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1/27/2024

Lumbar Disc Herniation: A Problem that Causes Back and Leg Pain

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Next in my series of ten common problems - Lumbar Disc Herniation and the leg pain, or radiculopathy, that often causes the most frightening concerns.

Lumbar Disc Herniation is a common cause of back and leg pain, presenting in different ways and with different degrees of intensity. Potential for recovery is actually quite good, but varies from patient to patient depending on size of the protrusion, size of the spinal canal, the patient's age, their activity level and functional demands, and the extent of the disc disruption associated with the herniation. That's alot of variables, and means that your neighbors disc herniation was probably different than yours, and their experience - the symptoms, treatment, and recovery - may be very different as well.

It's important to understand a little of the language used to describe disc herniations. Radiologists often use vague and descriptive terms to describe the herniation, ranging from "displaced" to "protruding", "bulging", "ruptured", all the way to "massive extrusion". When your primary doctor reads that report, it's not surprising that they occasionally over-react and translate to you that "your disc has exploded!" and that "you need surgery or you'll be paralyzed!" That's a pretty terrifying message, and it's almost never correct. That's why getting an opinion from a specialist is often the best decision for a patient with a severely symptomatic disc herniation. The important point: different types of disc herniation may represent both a different stage of disc deterioration and a different indication for treatment.

First of all, What is a Disc Herniation?

Disc herniation is a term applied to a wide variety of disc disorders, and the terminology can be confusing. Discs can be described as herniated, slipped, ruptured, bulging, protruding, disrupted, and more. The size of the disc can be described as massive, significant, focal, and others, and the terminology doesn't really get us closer to a treatment plan.

What is more important is where the herniation is relative to the nerve roots, how big it is relative to the spinal canal, and whether is a bulging disc, an extruded disc, or a sequestered fragment - a chunk of disc that has detached from its disk space and gotten lodged - like a stone in your shoe - in a spot where it is compressing a nerve.

The lumbar disc is made up of two parts. In the healthy disc, the vertebral endplates above and below, and the disc annulus hold the nucleus pulposus in place which preserves the internal pressure in the disc. When there is a disc injury or degeneration, disruption of the annular fibers can occur causing fissuring and degeneration, or cause a sudden traumatic rupture. Whether this disruption happens slowly (chronic) or suddenly (acute) an annular defect is created that lets the nucleus out.

The disc is made up of an annulus - the thick outer portion made up of layer after layer of tough collagen fibers, overlapping like the layers or belts of car tire, and the nucleus - the softer, inner matereial that works as a shock absorber and cushing when the disc is under a load. When young the nucleus is quite gel-like, but as we age it gets tougher, but can still be squeezed out of the disc under great pressure.

A disc herniation occurs when the soft inner portion of the spinal disc - the nucleus - gets pressed out of position and starts to bulge through the tough fibrous layers of the outer disc - the annulus. In some cases this happens over years and we see a narrowed disc on x-ray and a broad bulging disc on MRI. In other cases the soft material squeezes out through a tear in those annular fibers and protrudes directly into the spinal canal, like tooth paste squeezed out of the tube. In this case, the disc material can touch the nerve root directly and irritate it as well as put pressure on it.

When the annulus begins to fissure and slowly deteriorate, disc bulging or protrusion results. Although no disc material has escaped into the canal, the disc causes the remaining annulus to bulge or protrude beyond its normal limits, putting pressure on the adjacent nerve root. Since no disc material has escaped from the disc space, this is referred to as a contained herniation.

Once fissuring or tears have extended through the full thickness of the annulus, there is nothing to keep the nucleus in place, and the pressurized disc material follows the “path of least resistance”. Fragments of nucleus, annulus, and/or endplate can escape the annulus. Such herniations are termed non-contained, as displaced nucleus has pushed through and exited from the annulus. The central position of the tougher spinal ligaments tends to direct fragments laterally where there is less resistance but direct contact with the spinal nerve.

Different stages of disc herniation: From the top 1. Fissured disc with bulging annulus, 2. Contained disc herniation, 3. Subligamentous extruded disc, 4. Transligamentous, or full extrusion, and 5. Sequestered disc fragment.

Disc fragments may remain trapped under the that ligament (subligamentous) or less commonly may come through the ligament (transligamentous) into the canal. As long as the displaced disc material remains connected with the remaining nuclear material within the disc, this protruding material is referred to as extruded. When that fragment “pinches off” and becomes totally detached from its point of origin it is considered sequestered.

