  The implants now most widely used have been developed for placement with the most simple techniques and don't require complex surgical techniques such as placing fixation screws or fins, or cutting slots into the bone.  

​In fact, disc replacement is generally focused on the goal of minimal bone removal and minimal soft tissue exposure, which often allows a disc to be placed successfully without ever exposing the fused level above or below.

​These are implants specifically designed for the cervical spine (neck) and they have very specific applications – treatment of degenerated or herniated discs in otherwise healthy patients.  There are no discs designed for the thoracic spine, and they are not intended to treat fractures, infections, scoliosis, or spondylolisthesis.  And you can’t undo an old fusion and put in an artificial disc later!  But these discs treat the adjacent level cervical discs just as well as they do the primary disc herniations included in those original studies.
 
4. Artificial disc replacement can be carried out as an outpatient surgery, and utilizes many minimally invasive techniques.  So, even in cases where previous surgery has created a scar or affected other levels, disc arthroplasty can still be carried out without the extensive surgery needed to remove and replace a fusion plate with a longer plate, for instance, or move the delicate tissues away from the old fusion bed to get previous hardware out of the way!  

​The importance of surgeon experience and skill is reflected in the ability to recognize the ability to preserve motion at the adjacent level and carry out the motion preserving surgery with the minimum of soft tissue dissection and injury.  Your surgeon will provide a careful diagnosis and plan for treatment, and provide the skillful approach and placement of the arthroplasty implant that allows a rapid recovery from surgery and rapid return to function. 

​Surgeon experience with disc replacement procedures is important to the outcome in these revision operations.  And, it's ok to ask your surgeon what his or her own experience has been like.
 
5. Disc replacements last a long time and protect those adjacent levels for a long time as well. With most contemporary arthroplasty implants we use we don’t really know how long they will last, because – unlike artificial hips and knees – we haven’t seen any of the ones we use today wear out.  Most patients know either from their own experience or from what they've seen grandparents or family members go through, that hip and knee replacements tend to wear out after 10 - 15 years, and often need to be revised. 

​With disc replacements, we have had the opportunity to observe patients in Europe who have had disc implants in place for 35 years, and we still have not seen any failures.  Some of the early designs did not do as well, but those aren't in use any more and have not been for years.  

​In my own experience I have not seen disc replacement fail or require revision.  And I have followed my own patients for more than 18 years without seeing any cases where the disc I implanted has worn out or deteriorated.

Is this opinion or is this fact?  It is important to know that there have been over 150 peer-reviewed publications documenting the results of long-term trials and studies of total disc replacements, both here in the US and abroad.  Including investigational FDA trials, long-term follow-up studies, and large multicenter studies to ensure the safety and effectiveness of these implants, almost all of these papers speak to results for primary patients and not those treated for adjacent level disc disease. 

​These studies have shown that, when used for the correct indications in the right patients, disc arthroplasty can provide significant advantages over traditional fusion procedures.  Cervical Disc arthroplasty is not experimental or investigational, and the effectiveness of disc replacement is proven.
 
So, is there evidence that the same results can be expected for patients needing treatment for adjacent level degeneration?  Is there good evidence that disc replacement can be carried out in a revision surgery as safely and effectively as it can for a primary procedure, or - more to the point - as safely and effectively as for a patient receiving fusion for that revision procedure?

​There is that evidence, as well as numerous series and smaller reports establishing the suitability of motion preservation for these patients who've already lost a considerable amount of their normal motion due to their first fusion.
​
As an academic surgeon, one of my responsibilities over the years has been to track and document the results of my own patients, to identify problems before others encounter them and to establish the benefits and success of other techniques that other surgeons might subsequently take advantage of.  This has also included biomechanical and anatomical studies of surgical technique and implant design, but follow-up of individual patients has always been crucial to good surgical care and the improvement of every kind of treatment.

​In my most recent analysis of outcomes in patients treated both for primary disc disease and those with disc herniation or degeneration following an older fusion, we were able establish strong support for the clinical opinions discussed above:  Comparing adult patients receiving one or two level cervical disc replacements for radiculopathy and/or axial neck pain who had no previous surgery to patients treated the same way, who had adjacent level spondylosis or cervical fusion, and comparing all of them to a series of similar patients treated with fusion for similar degrees of neck pain and radiculopathy we found that:
​
Patients undergoing a primary cervical disc replacement reported excellent satisfaction and pain relief 2 years down the road - 76% percent reported minimal neck pain even with activity, and 36% reported no neck pain at all.  86% reported little or no arm pain at that point, of which 59% reported no arm pain symptoms at all.  Compared to this, the patients who had disc replacement for adjacent level degeneration did as well or better - 88% percent reported minimal neck pain with activity, of whom 50% reported no neck pain at all,  and 100% reported little or no arm pain at 2 years, of which 75% reported no arm pain symptoms at all! 

Compared to patients having cervical fusion - well, they did well also, but as early as 3-4 years after surgery 18% were reporting moderate to severe neck pain, and a few were experiencing moderate arm pain.  I was pleased to present the preliminary report of this peer-reviewed material at the MidAmerican and the Western Orthopaedic Association Annual Meetings in 2022.

While these numbers are too small to prove anything, they certainly support the use of a disc replacement device in patients who've already lost some neck motion, as opposed to forcing them to undergo additional fusions.
 
And what about the safety?

In our analysis of these patients - none of the patients in any group suffered a complication either during or after surgery, and none of the patients treated for adjacent level degeneration has required any other surgery.  Any neck operation requires superior care and technique to get a good result without complications.  None of these procedures should be considered minor surgery, even when they can be performed as outpatient operations. 

So, if you’ve been told you need to have a neck fusion, for a primary disc herniation or disc degeneration or for a problem that has arisen following a previous fusion, it’s ok to ask “is there another way - a better way - to treat this?”.  It's worth getting a second opinion to see if disc arthroplasty might be that better way for you!
 
I hope you found this informative and interesting! You can learn more about disc replacement surgery, and other types of spine surgery and treatment, by checking out more sections of this website, and you can follow me on Linkedin or Facebook to learn about new updates and post that may help you take care of your back and neck. 

​Thanks for reading!
​

​Low back pain is a common - essentially universal - problem for modern men and women.  Even though we continually improve our tools, our work environments, our recreation, we still encounter back and neck pain problems that interfere with or even curtail our normal daily activities.
 
So back pain problems must have been even worse for our ancestors, right?

It's not so clear-cut.  Although they are widespread among modern man, arthritis and back problems were not a common affliction among our ancient ancestors, at least not to the extent they would talk about them much.
 
While we do have extensive medical treatises and descriptions of illness and injury dating back to the hieroglyphics and Egyptian times, there is very little written about arthritis in early literature: Egyptian papyrus manuscripts (the Edwin Smith papyrus) discussed a wide variety of illnesses and injuries, but did not address the problems of joint disease at all. 

Disorders of infection, and skin lesions, and deformity were discussed, but the only discussion of spinal disease alluded to the care of someone who falls from height and injures his back, and can no longer move his legs or control his bladder; that patient cannot be helped and will, the manuscript tells us, soon die.  

And that was pretty much the standard of diagnosis and treatment up until the later decades of the 1800's.  Low back pain?  When you devoted your life to hard labor and warfare it had to be an issue, but, I guess, when you're building pyramids for a living you don't mention it.

It is difficult to find, among all the human archeological or fossil evidence, many specimens with typical knee or hip degenerative joint disease of even a moderate degree.  Why is it that a disease process so prevalent today would be so hard to find in material just a few hundred years old - a blink of an eye in evolutionary time? 
 
Is osteoarthritis, as we know it today, kind of a new disease to man? Is it truly a byproduct of civilization, reflecting changes in diet or environment, or alterations in activity patterns? 
 
The fossil remains of our predecessors suggest an interesting answer to these questions, and may provide insight into the evolution of bone and joint disease in modern mankind.
 

​Paleopathology is the scientific study of disease processes - pathology - of the past, defined as "the science of the diseases which can be demonstrated in the human and animal remains of ancient times". 
 
The importance of paleopathology lies in the ability to carefully examine the physical remnants of ancestors or ancestral species, and to determine not only how these animals or individuals functioned normally, but also the diseases which they faced and the way they responded and adapted to them.
 
The Ancient Fossil Record is all about bones:
Evidence of disease has been found in the fossil remains of dinosaurs and early mammals predating the appearance of man by 100's of millions of years.  

​Since bone is the only tissue remaining in most of these specimens, very little can be said about diseases of the blood or visceral organs unless that disease also had an effect on the bone.  For instance, we do know that bacteria and parasitic organisms were around and probably caused infections in pre-historic times much as they do now, but the only evidence we have of those infectious diseases comes from the rare examples where bone was involved.
 
Mummies, on the other hand: 
Mummification - either accidental or intentional - does provide an opportunity to study soft tissue disorders, infections by bacteria and parasites, and toxicology in ancient man

Although we are most familiar with mummification as it was practiced in ancient Egypt, mummification can occur naturally in any perpetually arid or frozen environment.  Well preserved mummies have been found in the Peruvian Andes, the Arctic, Siberia, and in the drier climates of the Mediterranean, North Africa, Australia and Japan.  Chemical preservation has produced mummies in pre-Columbian salt and copper mines of South America, and has resulted in a series of remarkable "Bog bodies" in Northern European peat bogs. 
 
The Tollund man is one of several bodies recovered from the peat bogs of northern Europe that demonstrated such startling preservation of the body's soft tissues - including features such as eye color and finger print pattern - that local police were summoned to the discovery, even more than 2,000 years after death.

​The maintenance of the soft tissues in Egyptian mummies is often remarkable. The diffuse rash seen on the face, torso and thighs of Pharaoh Ramses V, and on other mummies of the period, is highly suggestive for smallpox.  Histological examination confirmed the diagnosis.  The quality of histologic material after mummification can permit sophisticated analysis, and DNA analysis now opens the door to far more sophisticated study and pathological diagnosis.  

​Implications:
The fossil record of disease has historical and clinical importance, providing information about the types of diseases present prior to careful written accounting, and the spread of disease among peoples and populations who may not have had the capacity or time to write. 
 
For example: scholars argued for years that the hookworm, an intestinal parasite, was introduced into American native populations by infected African slaves brought to South America by the Spanish.  For years there was no physical or descriptive evidence to suggest that hookworm had ever existed in the New World prior to the arrival of the Europeans.  In 1960, however, while studying intestinal specimens from a 500 year old, pre-Columbian mummy found in Peru, researchers found well preserved examples of the parasites still attached to the intestinal wall.  

​Scanning Electron Microscopy showed details of the worms' head and buccal cavity, allowing conclusive identification of both the species and variety, proving that this parasite was established in America long before the arrival of the Spanish.
 
Musculoskeletal Paleopathology: 
What, then, were the predominant forms of musculoskeletal disease among our ancient ancestors? 
 
Deformity was a common cause of dysfunction in ancient man.  

​The deformed foot of the Egyptian Pharaoh Siptah, once described as an example of club foot, appears to modern observers to more closely mirror the residual deformity caused by polio. X-rays of Siptah's foot show a specific deformity classic for paralysis and not clubfoot, and the limb is shortened, a combination commonly seen with polio. 
 
On the other hand, examples of true, untreated clubfoot have been found in both Egypt and Europe, were illustrated in Egyptian writing, and seen in archeological specimens.  One European specimen from the Bronze Age demonstrates the dramatic inward rotational deformity of the mid-foot, (adduction), and rolling-in of the heel (inversion) so severe that the foot was actually inverted - upside down -  to the point that this Bronze age man could only walk on what should have been the top of his foot.

But walk he did, evidenced by the extensive calluses and bone spurs that formed on the dorsal surface of those bones.
 