At that point, disc material can migrate up, down, or sided to side, making an MRI image crucial to successful surgery.

There are many potential causes of a disc herniation:

Lumbar disc herniation, medically referred to as a herniated nucleus pulposus (often abbreviated as HNP) can result from a number of different causes. In young, healthy folks, a specific lifting or twisting injury can cause a sudden (acute) HNP, while in older patients with a longer history of wear and tear, a herniation can occur with very little trauma, and can even happen while you are sitting at your desk! Common causes include:

Overuse: Repetitive lifting or twisting movements that strain muscles can also lead to disc injuries. Activities such as repetitively lifting heavy objects, or repetitive twisting while lifting can cause disc deterioration and predispose to herniation, especially when done with improper body mechanics.

Poor Lifting Mechanics: Incorrect posture or body mechanics while lifting, bending, or twisting activities can place excessive stress on the lower back muscles and ligaments, but can directly overload the fibers of the disc.
Sudden Twisting or Turning, Slips and Falls: Abrupt and forceful twisting or turning motions, especially when lifting or carrying objects, can overload the disc and cause an acute herniation.
Heavy Lifting: Lifting heavy or awkward objects, or attempting to lift objects that are too heavy for the individual can result in lumbar strain and disc herniation.
Sports Injuries: Sports that involve repetitive or forceful twisting movements, such as weightlifting, golf, or tennis, and those that involve heavy lifting may sometimes result in a large HNP.
Accidents or Trauma: Traumatic events, such as falls or car accidents, can cause severe lumbar strain and also cause the lumbar disc to rupture and herniate.
Prolonged Sitting: The lumbar discs are under more pressure when you are sitting than when standing or even bending over. Activities that require you to maintain a seated position for long periods can strain the lower back muscles, predispose to disc degeneration, and contribute to disc herniation even when there is no specific injury.
Age-Related Changes: The spine undergoes natural degenerative changes with age and activity, and disc wear and tear, which can cause lower back pain, makes you more prone to disc protrusion and herniation.

Genetics can play a role in your risk of disc herniation. Some families seem to be prone to herniation, and others - where the spinal canal is smaller than average - are prone to having severe symptoms when they do get a herniation. Overall fitness and health can reduce susceptibility to lumbar disc herniation and improve your chances of recovering without surgery, but this is a condition that can occasionally disable professional athletes.

Understanding and practicing good body mechanics, maintaining a healthy lifestyle and body weight, and incorporating exercises to strengthen the core muscles can help reduce the risk of lumbar herniation and give you the best chance for recovery without surgery.

So, What causes the pain??

The pain experienced after a lumbar strain is primarily attributed to the inflammation and damage to the soft tissues, including muscles, ligaments, and tendons, in the lower back. Back pain after a disc herniation can involve all of these, but the damaged or ruptured disc can also be a source of severe, deep-seated back pain.

On top of that, and specific to disc herniation, irritation or pressure on the spinal nerve that is in contact with that disc can cause numbness and tingling, actual physical weakness, or severe - sometimes intolerable - burning pain in the leg, calf, foot, or toes. That is the symptom that most often brings patients to their local ER or doctor.

Several factors contribute to the development of pain in lumbar disc herniation:

Disc Injury: Lumbar strains typically involve acute damage to the muscles that support and control the lower back. When the disc ruptures, these tissues are also aggravated, but additional pain fibers in the disc are also triggered, and can cause serious pain. Microscopic tears in fibers of the outer disc can cause inflammation and trigger pain signals with even small movements or even just sitting, leading to spasm and stiffness.
Inflammation: Disc injuries trigger an inflammatory response in the deep tissues of the spine, and while they cause pain, there are no outward signs of swelling or redness. In the case of lumbar herniation, inflammation directly affects the spinal nerves, and makes them more sensitive to pressure and motion than normal.

Viewed through the surgical window, or laminotomy, the disc fragment can be seen pushing up from the left side of the disc space, shifting and compressing the long, round nerve root against the thecal sack - the thin tube containing all of the other nerves.

Nerve Irritation: In lumbar herniation inflammation or direct pressure can irritate or injure the large nerves in the spine. The spinal cord stops at the top of the lumbar spine, so spinal cord compression and paralysis are rare. However, pressure or injury to the nerves in the lumbar spine can cause pain, weakness, or paralysis of specific muscles in one or the other leg. Nerve root compression can cause burning pain, radiating down the leg, or numbness tingling tingling that may extend into the legs or feet.
Spasm of Muscles: Just as in lumbar strain, the body's response to injury often includes muscle spasms. These involuntary contractions can lead to increased pain and contribute to stiffness in the lower back.
Reduced Range of Motion: Pain and inflammation limit the normal range of motion in the lower back. Reduced flexibility contributes to discomfort and difficulty with movement. With disc herniation, however, certain motions are particularly sensitive. Straightening the affected leg out or flexing the hip can put an extra stretch on the irritated nerve and cause severe leg pain.
Psychosocial Factors: Emotional and psychological factors, such as stress or anxiety, can influence the perception and tolerance of pain. Leg pain symptoms and weakness are not affected by these factors, however, and treatment of the problem typically relieves anxiety and fear greatly.

It's important to note that the severity and location/distribution of pain differs greatly depending on the level of the spine where the herniation has occurred. Proper treatment and management of the back pain - including rest, physical therapy, and anti-inflammatory medications - can speed the recovery process and alleviate back pain and muscular discomfort. If back pain persists or worsens despite therapy, there may be a more extensive injury or damage to other tissues, and further evaluation and intervention may be needed to return the spine to good function.

The leg pain component can be treated non-operatively as well: this will typically start to get better in a week to three after onset, and should be much improved at six weeks. If symptoms are intense, if there is weakness associated with the pain, or the symptoms are not better in 6 weeks, something more may need to be done.

Diagnosis:

Medical History and Physical Examination:

Symptoms Assessment: Inquiring about the onset, duration, and intensity of pain, as well as any other associated symptoms like numbness or tingling, weakness or limp, and any issues with bowel or bladder function.
Circumstances of Injury: Understanding how the injury occurred provides insight into potential causes and helps in formulating a treatment plan.
Past medical history: It's important to recognize previous injuries and previous treatment. If you've had previous imaging studies, comparison of the old to any new studies can provide important clues as to the nature of your disc herniation and what to expect in recovery.

Imaging Tests:

X-rays: While not always necessary, X-rays can reveal the extent of disc degeneration, boney instability, or alignment issues that may result from disc disease or herniation.
MRI (Magnetic Resonance Imaging): This imaging technique is most detailed and specifically identifies and quantifies disc herniations, as well as nerve root compression caused by the disc. Most important, MRI confirms the diagnosis of level and disc size based on the physical exam.
CT (Computed Tomography) Scan: Useful for assessing bony structures and detecting fractures with greater precision.

Treatment:
Non-operative care:
Most disc herniations causing severe leg pain ( radiculopathy) are successfully treated non-operatively. At least 90% of patients will get better with appropriate conservative care. Return to full activity, work, and recreation is usually possible, but takes time and requires appropriate medication and a course of active physical rehabilitation and exercise. Common non-operative approaches include:

Pain Management: The pain of radiculopathy can be intense. It also responds poorly to pain-killers - you still have pain, you just get sleepier. Still, a short 2-3 day prescription for analgesic pain medications is sometimes warranted. Over-the-counter pain relievers and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, reduce inflammation and help reduce pressure on the nerve as well as dulling the pain. Topical treatments like ice or heat packs may also be helpful.
Rest and Activity Modifications: Giving the injured tissues time to heal, avoiding activities that aggravate the injury and worsen the pain, and limiting vigorous exercise is appropriate while the leg pain symptoms are intense. Bed rest for a day or two may be needed, but after that, you need to be up and around. Avoid heavy lifting, repetitive bending or twisting, or prolonged sitting.
Supportive Measures: As with lumbar strain, proper information on activities, concerning symptoms, restrictions to lifting activities, and instruction on body mechanics can reduce anxiety, improve function, and limit the risk of recurrent injuries.
Physical Therapy: A structured, progressive, physical therapy program can be designed to restore mobility and flexibility, and promote proper posture. Therapeutic exercises are tailored to the individual's symptoms and underlying condition. Aggressive exercise can aggravate back and leg symptoms if started too soon, so start with a very gentle stretching program and work with your health care provider as you get better. Incorporating exercises that target the core abdominal and lumbar muscles remains an important goal, as a strong core provides stability to the spine.