Systemic disorders or infections that left their mark on bone are also apparent among the fossilized and preserved remains of early man.  Examples of leprosy have been found in ancient Egyptian material and throughout Europe.  Specimens exhibiting signs of syphilitic infection are quite common in Native American remains of both North and South America, but have never been found in Egyptian material. 

​Tuberculosis, common around the globe today, was common then too. And since it did attack the bones - and the spine - quite frequently, we see it clearly in the archaeological record.

​What of the other common diseases of bones and joints we treat today, particularly those leading to degenerative joint disease and degenerative disc disease?
 
First of all, disease processes linked in any way to aging are significantly more common in our modern population than they would be in any period in the past.  We should expect significant differences in the incidence of most common cancers, chronic disease, and osteoarthritis relative to today's populations.  To be blunt, people didn't used to live that long!
 
The average age at death in Bronze and Iron Age man was approximately 25-35 years, depending on where you looked.  In some ancient cemeteries as many as 50% of all bodies are of infants and small children, which brings the averages way down, but even among those that made it to adulthood, longevity was not promised.

​Prior to the 1700's, people just did not live very long.  Going back 3,000-4,000 years, even among the Pharaohs -who were the best fed, most carefully protected individuals in the relatively advanced land of Egypt - the chances of long life were slim.  Of 26 royal mummies studied at the British Museum, only 10 had lived to the age of forty, and only 2 had lived beyond fifty. 
 
King Thutmose I, acclaimed as a great military leader, greatly expanded the territories and influence of Egypt through victories over both the Nubian and Syrian nations.  He sired three princes and a princess during his reign as Pharaoh and established a successful dynasty. 

​Yet x-rays of the Pharaoh's mummy revealed open growth-plates in the proximal humerus, distal femur, and proximal tibias, and no degenerative joint changes in any joint.  The fossil record shows us that, despite all of his accomplishments, Thutmose I was dead before he reached the age of 21 years!.

This dramatic improvement in individual survival has had an effect on the types of diseases we see in mankind.  In comparing a modern population - with an expected survival into the 70's and 80's - to an ancient population where only 5% of the people survived past age 40 - three predictions might be made:

• First, we can predict that diseases that don't start until adulthood but then progress throughout life will appear more common and far more severe in modern populations.  These conditions will be present among ancient peoples, but less frequently and only in their mildest forms.  Think arthritis.

• Second, we can predict that some diseases that typically occur as a result of some repetitive insult or toxic exposure will be rare in ancient populations, and others very common.  Diseases that require a threshold of exposures or trauma, such as carcinogen exposure, may not reach that threshold in the ancient population, but will become increasingly common in modern populations depending on age.  On the other hand, unprotected exposure to things we now avoid might lead to more common disease findings.  We see this in mummies around the world where dust and sand inhalation has resulted is a frequent finding of silicosis, a disease of the lungs we still see, but less frequently, today.

​

• Finally, we can predict that diseases that typically occur only with advanced age will be rare or unseen in ancient populations despite being common or ubiquitous in modern elderly populations, showing a significant difference in incidence when the two groups are compared, unless matched for age. Think of our most common cancers and osteoporosis.

 ​As an example of the first principle, consider osteoarthritis.  We know that degenerative joint disease is rarely present in people before 30 years of age, unless associated with a traumatic injury of the joint, and that clinically significant knee or hip degeneration rarely occurs before the age of 40.  This means that, even though the degenerative process was ongoing, only 5% Bronze or Iron age men would be likely to develop clinical osteoarthritis prior to their death, unless associated with some other pathology.
 
Causes of early, advanced degenerative joint disease in pre-historic men would be similar to the what we see among young patients today, occurring as a result of aseptic necrosis, or pediatric disorders like Perthes disease, slipped capital femoral epiphysis, and congenital dislocation or dysplasia of the hip.  

​These entities affected young individuals then as now, and produced crippling joint disease among the generations that came before corrective orthopaedics.  In fact, many archeological specimens presented in scientific texts as examples of "osteoarthritis" do show deformities more suggestive of acetabular dysplasia or slipped capital femoral epiphysis than of typical osteoarthritis.
 
End stage degenerative disc disease, the type we see after 15 - 20 years of symptoms, is very rare in Bronze Age populations.  What is seen is a high incidence of mild to moderate vertebral spurring, suggesting that the same degenerative processes were ongoing, but never got too severe.  Primitive man rarely lived long enough to "wear out" his vertebrae, though the rigors of his lifestyle frequently left a mark on his spine.
 
The leading cause of joint destruction in prehistoric populations was trauma.  This represents the second prediction above:
 
Anyone who accumulates sufficient exposures (trauma) can develop the disease, but if you don't live very long you need to experience a large dose early on to manifest the clinical disease.  Meaning, prehistoric man would develop joint disease after major traumatic events, but rarely "got enough steps in" to generate serious osteoarthritic degeneration.

To make matters even tougher, prehistoric man had to survive his fractures, and avoid starvation, in order to live long enough to develop even acute post-traumatic arthrosis.  There are examples of prehistoric poly-trauma, but they aren't common, and degenerative joint disease is seen in the survivors of these injuries.
 
One very old example of an individual surviving multiple injuries long enough to develop secondary degeneration is of a Neanderthal skeleton from an Iranian cave site discovered in the 1950's.  "Shanidar 1" was apparently a rare survivor of major trauma.  

​Standing about 5'6" tall, Shanidar 1 lived approx. 50,000 years ago, and probably lived to an age of 40 years.  Years before he died, Shanidar 1 sustained at least one, and more likely a series of serious musculoskeletal injuries.  At one point, probably a decade before he died, he sustained a severe crushing injury to his right arm and leg.

​Fossil remains show that he suffered an amputation of the right arm through the distal humerus, fractures of the clavicle, scapula, and right knee, and a crush injury to the foot.  He also sustained, perhaps at a different time, a crushing blow to the left side of his head which may have blinded him in the left eye. 

​Any time prior to the advent of antibiotics and modern medical care this combination of these injuries could have proved fatal.
​
Nonetheless, Shanidar 1's amputation healed, he survived the chronic osteomyelitis of the open clavicle fracture and severe post-traumatic degenerative joint disease of the knee and ankle.  The extent of bony healing and the degree of joint degeneration suggest that he lived for many years after his injury.

​Considering the violent and uncertain environment in which he lived it is impossible that he could have survived without extensive support from members of his tribe.
 
Septic arthritis was likely a cause of degenerative joint disease in prehistoric man, but acute sepsis in these people was probably routinely lethal.  Those dying soon after the onset of their osteomyelitis or septic arthritis would leave no bony evidence of their disease.  Chronic infection and obvious joint destruction would be more likely to occur in those suffering from tuberculous disease.  And we do know that was a thing!
 
There are many drawings and sculptures in both Old and New World antiquities illustrating the common features of tuberculosis.  There is excellent evidence that tuberculosis was prevalent in both hemispheres in pre-Columbian times. The mummy of an Egyptian high priest demonstrates the classic findings of tuberculosis of the thoracic spine recognized by physicians over the past centuries.

​A marked kyphosis and a large psoas abscess are clinically apparent in this mummy.  The severe kyphosis commonly caused by tuberculosis could produce paraplegia, a fatal condition in ancient times.
 
Finally, in considering diseases that only appear with advanced age, the age differences in modern and ancient populations greatly affect the perceived prevalence of some disorders.  Cancer would be an example of this third principle.  The tumors that commonly produce skeletal destruction in modern man most often arise in primary cancers of the organs, and only attack the skeletal structures if the patient survives long enough to develop metastases. 

​This would include most metastatic neoplasms, which make up 95% of all skeletal lesions we deal with today.  These tumors generally don't emerge until the fifth and sixth decade of life - or later - and probably had little impact upon prehistoric man and very little effect on his skeleton.  For this reason, we see a disproportionately large number of primary tumors - tumors of youth and young adulthood - predominating in archaeological material.

Ancient man didn't have a predisposition to these primary tumors compared to metastatic tumors, s/he just lived long enough to get the one type, but rarely long enough to get the other.
 
Post-menopausal osteoporosis would be another example of this third condition.  This malady is ubiquitous in our modern society with millions of elderly members, but would be exceptionally rare in a population where less than 5% of people survived their fifth decade.  For this reason osteoporosis is a disease entity that is not mentioned in texts on paleopathology, and the sequelae of osteoporosis - hip fractures, thoracic compression fractures - have not been reported.
 
It is apparent that many of the disorders which afflict man today have been present for thousands of years, little changed from the diseases represented in our earliest fossil material.  

​What has changed is this:

The prolonged life span of contemporary man has produced a previously unseen developmental phase in our life-cycle, within which new responses to chronic disease are necessary.  And, while we are getting better at treating problems in this new phase of life, we haven't been at it that long and we are still working out alot of kinks!
 
Conclusion:

​The primary cause of symptomatic joint and back degeneration throughout the early history of man was most likely trauma, less frequently sepsis, and rarely, primary osteoarthritis.  Congenital and acquired deformities, aseptic necrosis, and pediatric conditions such as congenital dysplasia, slipped capital femoral epiphysis, or Legg-Calve-Perthes disease may have played a relatively greater role in this much younger population, as they occur in a younger age group and are not lethal conditions.  Sepsis, though common, probably killed so many of its victims that degenerative disease due to chronic infectious arthritis would be uncommon. 

In most cases, then, degenerative joint disease in ancient man was the result of an acute injury, not a response to chronic wear and tear.  And it's also likely that few people of ancient times - Neanderthal through the middle ages - would survive long after an injury like that without considerable social support.  Even then, few people lived long enough or comfortably enough to call an arthritic hip or aching back their biggest problem and that likely explains why we read so little about those problems in our oldest literature or see them in the fossil record!

As always, I hope you find this presentation interesting and educational.  If you did, follow me on my Facebook page for updates on future posts and material on spine care and spinal surgery.  If you have suggestions for other questions that I can answer for you, please comment below. 

And feel free to like and share this content with others that might find it interesting or beneficial!
 

​A disc herniation can develop slowly over time or appear out of the blue, with no warning.  It can happen when you might expect it, while lifting too much or working at a heavy job, or when you'd least expect it - while sitting at your desk or turning to answer the phone.  Most will get better with non-operative therapy but, when they don't, surgery is often necessary.  The good news?  In the case of lumbar disc surgery, the operation is minimally invasive, very reliable, and quite effective!

What is a disc herniation?

​A disc herniation, or Herniated Nucleus Pulposus (HNP) is an injury to the disc that separates two adjacent (usually lumbar) vertebra and maintains spinal alignment and function.  The disc is a tough structure made up of an outer annulus, constructed of overlapping tough fibers (like those bias belts we used to see on tire commercials) and a more spongy and softer material in the center called the nucleus pulposus.  

The annulus keeps the nucleus contained so it can act as the shock absorber as the spine moves and works during the day.  When a disc herniates there is a displacement of the central portion of the intervertebral disc (nucleus) into or through the annulus fibrosis.

​A painful symptomatic HNP produces chemical and mechanical irritation of the adjacent spinal nerve, causing radicular pain - pain running down the length of that nerve into the leg or foot.

There are many different grades of disc herniation, but whether they cause symptoms depends not only on the size of the herniation, but the size of the spinal canal into which it protrudes.  Some small people have lots of extra room and may not be bothered much by even a large herniation.  Some very big people have a surprisingly tight spinal canal and may find even a modest herniation intolerable.

What kind of herniations are there?

You may see, if you read a radiologists report, discs described as Protruding or Herniated or Bulging and wonder which one is worse?  The first thing to know is that this terminology is descriptive, not really classified in any way, and can mean different things to different people.  And, different readers use different terms for the same thing. 