Pain Management: If leg pain persists beyond the first 3-4 weeks, a series of epidural steroid injections can be considered. Carried out under fluoroscopy, these injections place a numbing medicine and a steroid medicine in the immediate area of the compressed nerve. Response to epidural steroid injections is highly variable, with most patients getting relief for at least a day, half getting relief for two-three weeks, and about 20 per cent getting substantial long-term relief. That's long enough for nature to start the healing process, allowing the majority of patients to avoid surgery following epidural steroid injections. It's important to know: While epidural injections play an important role in controlling or relieving radicular leg pain symptoms, they do not provide reliable relief from the back pain and muscle spasm. Hence, patients with a disc herniation diagnosed on MRI, who are having only back pain, should not expect much benefit from an epidural injection, and might decline it if offered.
Chiropractic: gentle stretching and manipulation are helpful for some patients, and traction therapy has helped others. As the condition improves, a gradual return to normal activities is usually recommended under the guidance of healthcare professionals. Activity and job modifications are often needed to allow return to normal without reinjuring the back muscles.

Surgical care:
Surgery is generally considered only when conservative treatments fail, and the patient demonstrates evidence of a continued nerve compression and pain. Continued severe pain, neurological symptoms (such as persistent numbness or weakness), or evidence of a structural instability on x-ray imaging all suggest problems that may require surgical treatment.

Surgical options include procedures that decompress the nerve roots, such as laminectomy or microdiscectomy (removal of part of a herniated disc), but more extensive procedures, such as spinal fusion, may be necessary if the structure of the spine has started to shift or collapse.

Microdiscectomy: Decompression of the compressed nerve root is straight-forward, conceptually. Like removing a stone from your shoe, if you remove the disc material from the canal pain relief is reliable and often immediate. It's how you go about doing that which has improved over the years. Most spine surgeons treating disc herniations - orthopaedic or neurosurgical - will perform a microdiscectomy. Whether they use a tube or a small retractor, the point is to limit the size of the incision, remove just enough bone from the lamina over the disc fragment to reveal the nerve and the disc fragment.

The surgeon will then gently remove that fragment using an operating microscope to see everything in excellent detail and light.

Microdiscectomy is most commonly performed as an outpatient procedure, with roughly 90-95% good to excellent results in experienced hands.

Laminectomy: If multiple nerves are compressed or the disc protrusion is causing severe narrowing of the canal (stenosis), and particularly, if there are any signs of compression of the nerve controlling bladder function (cauda equina syndrome) the whole roof of the spinal canal may need to be removed. This is carried out through a larger incision, and may require a longer surgical time, but can still often be performed as an outpatient operation.
Lumbar Fusion: As with other lumbar disorders, if spinal alignment has been affected or there is clear evidence of instability (the spinal alignment changes during flexion and extension x-rays or there is severe loss of the normal disc space height) fusion may be needed at the time of discectomy. For a single lumbar disc herniation it is very rare to need more than one level of fusion.
Spinal Stimulators and Pain Pumps: These surgically implanted pain control devices have an important role in controlling chronic pain and pain that is caused by disease or scarring that can't be improved by surgery. However, they do not provide any anatomical relief of the nerve root compression or and spinal instability. They can only mask the symptoms. For this reason there is almost no indication for an implant like this in a patient with an acute or even a long-standing disc herniation where MRI imaging shows there to be a persistent and large disc protrusion.

Healthcare Professionals:

There are several kinds of healthcare professionals who can provide appropriate care and guidance after an acute lumbar disc herniation. The choice of provider may depend on the severity of your symptoms and the specialists available in your area, but should also take into account your own personal feelings about which kind of care you want to start with. Here are some of the professionals you may consider consulting:

Primary Care Physician (PCP):

Whether it's your regular primary care doctor or an ER physician seen on an acute basis, your PCP can assess your symptoms, provide an initial diagnosis and earliest supportive care, obtain the proper imaging studies and recommend appropriate follow-up treatment or specialist care if you need it.

Orthopedic Surgeon or Neurosurgeon:

If your symptoms are severe or persistent, or if there is a suspicion of nerve compression, your primary care doctor may refer you to a surgeon. Orthopedic surgeons and Neurosurgeons may both provide non-surgical and surgical treatment options, and can advise you whether your particular injury will improve with time and without surgery, or whether an operative procedure makes more sense.

Surgeons can perform the laminotomy and discectomy through quite small incisions when they combine an operating microscope with a small tubular or specialized microsurgical retractor.