The term "Herniation" implies displacement of nucleus material, not just bulge of the annulus, but some radiologists and doctors will call any noticeable bulge a "small herniation".  Why make this point?  Because I often meet patients who've been assured that they "have four herniations" in their back, when only one is truly herniated and the rest are pretty much normal for anyone over 40! 

The Normal nucleus pulposus sits centrally in the disc, 2/3 back from anterior rim of the annulus. The normal annulus fibrosis contains the nucleus, and does have a slight convex bulge when it's healthy.  There is no impingement of the annulus on the adjacent neural structures - the nerve roots or the spinal cord/cauda equina.

​A disc Protrusion implies that the nucleus protrudes through inner annulus and pushes the outer annular rim out into canal or foramen, impinging on the nerve roots and causing pain.  A protrusion may be broad-based or focal.

​An Extrusion implies that the nuclear material has pushed through the outer annulus and herniated into canal where it can now directly press on the nerves or irritate them due to inflammation. An extrusion can be sub-ligamentous, contained within the last layer of the annular structure, or free, meaning completely out into the canal. And, direct contact of this nuclear material with nerve root is irritating.

​A less common presentation is a Sequestered Herniation.  In a sequestered disc, the nuclear fragment has pushed through into canal, become separated from annular defect and remaining extruded disc, and may migrate some distance away from its original position.  

​MRI's show us this well, but if the MRI is old, the migration could happen later and leave you with a disc fragment that isn't visible during surgical decompression.  There's a reason we want a "recent" MRI!

Why does a herniated disc cause so much pain in the leg and foot?

Direct pressure on the adjacent nerve root results in numbness and weakness in the radicular distribution of the nerve, the region that that particular nerve gets sensation from and sends muscle messages to.  Direct pressure can cause rapid loss of sensation, severe pain and weakness, but even light pressure can be a problem. 

​With time, inflammation starts up around the herniation and the compressed nerve, and with inflammation, even minor irritation of nerve generates intense pain in the radicular distribution.  And, if the herniation is in just the right (or just the wrong!) spot, pressure over a specific nerve center called the Dorsal Root Ganglion generates immediate and intense pain. 

Depending on which nerve is involved, a patient with a symptomatic disc herniation loses sensation over specific area that that nerve serves (dermatome), loses strength in the specific muscles that nerve innervates, and may lose reflexes in specific joints those muscles control.

The Classic presentation of an acute HNP, often follows this pattern:

• Sitting and flexion produce progressive back and buttock pain, sometimes for months
• Over time the back pain intensifies, and then something "Pops" and the back pain goes away…
• Next day, leg pain has replaced the back pain and the patient gains a whole new perspective on pain…

 
That new pain is Sciatica - radicular pain traveling down one of the nerves that make up the sciatic nerve - L4, L5, or S1 - which are the most commonly affect because most disc herniations occur at L4-5 and L5-S1 levels.

​Because the anatomy of the nervous system is very consistent, and we can ask the patient exactly where their leg pain is most intense, clinical diagnosis of disc herniation and the level is usually precise and reliably.  In those cases surgical treatment is also, usually, precise and reliable.

Will disc surgery make my back pain go away?

That's harder to predict.  While most patients do get improvement in their low back pain, the actual cause of anyone's back ache is usually uncertain due to the many potentially pain sensitive structures in lumbar spine.  So, if the disc herniation was THE cause of the back pain, the prognosis is good.  If muscular deconditioning, degenerated discs at other levels, or arthritis of the small facet joints was the primary reason your back hurt, discectomy may not solve everything.

Will disc surgery make my leg pain go away?

This is far more reliable.  If pain is caused by direct pressure on the nerve or even direct contact with the nerve, removing that disc fragment relieves the leg pain symptoms in the vast majority of cases, and sometimes immediately.  How reliable is this?  It depends on how reliable our diagnosis and surgical plan were:

In years before MRI or myelogram were available, surgery was based on just one thing - the doctor's clinical examination of your neurological system.  Based on just this, a discectomy was more of an exploration, but was still successful in about 55% of cases.

​Over time, doctors became more aware of what was causing the pain and developed better examination techniques, one of which was called the Straight Leg Test.  This test slightly stretches the nerve over the protruding disc, and intensifies the pain for a moment, confirming the diagnosis that there is a herniated disc to be treated.  With the neurological exam and the straight leg test, surgical success improved to over 85%.

We still do that physical exam and are still pretty sure what we need to do before we do anything else, but now MRI lets us look inside the spine anytime we need to to confirm our suspicions and characterize the size, shape, and location of the disc fragment. 

With the addition of a quality MRI study, surgical success is routinely better than 95%, meaning 19 out of 20 patients come back saying:

"I'm much better.  I'm glad I did it.  Wish I'd done it sooner!"

​Will I get that "great" clinical result?

Our best surgical results are obtained among patients with

• Predominantly leg pain
• Minimal back pain
• Clear-cut neurological signs
• An MRI imaging that correlates with exam
• And no “baggage” - no history of previous surgery, medical disorders such as diabetes or neuropathy, thyroid or metabolic disease, chronic steroid or pain medication use.

This doesn't mean surgery won't work for you if you don't fit one or more of these criteria, just that it's harder to predict your result.

​What are the chances it's something that's more difficult to fix?

There are a couple of spinal conditions that we always look for on spinal imaging during our work-up.  Fortunately, the principle imaging studies we always do for a disc herniation - x-ray and MRI - will warn us when one of these problems threatens to "complicate" things:

​Spinal Stenosis often overlaps with HNP and the two may exist together for years.  

​The primary findings that suggest that spinal stenosis will require a more extensive decompressive laminectomy are:

• Age > 50 y/o
• Pain is much worse in the legs when Standing  or walking, and improves quickly if you can just sit down.
• Sitting or leaning forward (“leaning on your grocery cart sign”) allows you to stay active without leg symptoms(picture)

​Degenerative Spondylolisthesis can cause severe stenotic symptoms along with LBP.  

​This condition usually results in specific severe low back pain due to deformity and instability, but if the "slip" isn't unstable the back pain may be more tolerable than the leg pain and decompression may be all that's necessary.

So what are the surgical options, if time, physical therapy, anti-inflammatory medications and injections haven't gotten us anywhere?

​The primary approach to a symptomatic HNP is through microdiscectomy.  This is a minimally invasive operation, routinely performed as an outpatient procedure, that removes the offending disc fragment, decompresses the nerve and removes any bone spurs that may be contributing to pain, without disturbing the adjacent joints or soft tissues important to spine function. 

​Carried out in most cases using an operating microscope and fluoroscopic imaging to confirm levels and alignment, microdiscectomy is highly successful with a very low incidence of serious complications.

It's minimally invasive, but it's not minor surgery, however. 

Microdiscectomy is performed through a 1 to 2-inch incision in the middle of the back, centered over the level of the disc herniation.

​After incising the skin, the back muscles are separated from the bony arch (lamina) of the spine and pulled to the side. These back muscles are held to the side with a special retractor or penetrated with a tubular retractor so they are out of the way during the surgery.

In many cases a small portion of the adjacent facet joint is removed to relieve any bone spurs putting pressure on the nerve and make it easier to remove the herniated disc fragment.

After the nerve is decompressed, a careful search is made to insure that no fragments are left behind.  The laminotomy is covered with a material to limit scarring, sometimes along with an antibiotic, and the procedure is over. The retractors are removed and the muscles fall back into place.

The patient is usually up at bedside within half an hour, and able to go home an hour or two after that.  Nerve pain usually improves quickly - sometimes right away - but may take a few days to weeks to get back to its best level.

​There are potential risks with any operation, and your surgeon will discuss those individually when you talk about surgery, but major complications are rare in the hands of an experienced surgeon.

So, How do you know when you Need Surgery?

When pain is intolerable, unresponsive to the non-operative therapies that so often help others, and is clearly related to a large disc herniation, then continuing to put off surgery can lead to nerve damage or scarring that make later treatment less reliable and more difficult.

It is appropriate to give non-operative care a real chance though, as most patients will see improvement in the first few weeks after an acute herniation and may never need an operation.  If symptoms persist, however, or nerve root or spinal cord compression is severe enough to cause weakness or disturb bowel or bladder function, surgery may be the most reliable and rapid solution to the problem.  

Whether it's a simple disc herniation treatable through microdiscectomy and laminotomy, or it's a more complex problem involving spinal stenosis or a spondylolisthesis, you will want to talk to a spine specialist about the option that suits your situation best.

Which is where I usually come in.  So, if you are having problems similar to this or any condition that you've been told will require surgery, and we are in your area, please feel free to contact my office for a consultation!

I hope you found this article interesting and informative. Follow me on Facebook to get updates on new content, and feel free to comment if you like this post or have other questions you'd like me to address.
 
Thanks Again!
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​At the same time, we have developed better ways to treat bone disease and these fractures, allowing minimally invasive treatments that can prevent progressive deformity and speed healing and symptomatic relief.  So there’s rarely a good reason to treat these spinal fractures with what was once called "benign neglect".

​There are approximately 700,000 vertebral body compression fractures in the United States each year resulting in around 70,000 hospitalizations.  The most common fractures that affect our aging population occur in osteoporotic bone – bone that has lost some of its structural support and strength and some of its calcium mineralization.  Patients with osteoporosis, and those with metabolic bone disease (loss of bone mineral content due to metabolic disease) are at increased risk for a number of different fractures, but vertebral fractures are among the most common and, potentially, most disabling.

1. What is a pathological fracture?

​Fractures happen through any bone when the forces exerted on it are high enough to exceed its strength. This happens in automobile accidents, falls down the stairs, or poor decision-making on skis, skateboards, or bicycles, when normal healthy bone isn’t able to stand up to extreme loads.  These injuries often require surgical treatment because in these high-energy injuries the bone may be fragmented and the surrounding tissues traumatized.  These injuries are easily recognized, in most cases, and the need for treatment easily understood.

​Pathological fractures occur when the bone is not normal – it has lost much of its strength due to bone loss or mineral (calcium) loss or both – and it is liable to fail and fracture at much lower loads and forces, loads the normal body handles easily.

​Osteoporosis is the leading cause of the bone weakness that leads to these low-energy injuries, and it affects many older patients throughout the country, most of whom have no symptoms of pain or of impending danger until they experience a minor fall and break something.  Then it’s too late to take simple measures.

​2. What is Osteoporosis?

Osteoporosis is primarily a physical loss of bone structure – the struts and connecting pieces that make up bones internal structure get reabsorbed and removed from the marrow (trabecular) bone, progressively weakening the overall framework.

The bone that’s left behind is normal bone, mineral-wise, but there’s just not as much of it as there was when you were younger. Why would the body remove these important skeletal structures? Because the body is efficient and doesn't like carrying around stuff it isn't using!

If the patient has become less active, then the body has metabolic systems that will decide that not as much bone is needed to meet the daily physical demands.  The body is very frugal in some ways and will begin to remove the bone and mineral it thinks is excess from areas of lower load and either use it elsewhere or discard it. 

​This can happen at any age, and we do see this process in younger adults who spend time in a cast or in bed and can’t be as active as normal.  The difference is that young people catch back up quickly when they get back to activity.  In an older patient, who may have stopped exercising because of an arthritic hip, for instance, and then spent time in bed after another injury or illness, bone loss can be rapid and hard to recover from.

Illness, hormonal changes, or medication use can also affect bone strength, driving the loss of bone or depleting calcium and minerals away from the bone irrespective of activity or diet.  When all of this is combined with the loss of important hormones that naturally follows menopause in women, bone loss can be severe and pathological, or “fragility” fractures become common.

This is why bone health needs to be part of every woman’s routine medical follow-up and bone density (DEXA) scans should be periodically used to check for osteoporosis before it becomes severe.  That doesn’t mean men are off the hook!  Just that the problems are less common and tend to move more slowly in men as they age.

And, there are other causes of osteoporosis and fragility that can affect anyone, regardless of gender age or activity.  There are certain types of cancer that may severely weaken bone before they can be successfully treated with radiation or chemotherapy.  Many patients with inflammatory disease or different types of arthritis may require steroid medication that can cause severe osteoporosis.  And other medications and illnesses can do the same.  Some of these patients will experience vertebral compression fractures despite careful surveillance.

3. ​What is a Compression Fracture?

​Compression fractures are the most common and least dangerous vertebral fracture that we commonly encounter.  They are specifically defined as a fracture of the vertebral body that disrupts the anterior wall of the vertebral body, without disrupting the posterior cortex or pushing bone into the spinal canal.  The posterior elements are always uninjured, so the spine remains stable, and neurological injuries are very uncommon. 

​These fractures occur after an “axial-loading injury” – an injury where the forces applied to the vertebral body are directed straight down the spine and compress the vertebral endplates, the way a person might step on a pop can to try and crush it.  And the injury causes the bone to crush down much like that pop can – the top and bottom are left intact but the side walls collapse down, sometimes a little, sometimes alot!  

The vertebra shortens and tends to collapse into a wedge.  The higher the force applied, and the weaker the bone, the greater the degree of collapse and the weaker the bone, the easier it is to collapse the side walls in the first place.

​Most healthy people that have a compression fracture will get over the fracture pain pretty quickly, and the degree of collapse, if not severe to start with, will tend to stay stable and not progress.  The fracture will heal, pain will lessen and resolve, and the only long-term finding will be seen on future x-rays, where the comment may be “Looks like you had an old compression fracture”.  At that point the patient may recall something like “Well I did fall off the roof when I was younger…I was REAL sore for about a month, but I got better”.
However…

When osteoporosis is involved, that fracture force doesn’t have to be so great – “I just slipped off the stool I was sitting on!” – and the fracture is more likely to keep collapsing before it finally heals, which means the pain can persist for months.  Worse, the final healed spine can end up badly collapsed. 

​And that collapsed, wedged vertebra puts its neighboring vertebrae under increased stress which greatly increases the risk of another level experiencing the same fracture and collapse with the next minor fall.  This progressive, serial spinal collapse is responsible for the common hunched deformity seen in many elderly women, so uncharitably referred to as the “Dowager’s hump”. Not my terminology.

That progressive serial collapse has serious implications beyond just being painful.  The collapsed spine can collapse the chest cavity, compress the stomach region, interfere with breathing and eating, and seriously impact health and fitness!  And the persistent pain associated with these multilevel fractures and the spinal deformity may not go away once these fractures heal in such a bad position. 

​So we want to prevent that first fracture, and prevent it from collapsing down when it does occur.  And that’s where minimally invasive surgeries such as Vertebroplasty and Kyphoplasty come in.

4. Can Surgery Help?

Big open surgeries are rarely necessary or reasonable in treating osteoporotic compression fractures, but two minimally invasive surgical techniques - Vertebroplasty and Kyphoplasty  - have proven beneficial and easily tolerated by patients with persistent fracture pain and progressive collapse.  

​Both of these procedures are performed through a thin cannula (think fat needle) that can be guided into the fractured vertebral body under fluoroscopy.  

Once inside the fractured bone a doctor performing the vertebroplasty will inject the fracture region with a fluid form of polymethylmethacrylate – bone cement – to fill in the spaces between the pieces of broken bone and stop the collapse of the fracture.  The doctor will watch that cement flow carefully under fluoroscopic guidance and stop injecting as soon as the fracture region is filled in or there is any sign of leakage outside of the bone.   ​

​Through that same cannula system, a core of bone is removed or a pilot hole is made into the heart of the fractured vertebra.  Once that small hole is created, a specially designed “balloon” is advanced down into the bone cavity into just the right position.  Now, as the balloon is carefully inflated with a saline solution, the collapsed vertebra can be restored to a more normal height and the fracture corrected. 

​Because kyphoplasty allows the surgeon to create an open space where the fractured bone was, the cement is injected in a much thicker state, reducing the risk that it will leak out around the nerves or flow into the spinal canal.

​Again, at the end of the procedure the bone cement hardens and the patient awakens ready to get up and start back to activity without further restrictions.  The improvement is often remarkable – patients who were unable to get up and down from bed because of fracture pain can, after kyphoplasty, literally get up and make their bed.

5. What’s the downside to such a straightforward procedure?

​Fortunately, major complications are very uncommon, but since these procedures are often needed by elderly or frail patients, we take the risks of anesthesia and medication seriously.  Many patients will be kept overnight to insure there are no adverse reactions to the anesthesia. ​

​The most common complication of these vertebral augmentation procedures has been radicular (nerve) pain caused by migration of cement into the space around the spinal nerves. In most patients, small intradiscal and paravertebral leaks of cement have no clinical importance, but there have been case reports of severe neurologic complications, underscoring the need for appropriate technique and safeguards provided by skilled practitioners.  Permanent paralysis has been reported, but is exceptionally uncommon if the procedure is performed in a controlled, image-guided fashion (by using a bi-plane real time fluoroscopy unit).  The anticipated complication rate is higher when treating tumors (10%) than for osteoporotic compression fractures.

So then, Who needs Kyphoplasty?

Most compression fractures that occur in normal bone heal rapidly, without trouble.  And fractures in osteoporotic bone usually do as well...but they need to be watched.  ​

​If you have a compression fracture, diagnosed by x-ray after a fall, and you have osteoporosis or other risk factors, you should see your primary doctor back for a follow-up x-ray at 4 - 6 weeks to make sure the fracture isn't continuing to collapse.  If it is, then vertebroplasty or kyphoplasty may be needed to avoid progressive deformity and pain.  And, if you've had a fracture, and even though it doesn't seem to be progressing the pain just isn't going away either, this may represent another form of failed healing - a nonunion - that can be effectively treated with kyphoplasty.

In either case, it makes sense to see your spine surgeon for a consultation to make sure nothing has been missed. If you happen to be the one with the fracture, and you need to see a specialist, I'm glad to see you if we're in your area.

If that's the case, call 800 670-0302 to arrange an appointment!

I hope you found this discussion useful and interesting.  Please let me know if there are other topics you'd be interested in learning about, and check out my Facebook page for updates on future topics.

It is one of the most common complaints of patients presenting to emergency rooms, doctors offices, and urgent care centers, which means it often gets the kind of attention we give the "common cold".  Because the causes of pain typically relate to minor trauma or benign, age-related degenerative changes, and because 90% of patients will improve with simple supportive care and physical therapy, patients rarely see a specialist - and may not see a doctor - before being sent home with mild medications and advice to follow-up with their regular doc if the pain persists. 
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While the vast majority of back pain episodes do respond to time and a little supportive care, there are some serious, uncommon causes of back pain that physicians can't afford to overlook, yet may not recognize right away. 

​Doctors like the saying "Common things happen commonly" to remind younger Docs to focus on the most likely cause of a patient's problems first.  Serious but uncommon medical disorders account for less than 1% of all causes of back pain seen in a primary care practice, and the time and effort invested in looking for these uncommon disorders is considerable.  So, if a patient's symptoms are typical and their presentation is common, then there is little reason to put the patient through the time and expense of searching for something that's not likely to be there. 
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That doesn't mean we should forget about those more ominous conditions: When the symptoms are unusual, or the story isn't quite ordinary that your doctor may want to look for more serious underlying problems.  When symptoms don't fit the usual pattern for a back strain or disc herniation, or when the symptoms persist too long to be explained by the usual conditions that affect the spine, that when we consider the diagnosis of Atypical Back Pain. 

Patients with Atypical Back Pain warrant a more careful evaluation: a more detailed history and a more extensive physical examination, looking for specific signs and symptoms, may turn up a clue that something more serious is lurking in the background.  And more focused and specific diagnostic studies may look not only at the spine but at the associated systems that can mimic back pain symptoms.  In most cases this careful examination can confidently "rule-out" more ominous underlying disease, and focus attention back on the proper course of rehabilitation and low back care, but in an important few, a serious underlying cause can be identified and treatment started!
 
When do we consider back pain "Atypical"?
The character of pain in patients with a more serious underlying disorder differs from common low back pain . Benign (ordinary) back pain is typically activity related, relieved by rest, and is often precipitated by a recognized injury. Typical, acute back pain begins to subside after four to six weeks.

Pain caused by more serious spinal or physical disorders is atypical in that it:

• tends to be more persistent,
• tends to be progressive despite treatment,
• not well relieved by rest
• pain may seem more intense at night,
• persists when trying to rest, and
• often wakes the patient from sleep.

​Typical muscular strains and sprains may be most tender in a region, often across the lumbosacral junction, but pain that is intense and focal to the thoracic or upper lumbar spine is less typical, and deserves a closer look.  If that pain is associated with belt-like symptoms of rib or flank  pain, or radicular symptoms of pain or weakness in the legs, the need for more careful assessment is clear.

​If you have atypical pain, what will your doctor be looking out for?
 
Cancer in the Spine 
Unremitting pain often raises fears – in the patient and in the care-giver – that “something bad” is going on, and cancer is the bad thing that most people fear.  Since back pain is the presenting symptom in 90% of patients with a spinal tumor, cancer is one of the first things we look for in any case of persistent, unremitting back pain.
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​The concern is legitimate: Almost every kind of cancer can be found in the spinal column at one time or another.  It is the most common site of bony metastases in the body, and it contains or is adjacent to just about every type of cell that can become a neoplasm.  Tumor cells often find the highly vascular marrow of the vertebral body an easy place to grow and expand. 

​As that happens, the surrounding bone may be distorted or expanded, or it may fracture.  A growing mass of tumor tissue in the spinal canal can cause symptoms of weakness or nerve related pain by directly compressing the spinal cord or the nerve roots that serve the muscles of the body. 

If direct destruction of the involved bone results in weakened vertebrae, a pathological fracture may be the first sign that a tumor is present.

History: Signs and symptoms of systemic cancer including fatigue, weight loss, abnormal bleeding, abdominal swelling, subcutaneous masses, or swollen lymph nodes. (AmCancerSoc).  Symptoms typical of common types of cancer, such breast, lung, colorectal, kidney, or thyroid cancers, such as a palpable, mass, coughing and particularly coughing up blood, blood in the stool or urine, change in bowel habits, or unexplained weight loss should prompt a visit to your primary care doctor in and of themselves. and will guide a specific diagnostic approach when it comes to the back pain.
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There are risk factors that also raise our suspicions: Age greater than 50 years, previous history of cancer, duration of pain greater than 6-8 weeks, failure to improve with conservative therapy, and abnormal routine lab values including an elevated erythrocyte sedimentation rate (ESR), or finding of anemia.  If this history is concerning for the possibility of a cancer in the spinal column, the next step will be to obtain an x-ray of the symptomatic level, but also an MRI of the region (cervical, thoracic, or lumbosacral) involved.  Depending on what that shows, a more specific work-up will proceed, and allow us to plan for treatment and tumor removal.

Physical Examination: Carcinomas of the lungs, breasts, prostate, kidneys, colon and thyroid, along with multiple myeloma, account for 88% of all spinal tumors that we see for treatment. A careful examination of these organs and systems is carried out whenever we find a lesion in the spine that is suspected to be cancerous.  We examine the spine to identify sites of focal pain, and elicit signs of spinal cord compression.
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Diagnostic Studies: When cancer is suspected, our initial workup will include chest x-rays, mammography, and an abdominal CT to identify the underlying primary malignancy, if one exists.  Imaging of the spine itself will included the x-rays and MRI, but other studies may look for signs of metastatic disease in other bones.