After the discectomy, the protruding fragment of disc is gone, the nerve is no longer compressed, and a microsurgical probe can be passed along the nerve root to ensure that its pathway is clear.

Orthopedic surgeons and Neurosurgeons specializing in spine surgery can provide the same range of operations and procedures, with the same reliably excellent results.

Physiatrist:

Physiatrists are medical doctors who focus on physical medicine and rehabilitation. They can assess and treat many musculoskeletal conditions, provide rehabilitation plans, and may offer interventional procedures for pain relief. They are also trained to recognize conditions that are more serious and may require interventional care or surgery.

Physical Therapist:

Physical therapists are trained in rehabilitative exercises and therapies. They can design a personalized exercise program to improve strength, flexibility, and reduce pain. Physical therapy is often a key component of lumbar strain treatment.

Chiropractor:

Chiropractors specialize in diagnosis and treatment of injuries to the musculoskeletal system, particularly the spine. A chiropractor with appropriate credentials and experience will obtain the right x-rays and MRI imaging before starting treatment, and avoid aggressive manipulation in the earliest phases of treatment. Most use manual adjustments to relieve pain and improve spinal function, but many also provide treatments such muscle stimulation, physical therapy, and ultrasound to calm muscle pain.

Pain Management Specialist:

A pain management specialist may be consulted if the pain is persistent. They can offer a variety of interventions, including medications, injections, or other minimally invasive procedures to manage pain. Nerve root blocks or epidural steroid injections are commonly offered in care of ongoing back problems, and can be very helpful in cases of acute disc herniation that hasn't responded to initial care.

Conclusion:
The radicular leg pain associated with a disc herniation will usually start to improve on its own in the weeks after injury, and should be well tolerated by the end of six weeks. It can take quite a while for the back pain of a lumbar strain or sprain to completely heal, and the back pain aspect can be intense and limiting for weeks or even months after a severe strain. Because the back pain can be re-aggravated, patients may need to hold off of return to activity for a while after the leg pain calms down. With time and a good rehab program there is a great chance of getting back to normal activity without surgery. However, for those whose leg pain persists or flares every time they try to get back to work, surgical treatment may be necessary.

The good news is that, for the majority of disc herniation patients, the surgery can be performed with a minimally invasive approach, requires a brief anesthesia time, and no hospitalization, and, if the disc fragment can be successfully removed from the canal, relief of leg pain and much of the back pain can be immediate! In any case, - with or without surgery - disc herniation is one low back problem that has a good prognosis for recovery and return to normal life.

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1/15/2024

Lumbar Back Sprain: One of Our Most Common Back Pain Problems

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Lumbar Back Strain: Understanding and Managing a Common, Painful Injury

I want to provide you with the important information you need to understand these common spine problems, the ones that patients most often ask me about. While specific medical advice about your problem should come directly from your healthcare professional, here is the next big concern in our list of ten spine problems that patients often ask about:

LUMBAR SPRAIN AND STRAIN:

Lumbar strain or sprain refers to an injury affecting the muscles, ligaments, or tendons in the lower back region, specifically the lumbar spine. These injuries are common and often result from overuse, improper lifting, sudden twisting, or traumatic events. Here's information on diagnosis and treatment:

There are many potential causes of a lower back or lumbar strain:

Lumbar back strain is often caused by overuse or injury to the muscles, ligaments, and tendons in the lower back. Common causes include:

Muscle Overuse: Repetitive activities or movements that strain the muscles in the lower back can lead to overuse injuries. This is common in activities such as lifting heavy objects, especially when done with improper body mechanics.

Poor Body Mechanics: Incorrect posture or body mechanics while lifting, bending, or performing other activities can place excessive stress on the lower back muscles and ligaments, leading to strain.
Sudden Twisting or Turning: Abrupt and forceful twisting or turning motions, especially when lifting or carrying objects, can strain the muscles and ligaments in the lumbar region.
Heavy Lifting: Lifting heavy objects without proper technique or attempting to lift objects that are too heavy for the individual's strength can result in lumbar strain.
Sports Injuries: Participation in sports that involve repetitive or forceful movements, such as weightlifting, golf, or tennis, may contribute to lumbar strain.
Accidents or Trauma: Traumatic events, such as falls, car accidents, or blows to the lower back, can cause immediate strain on the muscles and other structures in the lumbar region.
Prolonged Sitting: Maintaining a seated position for extended periods, especially with poor ergonomics, can strain the lower back muscles and contribute to stiffness.
Sedentary Lifestyle: Lack of regular physical activity and weak core muscles can make the lower back more susceptible to strain.
Obesity: Excess body weight can increase the load on the spine and contribute to lumbar strain.
Age-Related Changes: With aging, the spine undergoes natural degenerative changes, such as disc wear and tear, which can make the lower back more prone to strain.
Deconditioning: Lack of regular exercise and physical conditioning can lead to weakened muscles and reduced flexibility, making the lower back more vulnerable to strain.
Inadequate Warm-up: Engaging in physical activities without proper warm-up can increase the risk of muscle strain.