Basic laboratory studies may reveal anemia, hypercalcemia, and elevated levels of alkaline phosphatase. Serum and urine protein electrophoresis (SPEP and UPEP) are specific for bone marrow tumors called multiple myeloma or plasmacytoma. Urinalysis may reveal hematuria, suggestive of renal cell carcinoma.

Imaging: Spinal tumors are poorly visualized on plain x-rays until the bony destruction is advanced.  MRI can screen the whole spine, identifying lesions in patients with both normal x-rays and bone scans, and is the study of choice to rule-out spinal a cancerous spinal lesion (neoplasia).  Special imaging studies can also localize a lesion so that modern, image guided systems can allow accurate biopsy or minimally invasive removal. 

If all of these studies return normal after having found a lesion of the vertebral body or surrounding soft tissues, then a needle biopsy is generally the next step in confirming the diagnosis, or to confirm that there is no cancer and that the back pain can be cared for in a more typical and less anxiety-causing way!

Infection 
Spinal infections can come on suddenly (acute) or become apparent over the course of months (chronic). 

​Acute infections are most often the result of a bacterial infection, while chronic infections may result from less aggressive bacteria, from rare fungal infections, or from tuberculous (granulomatous) disease.

Vertebral osteomyelitis (infection of the bone) represents about 5% of all cases of osteomyelitis and is an uncommon cause of back pain. Half of patients affected are more than 50 years old and two thirds are men. The most frequent source of bacterial infections come from an underlying urinary tract infection, but any source of infection (dental abscess, infected wound, pneumonia) can spread to the spine.  Immuno-compromised and diabetic patients are at particular risk.

History: Patients with a spinal infection usually present with intense focal back pain, worsened by weight-bearing and activity. Patients often complain of exquisite pain relieved only when laying down.  Sixty percent of patients have some sense of nerve irritation or compression (radicular pain), and nearly a third will have some signs of spinal cord compression.  Fever, chills, headache, and systemic illness are present in many but not all patients.  Chronic infections such as tuberculosis are often associated with weight loss and fatigue, episodic fevers, and night sweats.
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Physical Examination:  Pain is usually well localized and reproduced by palpation or percussion over the involved level.  Severe pain may be elicited simply by sitting the patient up, or by changing position.  If the vertebra has collapsed, focal deformity (kyphosis) may be seen. 

​Diagnostic Studies: The erythrocyte sedimentation rate (ESR) is a sensitive test that may be the only abnormal laboratory value found, but it is increased in 92% of patients with a spinal infection.  The C-Reactive Protein test will also be elevated, but almost half of patients with a spinal infection will have a normal white blood count. Remaining labs are typically normal. 

A TB test should be administered, with few exceptions, as many patients are at-risk individually (emigrants from areas where TB is very common, immuno-compromised patients, and patients with known exposure), and others may have no idea they have been exposed to a sick person. (Figure 2).  Blood cultures are drawn in any patient with high fever, chills, or shaking chills (rigors).
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Imaging: The x-ray changes associated with osteomyelitis are usually not apparent for at least 4 - 8 weeks, and they may be subtle even then. An MRI is our most accurate and sensitive test as it will reveal signal changes as soon as tissue become inflamed or start developing a fluid collection. MRI is capable of differentiating degenerative and neoplastic disease from vertebral osteomyelitis.
 
Epidural abscess occurs in 10% of spine infections, yet 50% of patients with an epidural abscess are not diagnosed until MRI imaging is completed.

Patients with an epidural abscess initially complain of localized back pain, followed by radicular leg or arm pain, then weakness, and finally paralysis.  With contemporary imaging capabilities and lab facilities, infection rarely comes to this point.
 
 
Fractures of the Spine
 
Fractures associated with major trauma - a motor vehicle accident or fall down the stairs - are usually recognized right away, and present little mystery.  Even if the patient's pain doesn't immediately signal the presence of a broken bone, the history of recent trauma will trigger a more careful evaluation and x-ray or CT imaging will identify the problem in time for prompt treatment.
 
Fractures associated with weakened or osteoporotic bone may be much harder to recognize.  These fractures are called pathologic because they occur in weakened bone, and can be a result of osteoporosis, metabolic disorders, malignancy, or infection,.  And they are common!  In years past, one-third of American women over the age of 65 would suffer an osteoporotic vertebral fracture in their lifetime, making these the most commonly encountered fractures in the primary care setting.  And. while fractures in normal bone are almost always associated with some traumatic event, pathologic fractures can occur after a minor slip and fall, a vigorous cough or sneeze, or just by changing position.

​This is less common now that we have better treatment for severe osteoporosis, but it can still happen!
 
History:  In osteoporotic patients the cause of the fracture may be minimal – a sneeze, fall from a chair, slip and fall in the home. Localized spinal pain, age over 65, female gender, European descent , and low body mass index (thin women) are highly associated with osteoporotic compression fractures.  

​Patients  receiving corticosteroid therapy for any length of time have an increased risk.  Patients who have been bed- or chair-bound for any length of time will loss bone density quickly and be at increased risk when they start to get up and around again.  Compression fractures are rarely associated with neurological deficits, but once you've had one, you tend to have more, because all of the bones suffer from the same degree of weakness.  

Plain x-rays are not as good as MRI at distinguishing a recent compression fracture from other pathologic fractures caused by infection or malignancy, and your doctor will want to investigate other areas of health if there are any other signs of generalized illness.
 
Physical Exam: Localized pain over the involved vertebra is moderate and increased with motion and weight-bearing. Patient may complain of inability to bend or twist due to pain or muscle spasm.

Diagnostic Studies: Routine labs and thyroid function tests are normally obtained. Specific laboratory studies may be ordered if there is a question of pathological fracture due to myeloma or other cancer.
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 AP and lateral roentgenograms are the initial study of choice as they are easily obtained and compared to determine if the fracture is stable or progressively collapsing. If a fracture is diagnosed or the exam is equivocal then an MRI is appropriate to determine whether the fracture is recent or an old an previously unrecognized one. If the fracture is progressively collapsing, it's important to recognize this early as there are minimally invasive surgical treatments that can stop the collapse and relieve the pain, if the problem is recognized in time.   
 
Intra-Abdominal Diseases that can Cause Back Pain Symptoms
 
There are a variety of disorders of the abdominal organs that can, on rare occasions, produce severe back pain, mimicking lumbar or thoracolumbar spinal disease.  Though quite uncommon, some of these disorders are potentially life-threatening, and in these cases it is important that your doctor hears about symptoms that may seem to you like they wouldn't have anything to do with your spine!

​History: Back pain caused by abdominal (visceral) sources is usually not directly triggered by physical activity, but may come on suddenly and severely when at rest or when eating.  The pain may be intense and unremitting, or may come and go, being intensely colicky, or throbbing, in nature. 

Pain that is:

• associated with eating,
• associated with the menstrual cycle,
• colicky or cramping in nature,
• associated with nausea, constipation or diarrhea
• reproduced by abdominal pressure or examination,

is unlikely to originate from the spinal tissues and a careful abdominal exam is called for.

​  Any history of previous abdominal surgery, renal stones or gall bladder stones, gastric ulcer, or abdominal aneurysm needs to be reported to your doctor at the time of the initial evaluation.  

​Physical Examination: Percussion over the costovertebral angle of the back will typically reproduce pain of kidney infection (pyelonephritis) or renal stone. 

​Rectal examination will identify blood in the stool in cases of stomach ulcer or colorectal disease.  Depending on the cause, the abdomen may be tender and bloated, or silent and rigid.  Deep palpation by the physician may reveal guarding, rebound, or focal tenderness which are signs of an abdominal problem requiring immediate evaluation.  Signs of an "acute abdomen", or palpation of a pulsatile mass in the abdomen should generate an immediate surgical evaluation.  

​Diagnostic Studies:  In addition to the routine metabolic panel, an abdominal x-ray will reveal evidence of free air, small bowel obstruction, biliary disease, or aortic aneurysm.  Abdominal CT can further elucidate these findings, if indicated.  Lumbar x-rays typically show the outline of the aorta as it passes along the front of the spine, and the presence and severity of an aneurysm can often be estimated from these views before the abdominal studies are ordered.
 
 Abdominal Aneurysm
Thirty percent of patients with an abdominal aortic aneurysm (AAA) are misdiagnosed on initial presentation. An aortic aneurysm that is expanding (dissecting) can produce intense mid-thoracic or lumbar back pain, and is the most serious of vascular problems that can masquerade as a back problem.  The pain of the aneurysm can be caused by compression of adjacent structures by the aorta, or by dissection of the arterial wall. The pain of aortic dissection is intense and undiminished by narcotics, and the patient appears to be in shock - sweating, apprehensive, pale and incapacitated. 

A pulsatile abdominal mass can be felt on exam in almost all cases. Lower extremity pulses may be diminished or asymmetrical.  Patients with risk factors for peripheral vascular disease (smoking, HTN, diabetes) and those with a known aneurysm, should be assessed for an aortic dissection anytime they present with atypical back pain.  Once recognized, a dissection aneurysm requires emergency treatment! 

Intra-abdominal (Visceral) Disorders
Ulcers, especially those involving the posterior stomach wall, may cause thoracolumbar and upper lumbar back pain. A previous history of ulcers is important to know about.

Renal (kidney) pain is usually experienced as colicky pain at the thoracolumbar junction and flank.  Kidney infections (Pyelonephritis), renal artery occlusion, or Kidney stones (nephrolisthiasis) may all cause severe, colicky back pain.  Bladder disorders may cause low back symptoms, usually concurrent with suprapubic discomfort and urinary symptoms of burning and bladder frequency.

Pancreatic disease produces pain in the upper lumbar region, worse when laying down, and often associated with severe generalized illness. A past medical history of pancreatitis, jaundice, or alcoholism, with increased lab values of amylase and lipase, differentiates pancreatic pain from spinal pain.

Pain of pelvic origin caused by ovarian torsion or rupture, ectopic pregnancy, endometriosis, or fibroids, may present as back pain unrelated to changes in body position or movement.  New, acute onset of atypical back pain, should prompt a discussion of possible pregnancy and appropriate testing.
 
Spinal Cord And Cauda Equina Compression
 
Finally, there are situations where the problem is definitely coming from the spine, and the pain is definitely the result of disc disease and nerve compression, but the usual plan for the patient to rest, wait, and recover is absolutely not the right thing to do!


Spinal cord compression occurs when any portion of the spinal canal above the lumbar spine is narrowed or invaded by tumor, disc, infection or bone fragments from a fracture.

Cauda equina compression occurs when severe lumbar nerve compression is caused by a massive disc herniation, or by a more ominous problem such as fracture, tumor, or epidural hematoma or abscess.  

The finding of a cord level or cauda equina level neurological deficit should trigger your doctor to start an immediate and aggressive search for the cause.

Patients with cauda equine syndrome typically present with urinary retention (can't pee) while those with spinal cord compression present with incontinence (can't not pee). The classic symptoms of low back pain, bilateral leg pain symptoms, saddle anesthesia, and lower extremity weakness progressing to paralysis, develop over hours or days, and are variably present at the time the patient presents for care. 

Any combination of these symptoms may exist at the time of first evaluation, requiring a high degree of suspicion by the examining physician.  Decreased reflexes (Hypo-reflexia) is typically a sign of cauda equina compression, while spasticity (hyper-reflexia), suggests spinal cord compression, necessitating an evaluation of the cervical and thoracic spine. MRI is the diagnostic study of choice.  Surgical decompression is warranted on an emergent basis if a compressive etiology is identified.
 
Epidural Hematoma:
Rarely, thoracic and low back pain may be caused be an epidural hematoma. The clinical presentation of a hematoma may mimic a disc herniation, and the lesion functions much the way an epidural abscess does - the expanding collection of fluid compresses and eventually compromises the nerves or spinal cord at that level.  This produces back and leg pain symptoms early on, but progresses to weakness and paralysis if untreated.  The hematoma can progress much more rapidly, however, and there are no symptoms of fever or infection to provide a warning.

​Because epidural hematomas most often occur following spine surgery or in patients receiving anticoagulation therapy, your doctor's level of suspicion should be heightened in these patients. Patients with motor deficits (weakness) or urinary retention need emergent surgical decompression of the hematoma.

Summary:
 
These uncommon spinal disorders are not likely to play a role in your common back pain problem, and persistence of low back pain or leg pain associated with a recognized disc herniation or spinal disorder does not suggest that there is "something else" going on.  The work-up involved in making a good diagnosis of a known lumbar spine disorder will typically rule out any of these more ominous problems right from the start.

However, if you have pain that doesn't seem typical of a lumbar spinal problem, and which hasn't been fully evaluated by a careful medical work-up, then it may be to your benefit to see a specialist to get a complete assessment and a clean bill of health!
 
The evaluation and identification of even the most dangerous causes of back pain is more a matter of careful medical evaluation – taking a good history and performing a careful exam -  than of specialized spinal knowledge or testing. So, getting a careful exam from your doctor is the right place to start.  After that, it's important to remember that our most fundamental imaging studies for back pain problems - x-ray and MRI - are very good at revealing or ruling out many of these most concerning disorders.  Incorporated into a comprehensive work-up for atypical back pain, our modern imaging and diagnostic laboratory tools can help identify even the most uncommon problems and get us started on the right treatment path without delay.
 
I hope you've found this discussion interesting and informative.  Please share with friends and others who may benefit, comment if you have other questions you'd like to see addressed, and follow me on Facebook for announcements of other blog posts in the future.
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Thanks for reading!

Most patients experience back pain as their primary symptom, sometimes severe and disabling, sometimes dull and constant and mostly aggravating.  Less frequently, but still pretty often, patients experience leg pain, a burning or tingling sensation running down the thigh or calf towards the foot, sometimes associated with muscular weakness.  Finally, many patients are unlucky enough to suffer with a combination of both back and leg pain. 

​Which of these pain patterns a patient has determines more about his or her subsequent evaluation, treatment, and prognosis for recovery than does any other aspect of evaluation or care.  So, the first and often most important question your doctor will ask is, “Where does it hurt?”.

​The Causes of Back Pain:
The sensation of pain that any individual experiences is determined by the nature, or cause, of the pain, and the location of the pain generator – the actual structure or tissue that is generating the pain signals.
 
Pain is produced when:

• normal tissue is fractured, torn, or crushed
• any tissue with nerve endings is exposed to prolonged or excessive mechanical pressure
• blood supply is cut off to muscle or nerve
• a nerve is directly compressed or irritated
• abnormal or excessive motion stretches or pinches connective tissues
• nerve endings are exposed to chemicals that irritate and inflame them

 
The kind of back pain that most people experience is the result of several things happening all at once.  Or more likely, a number of things piling up over the years until they all start affecting you all at once!

An underlying level of “wear and tear” may have been building up for years.  The disc may have lost some of its water content, or the facet joints may have become arthritic.  A direct injury to the back could result in a fracture or ligament injury.  On top of these issues, the back muscles have gotten out of shape and flabby, and can no longer do their required job without becoming painful and going into spasm.  And that leads to all of the other muscles of the buttocks, hips, and back to become de-conditioned and easily irritable. 

With all of these things going on, no wonder your back hurts!
 
Now imagine trying to provide one simple treatment that can fix all of those things – and more – at the same time.  This is why back pain care requires a multidisciplinary approach (calling on health care providers with a variety of skills and interests) and lots of patience.
 
Back Pain

80 – 90% of all back pain is idiopathic – meaning that we don’t really know what exactly is causing it.  We call it mechanical back pain if it’s made worse by activity or motion, but that doesn’t always get us closer to understanding the source of the pain.  And that’s because there usually isn’t just one source.
 
Back pain that persists long enough to warrant a specific evaluation usually has more than one contributing factor:
 
If the pain came on suddenly, after an acute injury, then it’s likely that there has been an acute injury to the muscles and ligaments of the back.  But there is also an immediate release of inflammatory substances into the tissue that causes swelling and pain. These substances make the local nerve endings more sensitive to minor irritations.  If there is a fracture and bone is disrupted, then a hematoma forms which exerts pressure on the surrounding tissues.
 
If the pain came on insidiously over time, or has become chronic, then degenerative processes have probably affected the intervertebral disc and the facet joints, and may do so at several adjacent levels.  Inflammation plays a role here as well, and back muscle fatigue and spasm are common. 

In either case, conservative therapy is the first line of treatment, and it has a lot to offer.
 
The vast majority of acute injuries will resolve and recover on their own, and physical therapy and pain management can help speed that process.  Except in severe injuries such as major fractures or ligamentous disruptions, surgery for these acute injuries provides no benefit over non-operative care, only serving to increase risk and local tissue trauma.
 
 
Back Pain in Acute Strain or Injury is produced by:

• Any of the back muscles overlying or near the area of injury or irritation
• The structures of and around the facet joints
• The disc and its accompanying ligaments, the anterior and posterior longitudinal ligaments
• The neural elements within the thecal sac and the sack itself
• The nerve roots as they leave the thecal sac and exit the spinal canal
• The bones of the anterior and posterior elements: lamina, processes, pedicles, and the vertebral body

 
Even when acute back pain lingers or progresses, sorting out exactly which tissue is causing the pain, or even which level of the spine is painful, can be very difficult.  There is no test or imaging study that shows "pain", and the physician must be careful not to attribute poorly localized or diffuse symptoms to a single structure just because it looks odd or diseased on radiographs.  That’s because:
 
MRI overestimates back disease: 30% or more of normal, middle aged adults, and 60 – 70% of normal, asymptomatic, older adults (people with no back pain at all) have clearly abnormal MRI studies – with disc degeneration, herniations, facet arthritis, and or stenosis.
 
And when degeneration affects multiple levels of the spine, it’s not only hard to sort out which level is the primary pain generator, it’s probably true that every level is at least a little bit painful, and that all are contributing to pain and poor function.  Operating on multiple levels of the spine can cause more harm than good, so sorting out the primary source of pain is crucial to a successful operation.  In the same sense, if you can’t locate a primary pain generator, or if all of the spinal levels are equally symptomatic, then surgical fusion is not likely to help, and probably shouldn’t be attempted without more information.
 
Although physical therapy can’t reverse the aging process, it can improve function and mobility.  Surgery, on the other hand, adds further trauma to the situation without reliably reducing the symptoms of myofascial (muscle, tendons,  and ligament) back pain.
 
Unless back pain symptoms are well localized, and clearly associated with signs of structural instability, deformity, or disc injury, surgical fusion cannot reliably improve the situation. 
If instability does exist, however, fusion can provide significant improvement.
​

Surgical Treatment for Back Pain:
​
There are a number of causes of back pain that can be helped by surgery, but almost none that can be cured outright, or without some form of rehabilitation and conditioning program after surgery. 
 
Fusion, also called arthrodesis, is the cornerstone to surgical treatment of back pain.  A posterolateral lumbar fusion is the key part of the surgical management of many spinal disorders.  This utilitarian surgical procedure has been used to treat thoracolumbar and lumbar instability caused by fractures, disc degeneration, or spondylolisthesis.  It has been used successfully in the treatment of lumbar disc disease and discogenic pain.  Additionally, posterolateral arthrodesis may be used to reconstruct the spine when more destructive processes, such as tumors or spinal infections, disrupt the spinal column.

The posterolateral fusion is the most commonly performed spinal fusion.  It consists of a surgical exposure of the dorsal elements of the involved spinal segments, followed by preparation of the "fusion bed", and placement of a bone graft.  In essence, the surgeon tries to confuse the body’s normal repair process: by removing the outer shell of bone – the cortex – and exposing the inner portion – the cancellous bone – the body is convinced that the spinal elements have been fractured.  The normal healing response is triggered and the decorticated bone segments are incorporated into a single segment as the body seeks to heal the “fractured” parts. 

The success of the fusion depends on the biological preparation of the fusion bed - the area where new bone is going to form.  Blood supply to the fusion mass comes from the decorticated transverse processes and the surrounding walls of muscle tissue.  Also, the maximal area possible must be decorticated as fusion rates may be related to increased surface area.  Finally, new bone material needs to be placed in the bed - sometimes from allograft (other patients donated, sterilized bone), or autograft (your own bone) taken from the spinal segments being decompressed or transplanted from the iliac crest.  Autograft bone increases the likelihood of fusion success, but harvesting it can take time and cause additional pain.

Failure of the fusion to occur can cause treatment failure.  Nonunion occurs in 5-35% of un-instrumented spinal fusions - fusions carried out by simply placing bone graft into the fusion bed.  Spinal instrumentation (rods and screws) has reduced the failure rate to 5-15%.  Spinal instrumentation allows patients to get up quicker and to mobilize without a cumbersome brace.

Although a variety of novel internal fixation devices have been used since the early 1900’s, pedicle screws, used with fixation rods, have significantly improved the treatment of spinal disorders and have been incorporated into most current implant systems.  The majority of posterolateral fusions performed today are stabilized with a pedicle screw and rod construct.

A second option for fusion, particularly useful for degenerative disease at the lowest lumbar levels, is an anterior lumbar interbody fusion, or ALIF.  This procedure approaches the spine through the abdomen, avoiding the nerve roots and spinal canal all together.

From the anterior approach the disc can be removed entirely, and the broad surfaces of the vertebral endplates prepared for fusion.  A variety of cages and graft materials are available for placement into the disc space.  In addition to enhancing the likelihood of fusion, these devices are designed to restore the height and alignment of the diseased spinal segment. 

​Most cages are designed to be filled with bone graft, to enhance the fusion process.  The majority of these devices are intended to be used with supplemental spinal instrumentation, usually posterior screws and rods, placed at a second operation, but many now incorporate an interbody fixation strategy that locks them in place without any need for additional surgery.

​A third approach to lumbar fusion combines the principles of the posterolateral and anterior interbody fusions to give the highest likelihood of a solid fusion and a stable spine.  These procedures are often referred to as “360 degree” fusions because they address the spine from both front and back.  There are three ways to carry out a 360 fusion.

First, the most traditional way of performing a 360 fusion is to carry out a direct ALIF procedure using a cage or spacer, followed by a traditional posterolateral fusion with instrumentation.  Fusion rates are high and success is quite good in well selected patients.  This is a big operation to go through, but the spine is stable at the end of surgery and patients can begin getting out of bed very quickly after surgery.  Newer, minimally invasive techniques now allow surgeons to perform both aspects of the 360 fusion through small, minimally invasive approaches, resulting in less muscle trauma and incisional pain than seen with traditional techniques

​The second option is performed through a single posterior approach - often called a "TLIF" (Transforaminal Lumbar Interbody Fusion procedure - obtaining a fusion of the interbody space through the posterior surgical approach.  In this approach the surgeon performs all of the surgery from a posterior approach, frequently taking away all of the overlying bone at the operative level through a laminectomy technique. 

Once the spinal canal is open, the nerves are moved out of the way and the surgeon removes all of the affected disc material from behind, in similar fashion to a discectomy. 
​

​The third option is carried out as a minimally invasive approach through the flank, getting at the disc space from the side, behind the abdominal contents, and either fixing the segment in place with a lateral plate or screws, or reinforcing the fusion with screws delivered from behind.  This "XLIF" or "DLIF" approach is suitable for fusions from the L4-L5 level to the lower thoracic spine, but can't be used at the Lumbosacral level. 