Individual factors, such as genetics, overall fitness and health, and pre-existing conditions, can influence susceptibility to lumbar strain. Additionally, a combination of factors may contribute to the risk of lower back injury. Understanding and practicing good body mechanics, maintaining a healthy lifestyle and body weight, and incorporating exercises to strengthen the core muscles can help reduce the risk of lumbar strain. Also, there are just some activities that carry a high risk of back injury and lumbar strain. Whether it's at home or on the job, activities that involve repetitive bending, lifting, and twisting, particularly with heavy weights, will eventually cause a lumbar strain.

So, What causes the pain??

The pain experienced after a lumbar strain is primarily attributed to the inflammation and damage to the soft tissues, including muscles, ligaments, and tendons, in the lower back. Several factors contribute to the development of pain in lumbar strain:

Muscle Injury: Lumbar strains typically involve acute damage to the muscles that support and control the lower back. When they are overused, stretched, or torn, muscles can cause serious pain. Microscopic tears in muscle fibers can cause inflammation and trigger pain signals in nerves in the muscle and in tissues near the muscle, leading to spasm and stiffness.

Ligament or Tendon Damage: In addition to muscles, the ligaments, which connect bone to bone, and tendons, which connect muscle to bone, can be stretched or torn. Overstretching or tearing of these structures can result in severe immediate pain and persistent discomfort for weeks afterwards.

Inflammation: These soft tissue injuries trigger an inflammatory response, causing pain, swelling, and redness. In the case of lumbar strain, inflammation contributes to the sensation of pain directly and makes all of the affected tissues more sensitive to pain for some time afterwards.

Nerve Irritation: In some cases, lumbar strain can lead to irritation of nerves in the spine. This can cause burning pain, radiating down the leg, or numbness tingling tingling that may extend into the legs or feet. Nerve irritation can result from direct pressure on the nerve, or inflammation in the affected area irritating the nerve.

Spasm of Muscles: The body's response to injury often includes muscle spasms. These involuntary contractions can lead to increased pain and contribute to stiffness in the lower back.

Reduced Range of Motion: Pain and inflammation can limit the normal range of motion in the lower back. Reduced flexibility contributes to discomfort and difficulty with movement.

Psychosocial Factors: Emotional and psychological factors, such as stress or anxiety, can influence the perception of pain. Fear of pain is normal, but can sometimes make it hard for patients to push forward in their rehab. All that is true, but be aware: SOME DOCTORS ARE WAY TOO INVESTED IN THIS ISSUE and will routinely dismiss their back injury patients as having "psychological problems". Chronic pain conditions may be influenced by a complex interplay of physical and psychological factors, but this is rarely the big issue in a new, acute injury. A good doctor will acknowledge those issues while treating your back problem, and offer support. If your doctor doesn't recognize the need for treatment of the back injury, though, seek another opinion.

It's important to note that the severity of pain can vary based on the extent and location of the injury, individual pain thresholds, and the presence of any underlying conditions such as arthritis. Proper treatment and management, including rest, physical therapy, and pain medications, can aid in the recovery process and alleviate discomfort.

A common component of any lumbar strain is the muscle spasm that follows the muscle injury - that can be intense and disabling, and can last alot longer than you'd expect. None the less, that aspect will get better over time. If pain persists or worsens, there may be a more extensive injury or damage to other tissues, and it's time to seek additional medical advice for further evaluation and intervention.