​Patients who are good candidates for fusion include those with radiographically proven segmental instability (excessive motion) secondary to disc degeneration, degenerative spondylolisthesis, degenerative scoliosis, post-discectomy degeneration, or instability caused by previous spinal procedures such as laminectomy or facet joint removal.  Other universally accepted indications for lumbar fusion include persistent back and leg pain in the adult related to isthmic spondylolisthesis, adult scoliosis, failed prior surgery, tumor, trauma and infection.  There is good evidence that patients with severe back pain due to these conditions will benefit, often dramatically, from a well performed spinal fusion.
 
There are a number of factors which may have a negative impact on the success of a spinal fusion surgery.  These include:

• a lack of focal, well defined symptoms of leg pain or back pain,
• advancing age with poor bone quality and poor fitness,
• a history of previous low back surgery,
• increasing number of vertebral levels to be fused,
• diabetes, and – importantly -
• tobacco use. 

While neither the patient or the surgeon can do much about the patient’s age, or the fact that they had surgery in the past, every patient can stop smoking.  Stopping tobacco use (stopping nicotine exposure altogether) and the use of pedicle screw instrumentation and autograft bone have been shown to increase fusion rates in tobacco smokers. 
 
There is one area of spinal disease that is not so clear-cut when it comes to either diagnosis or surgical care.  There is currently no area in lumbar spine surgery more controversial than fusion for "discogenic" back pain.  Discogenic pain is pain caused by degeneration or disruption of the disc itself, often with no apparent mechanical instability.  Whereas fusion for instability is thought to reduce pain by stopping abnormal and painful motion, surgery for discogenic pain is thought to work by relieving the disc of its normal loads and stresses, and by removing the painful disc itself.  Despite the difficulty of accurately and reproducibly diagnosing pain caused directly by the damaged disc, many authors have reported successful outcomes in properly selected patients treated with isolated fusions for focal, activity related back pain caused by deteriorating discs. 
 
While fusion for discogenic pain has proven successful in reducing pain and improving function and activity levels in well selected patients, another option has become available which may achieve the same result without resorting to fusion.  Disc arthroplasty, or artificial disc replacement, has been used in Europe for nearly two decades, with steadily improving results with each new design.  Current designs have been under investigation in the United States over the last few years, with very promising results.  In 2004, the Food and Drug Administration (FDA) approved the first artificial disc for general use in the treatment of single-level degenerative disc disease and discogenic pain.
 
Disc arthroplasty is carried out through an incision similar to the one used for anterior interbody fusion.  The exposure to the disc is carried out by a surgeon well experienced in anterior spine surgery.  The disc – either L4-L5, or L5 –S1 – is almost completely removed, with care taken to remove all the disc material back to the posterior rim of the vertebral body.  Once the disc space is meticulously prepared, a properly sized implant, consisting of plates that fit the vertebral endplates and a polyethylene spacer that permits a limited degree of motion, is inserted and carefully embedded into the bone

​Once the wound is closed, the patient is mobilized immediately; as there is no fusion desired, the patient can be up and about and moving right after surgery.  Results to date have been very encouraging.  Long term results can only be estimated, however, since these implants are new to general use.
 
Spinal Instrumentation
 
In the realm of spinal fusion, spinal instrumentation serves three purposes: 1) it reduces or eliminates the need for external bracing  2) it improves the likelihood of successful fusion  3) it minimizes the number of spinal motion segments that need to be fused. 

​Patients who have instrumentation can be started on more aggressive post-operative rehabilitation and are more easily mobilized.  Addition of rigid instrumentation has also been shown to increase fusion rates in degenerative disease with little increased risk of complications.

Posterior instrumentation consists primarily of pedicle screws and connecting rods.  The pedicle screws are inserted in a very precise manner, entering the vertebral posterior elements at the junction of the transverse process and the inferior rim of the upper facet, and traveling through the interior of the vertebral pedicle into the vertebral body.  Placed correctly, the screw is entirely contained inside the bone, and provides strong fixation to the vertebral body.

Screws placed in adjacent vertebrae are then connected with longitudinal rods, providing an internal splint far more effective than any external brace or cast.
 
Pedicle Screws:
Pedicle screws and rods are used to insure successful posterolateral fusion, and to reduce the number of motion segments that must be fused.  They are placed through the junction of the transverse process and facet, traveling through the inside of the pedicle and into the vertebral body.  Pedicle screws have been used in Europe for more than 40 years and have been shown to be safe and effective when properly and carefully inserted.  Computer assisted navigation and fluoroscopy help limit the risk of a screw being placed in poor alignment, and some surgeons now employ robotic systems to help place the screws accurately and consistently.

The screws selected are picked according to the size and depth of each vertebral pedicle - the bone that connects the vertebral body in front to the lamina and facet joint in the back.  Screws can be placed "free-hand" with the surgeon creating a starting hole and passing a probe down the pedicle under fluoroscopic control, or under image guidance where the landmarks for starting and finishing screw placement are determined from an imaging system with computer guidance built into the probes and drill systems. 

Most surgeons use a blunt tipped probe to minimize the chance of perforating the pedicle wall as the pilot hole for the screw is created, and then use a ball-tipped probe to directly feel the wall of the pedicle to confirm integrity. 

​If the bone is intact all around the screw hole, the screw can be placed with excellent safety.  The position of the screw is then double-checked on x-ray or fluoroscopy.
​
With the screws in place the bone graft is applied over the transverse processes and the screws are connected by rods to provide the internal splint that will help the fusion to heal.  Most contemporary systems used in the spine are made from titanium, which heals in well with the surrounding bone, is easier to image around, and does not contain any of the metals that can cause metal allergies or "metallosis".
 
Interbody Cages
Along with pedicle screw placement, the surgeon may elect to perform an interbody fusion using either an ALIF or TLIF approach.

The TLIF is carried out at the time of pedicle screw placement, and requires a laminectomy, which is often already needed to allow discectomy or removal of bone spurs to take pressure off of the nerve roots.  Beginning in an anatomic “safe zone” between the nerve root and the thecal sac, the surgeon removes disc material to complete a full discectomy.  The surgeon then inserts a series of blunt paddles that distract the disc space, restoring the disc space height, correcting sagittal alignment, and creating a space for the fusion cage that is placed next. 

​Once maximal distraction has occurred, the pedicle screw fixation nuts are tightened on the working rods to hold the space open.

The surgeon now removes all of the end-plate cartilage from the vertebra on each side of the disc space, and exposes a large surface of bone for fusion.  If too much endplate bone is removed, the interbody cages are more likely to sink into the softer cancellous bone. 

​The prepared interspace is then filled with bone graft material, and an interbody spacer.
​
There are several options for an interbody cage but most cages used now are made of PEEK - a plastic like material that is well tolerated by bone and easy to x-ray through, or titanium, which can be made with a microsurface that bone actually grows into. 

​While the goals and fundamental principles are the same for each of the different types of spacer, the application techniques, and the nuances of their use do vary.  This is particularly true of MIS techniques that may include quite unique interbody spacers.

When used in combination with appropriate posterior instrumentation, these cages provide excellent initial stability, allow correction of deformities, and provide a high rate of fusion success.  Radiolucent devices permit us to accurately assess how the graft incorporates and see the interbody fusion.  Successful cage placement and solid fusion requires meticulous preparation of the interspace and endplates, however. 

Before placing the cages, morselized bone graft is packed into the anterior interspace to densely fill that portion of the disc space.  The cage, packed with autograft morsels, is introduced and impacted into place.  The distraction force is released, and the pedicle screws are compressed towards each other to capture the cages and restore lordosis.
 
Things We Worry About During Spinal Surgery
Regardless of surgical strategy or operative approach, complications can occur with any surgical procedure.  Surgeons work hard to prevent as many complications as they can and to anticipate and minimize those that they can’t prevent.

Intraoperative complications can arise from problems with the instrumentation whether it is placed correctly or not.  Injuries to vascular or visceral structures are very rare with pedicle screw fixation, but misplaced pedicle screws may occur in up to 5% of patients.  Many of these screws will cause no problem, work satisfactorily, and not require revision.  Misplacement occurs more frequently in scoliosis and with more inexperienced surgeons and can occasionally injure or irritate a nerve root, requiring another surgery. 

Permanent neurological injury is the most feared complication in spinal surgery.  The rate of injury associated with instrumented lumbar fusions has been seen to be slightly higher than in un-instrumented fusions, but in experienced hands both rates are very low.  Most nerve irritation comes from moving the nerve around during decompression or removal of scar.  When nerve monitoring in the operating room shows that nerve signals have changed during placement of a screw, prompt removal of that screw is indicated.  Nerve or spinal cord injury can be related to pressure on the tissue itself, or damage from a probe or instrument, but can also occur if the patient's blood pressure drops for an extended period.  For this reason spine surgery is often carried out by  anesthesiologists with extensive spine experience.

Injury to the neural tissues may not always injure the nerves, but a tear in the covering (dura) that protects the nerves can be a big problem during surgery as well.  Dural tears result in cerebrospinal fluid leaks, which can occur during decompressive procedures performed to treat nerve compression, require a microsurgical repair with very fine suture to prevent persistent fluid leaks and post-operative headaches 

​Dural tears, or durotomies, are significantly more likely during revision surgery.  Patients suffering a dural tear will have a longer surgery, as the tear is typically repaired using an operating microscope.  They will also spend a little more time in bed after surgery, to let the tear seal before standing up.  If the leak persists, the patient may experience headaches, similar to "myelogram headaches", necessitating further treatment to seal the tear.

Finally, the most common complication, and a serious complication in any patient, is infection.  Patients undergoing any kind of procedure that breaks the skin - even an injection - have a risk of getting an infection.  And the usual bacterial agents that cause infection are the ones we can't get completely away from...the ones that live on our own skin.  All the preoperative methods we use to sterilize the incision site, our instruments, and our gown and gloves greatly reduces the risk of infection, but that risk is never down to zero. 

So we take several precautions to reduce that risk as low as we can.  It is routine nowadays (standard of care) for Orthopaedic patients to receive a dose of appropriate antibiotics, by IV, prior to the start of surgery, and if the surgery is long or complex, they may get additional doses. 

Many surgeons will add to antibiotic coverage by washing the wound with an antibiotic solution prior to closure, and others will apply an antibiotic medication into the depths of the wound itself.  Proper post-operative wound care keeps the wound clean and safe until the skin has a chance to seal and protect itself.

Still, there is a measurable rate of superficial wound infections that require examination and oral antibiotics, and a small but never "zero" number of patients that develop a deep infection that requires re-operation and hospitalization, along with long-term antibiotics, no matter what strategy is used.  Patients with excess body weight, diabetes, impaired immunity, smokers, and those undergoing revision of older surgeries are all at increased risk.
 
 
Post-operative Care and Activities
Patients undergoing posterior instrumentation for degenerative disorders, spondylolisthesis, or discogenic pain, are really quite stable after surgery and need only a corset for comfort after their operation.  Those with more post-operative instability, due to removal of a tumor or treatment of a fracture, may benefit from external bracing, such as a thoracolumbosacral orthosis, (TLSO).  Depending on the number of levels treated, the extent of blood loss, and the patient's baseline health, hospitalization and physical therapy may be needed, but many single level and minimally invasive spinal fusions can be carried out as outpatient surgeries, with patients up at bedside an hour after anesthesia and home later the same day.

Patients who have undergone more extensive or anterior/posterior surgeries will generally be fully ambulatory within 2-3 days postoperatively unless neurologic problems or other medical problems exist that interfere. The patient can expect "surgical" pain for approximately 5 to 7 days after surgery, and some pain for up to 6 weeks should be expected as muscles recover from the injury of the operation.
 
Patients with a stable spine, and those with a combined anterior and posterior reconstruction wear their brace to protect muscles during the early healing phase, but can be up without it with little fear of problems.  These patients can advance activities as tolerated, can bend to put their socks and shoes on, and can begin lifting and carrying limited loads within a week of surgery.  They may discontinue the brace after 4 – 6 weeks, but often find the support helpful when increasing activities thereafter.  They can start back to light duty work at three to six weeks from surgery, and should be back to full duty or to active physical therapy by 12 weeks.  Patients with spinal instability or poor bone quality may need to wear their TLSO for up to 4 months, and will also be fitted with a bone stimulator that aids the bone formation process.

Patients may ambulate to tolerance and are encouraged to walk up to 2 miles per day. Riding in a car is fine, but driving is not recommended for approximately 4-6 weeks. Heavy lifting (objects over 15 pounds) should be avoided for the first 6 weeks. At 6 weeks, bicycle or treadmill activity may be added to the physical therapy program, as well as increased walking and stair climbing. Work hardening, depending on job classification, is begun at 12 to 24 weeks. Light‑duty work activities are begun at 3 - 6 weeks and heavy‑duty, unrestricted activities at 3 - 6 months depending on the patient and the job.  
 
The surgical implants (screws and rods or plates) are only necessary during the fusion period. Once the spine is fused these devices become more or less redundant. Currently, surgeons rarely remove the implants unless the components are prominent under the skin or have become loose in the face of a failed fusion.
 
Conclusion
Surgical care for back pain is more about the correction of instability, deformity, disc disruption, or decompression of nerve elements, and less about "fixing pain".  If the basic problem is one of the above, then the pain is very likely to improve or resolve when the underlying problem is fixed.

Spine surgeons go to lengths (sometimes frustrating lengths) to make sure your pain is coming from a correctable, treatable cause, and then to plan the operation that will eliminate that problem and the pain safely and reliably.

​Understanding your diagnosis, and what the goals of surgical treatment are, as well as understanding what recovery and rehabilitation will entail, will help you make good decisions and get good results if you have a back pain problem that requires spinal surgery.
 
I hope you have found this overview interesting and informative.  If you have a problem that you think may require surgical treatment, or have been told you need surgery or fusion, I would be glad to see you in my Cleveland office.  If you have suggestions or comments about this article, please let me know in the comments below.
 
Thanks!

The most common source of confusion after lumbar surgery revolves around what kind of surgery a patient may have had.  And, in this case, any confusion is usually the result of confusing spinal decompression surgery - microdiscectomy or laminectomy - with spinal fusion surgery.

So here's what you need to know about post-operative care following lumbar surgery:

Wound Care After Lower Back (Lumbar) Surgery - For All Patients:
​
The sterile dressing applied in the Operating Room needs to be left in place for four to six days.  If there is a little blood on the dressing do not worry about it, but if the dressing becomes soaked or loose, it can be reinforced with a bulky cover dressing until it can be peeled away with clean hands and a new gauze pad placed over the surface dressing. Tape this back in place and keep it clean.

Do not get the dressing wet.  You may shower after three days, but cover the dressing with saran and tape and avoid directly soaking it.  DO NOT take a tub bath or submerge the wound in water until fully healed and sealed - 10 - 12 days.

After 4-6 days, you may remove the outer dressing and cover the inner dressing with gauze for comfort or leave open to air.

If you find a piece of suture protruding from the skin don't fiddle with it.  The surgical closure for my lumbar wounds, just as with my cervical incisions, is a plastic surgery closure with stitches that are absorbable.  The small knot tied on the skin will blow away after the stitches have resorbed.

If the wound is sore, you may place a bit of ice in a bag (a bag of frozen peas works great) for a bit to reduce swelling and pain.  Do not put ice directly on your skin.

At ten to twelve days the wound should be completely sealed and you can peel away or wash away any remaining dressing over the wound, or you can leave it to peel away on its own.
​
Slight bleeding from the wound may persist for 3 -5 days after surgery, but should then stop.  Continued drainage, drainage that starts up again after the wound appeared to seal, or swelling redness, or increasing pain at the incision site are all things I want to hear about, so please call the office early in the day before things become severe, or go to your emergency room for an examination.
​

For Lumbar Discectomy and Laminectomy Patients:

If you've had a discectomy, Microdiscectomy or laminectomy, without a fusion(this means the surgeon felt your spine was stable and back pain wasn't the biggest issue) follow these instructions.

Care and activity after a lumbar decompression surgery  is VERY DIFFERENT from care after a lumbar fusion!  I discuss these four points with every single patient I operate on.

1. After surgery, fusion patients do need to avoid back motion, and limit bending, lifting and twisting for several weeks, but the discectomy patient does not need to limit motion for as long or as completely, and they should start gentle range of motion as soon as they are comfortable (3-5 days).
2. After surgery, fusion patients may need to wear a rigid brace, full time, for several weeks, but the discectomy or laminectomy patient usually needs no brace, or may wear a soft corset for only three weeks before starting light activities.
3. After surgery, fusion patients need to avoid anti-inflammatory medications (NSAIDs) for eight to twelve weeks, but the discectomy or laminectomy  patient can take NSAIDs, and they can start using NSAIDs (Advil, Aleve, Ibuprofen, Naprosyn, etc) to treat back and muscular pain after the first week following surgery.
4. And finally - if fusion patients overdo it after surgery or don't follow instructions they can harm themselves, seriously affect their result, and end up needing more surgery.  If discectomy or laminectomy patients overdo it, get active too soon, or don't follow advice, they tend to make themselves sore, but they won't harm themselves or damage the spine unless they persist despite pain and against advice, in activities that subject them to heavy loads or repetitive bending and twisting.

 
Post-Operative Care for Lumbar Discectomy/Laminectomy Patients:

The first one-two weeks after surgery are about getting over the incisional pain.  Lumbar incisions traumatize a lot of muscle and muscular/incisional pain can be severe and can persist for weeks.

Patients should limit bending, lifting, and twisting activity during the first two weeks to avoid aggravating the healing wound and causing pain at the surgical site.  Standing, walking, and careful bending will not cause any injury or damage, but over-activity may aggravate incisional pain.  If that happens, the patient should back off, rest a bit, and ice the site before they get going again.
​
Back Brace: A corset is provided after lumbar disc surgery to wear while the incision is healing, but only for the first few weeks until muscle pain is under control. It is not used at night, when eating, or during light daily activities – gentle frequent motion is desirable. And after 3-4 weeks, we will want to have you take it off and start working on strengthening your back muscles!

Activities:

After discharge from the hospital - right from the start:
Every day, get up and walk three to four times every day– Walk briskly, fifteen to thirty minutes without stopping to sit down – indoors or out, as tolerated.  Bend carefully, but bend to put on your own slippers or shoes.  Limit lifting, but feel safe lifting and carrying 5 – 10lbs as needed.

After 7 - 10 days:
Increase daily walking, and start back to regular exercise on treadmill or exercise bike.  Start gentle range of motion exercise – flexion/extension and side bending – within the range of pain-free motion.

Increase normal bending and gentle twisting during light activities at home. 

When back motion is comfortable and you are no longer taking pain medications, you may start driving short distances. You may increase lifting and carrying up to 10 – 15 lbs as comfortable.

Add activities a little at a time, and don’t overdo it.  Change positions every half-hour. When you go back to a common activity, do a bit for 15 minutes then stop, rest, and reassess: If you're starting to stiffen up, knock off for the day.  If you feel good, you can take on more.

At three weeks:
Return to Dr. McLain’s Clinic for your post-operative x-rays and check-up.  Start light daily activities without restrictions.  Increase walking and exercise activities, and increase bending and lifting as tolerated for light activities in the house. 

Aerobic activity as tolerated – may start running if you like, increase cycling, or add a pool program.

At six weeks:
Return to Dr. McLain’s Clinic for your post-operative check-up.  If all is well, we’ll start home or formal Physical Therapy for the lower back and core strengthening, flexibility, and conditioning.

Recommended Physical Therapy Exercises After Week Four to Six for Cervical Total Disc Replacement Patients:
Daily activity, and a regular aerobic exercise program, are the keys to getting most people back to good function, and are important in all neck and back surgery patients.  Time invested in a physical therapy and exercise program is never wasted.
 
For Lumbar FUSION Patients:
​

​If you've had a Lumbar Fusion, (most often a Posterior Decompression and Fusion or TLIF) follow these instructions:
​

1. After surgery, fusion patients do need to avoid back motion for several weeks, and cannot start back range of motion until the fusion has had a chance to get started (4-6 weeks).
2. After surgery, fusion patients may need to wear a rigid back brace, full time, for several weeks, and should take it off only to bathe, and later when they sleep.
3. After surgery, fusion patients need to avoid anti-inflammatory medications (NSAIDs) for eight to twelve weeks, as these medications (Advil, Aleve, Ibuprofen, Naprosyn, etc) can interfere with the fusion.
4. And finally - if fusion patients overdo it after surgery or don't follow instructions they can harm themselves, seriously affect their result, and end up needing more surgery.  Pushing forward too fast, cheating on brace-wear or restrictions, or cigarette smoking increases the risk of a non-union (pseudarthrosis) or can even cause the fixation implants to loosen or break.  That would mean more surgery.

 
Post-Operative Care for Lumbar Fusion Patients:
The first one-two weeks after any surgery are dedicated to getting over the post-operative pain.  Patients should limit activity to avoid aggravating the healing wound and causing pain at the surgical site, and to avoid stressing the fusion before it has had a chance to get started. 

Standing, walking, and careful bending will not cause any injury or damage, but over-activity may aggravate incisional pain or slow or disrupt the early fusion, which can lead to a surgical failure.  Patients can safely bend to put their socks and shoes on, but must avoid repetitive bending, lifting, and twisting.

Activities:
After discharge from the hospital - right from the start:
Every day, get up and walk three to four times every day– Walk briskly, fifteen to thirty minutes without stopping to sit down – indoors or out, as tolerated.  Bend carefully, but bend to put on your own slippers or shoes.  Limit lifting, but feel safe lifting and carrying 10 – 15lbs as needed.

After 7 - 10 days:
Increase daily walking, and start back to light exercise on treadmill or exercise bike.  Do not start trying back exercises or back range of motion exercises yet.
​
Increase normal bending and twisting of the lower back during light activities at home.  

At three weeks:
Return to Dr. McLain’s Clinic for your post-operative x-rays and check-up.  Start light daily activities with restrictions.  Increase walking and exercise activities, and increase bending and lifting as tolerated for light activities in the house.  Continue wearing your collar as instructed.  Patients with a desk or phone job can work from home or be driven to work for light duty as tolerated. 

Aerobic activity as tolerated – may start treadmill or elliptical exercise if you like, increase stationary cycling, but cannot add a pool program that involves swimming until fusion is solid and range of motion is restored.

At six weeks:
Return to Dr. McLain’s Clinic for your post-operative check-up and more x-rays.  If all is well, we’ll start weaning you out of the back brace and plan to start a formal Physical Therapy Program for back and core strengthening, flexibility, and conditioning for week eight to ten.

Recommended Physical Therapy Exercises After Week Eight to Ten for Cervical Fusion Patients:
Daily activity, and a regular aerobic exercise program, are the keys to getting most people back to good function, whether they've had a disc removal, a lumbar fusion, or treatment for a fracture or other disorder.

You can learn more about disc replacement surgery, and other types of spine surgery and treatment, by checking out more sections of this website, or find me on Linkedin or Facebook at Robert McLain MD.  Thanks!
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