Diagnosis:

Medical History and Physical Examination:

Symptoms Assessment: Inquiring about the nature, duration, and intensity of pain, as well as any other associated symptoms like numbness or tingling.
Circumstances of Injury: Understanding how the injury occurred provides insight into potential causes and helps in formulating a treatment plan.
Past medical history: If you've had problems with your back before, it's important to be up-front about those injuries and previous treatment. If you've had previous imaging studies, comparison of the old to any new studies can provide important clues as to the nature of your injury and what to expect in recovery.

Imaging Tests:

X-rays: While they are not always necessary, X-rays can reveal fractures, boney abnormalities, or alignment issues in the spine.
MRI (Magnetic Resonance Imaging): This imaging technique is more detailed and helps identify soft tissue injuries, such as disc herniations, as well as muscle or ligament strains.
CT (Computed Tomography) Scan: Useful for assessing bony structures and detecting fractures with greater precision.

Treatment:

Lumbar spine strains can typically be managed through conservative, non-surgical treatments. These treatments focus on reducing pain, inflammation, and promoting the natural healing of the injured tissues. Return to full activity, work, and recreation is the norm, but takes time and usually requires a course of active physical rehabilitation and exercise. Common non-surgical approaches include:

Rest and Activity Modification: Giving the injured muscles and ligaments time to heal, while carefully avoiding activities that aggravate the injury and worsen the pain, such as heavy lifting, repetitive bending or twisting, or prolonged sitting.
Pain Management: Over-the-counter pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can reduce inflammation and help reduce pain. Topical treatments like ice or heat packs may also be helpful.
Preventive Measures: Providing information on proper lifting techniques and body mechanics to reduce the risk of recurrent injuries.
Physical Therapy: A structured, progressive, physical therapy program can be designed to improve strength, flexibility, and promote proper posture. Therapeutic exercises are typically tailored to the individual's condition. Aggressive exercise may aggravate symptoms if started too soon, so start with a very gentle stretching program and work with your health care provider as you get better. Incorporating exercises that target the core abdominal and lumbar muscles is always a goal, as a strong core provides stability to the spine.

Muscle Relaxants: In cases of severe muscle spasms, healthcare providers may prescribe muscle relaxants to alleviate tension in the first days after the injury. Prolonged use is not helpful, can be harmful, and should be avoided.
Supportive Measures: Braces or lumbar supports may provide additional stability and aid in the healing process if a fracture or instability is recognized, but will not take the place of exercise and physical therapy.
Gradual Return to Normal Activities: As the condition improves, a gradual return to normal activities is usually recommended under the guidance of healthcare professionals. Activity and job modifications are often needed to allow return to normal without reinjuring the back muscles.

Surgery is rarely required for lumbar strains, and surgical treatment is generally considered only when conservative treatments fail, and the patient demonstrates evidence of a more severe associated or underlying injury such as a fracture or severe disc injury. These conditions may cause severe pain, neurological symptoms (such as persistent numbness or weakness), or show evidence of a structural instability that requires surgical correction.

Surgical options may include procedures such as discectomy (removal of part of a herniated disc), spinal fusion, or decompression surgery. However, surgery comes with its own risks and recovery periods, and it is usually considered a last resort when conservative measures are not effective.

It's important for individuals experiencing lumbar strain to consult with a healthcare professional for a thorough evaluation and to determine the most appropriate course of treatment based on their specific condition. In the majority of cases, non-surgical approaches prove effective in relieving pain and promoting recovery.

Healthcare Professionals:

There are several kinds of healthcare professionals who can provide appropriate care and guidance after a lumbar soft-tissue injury. The choice of healthcare provider may depend on the severity of your symptoms and the specialists available in your area, but should also take into account your own personal feelings about which kind of care you want to start with. Here are some professionals you may consider consulting:

Primary Care Physician (PCP):
Your primary care doctor can assess your symptoms, provide an initial diagnosis and earliest supportive care, and can recommend appropriate follow-up treatment or specialist care if you need it.

Orthopedic Surgeon:
If your symptoms are severe or persistent, or if there is a suspicion of a structural issue like a fracture or instability, your primary care doctor may refer you to an orthopedic surgeon. Orthopedic surgeons may provide both non-surgical and surgical treatment options, and can reassure you that - despite your significant pain - this is a soft tissue injury that will improve with time and without surgery.
Physiatrist (Physical Medicine and Rehabilitation Doctor):
Physiatrists are medical doctors who focus on physical medicine and rehabilitation. They can assess and treat many musculoskeletal conditions, provide rehabilitation plans, and may offer interventional procedures for pain relief. They are also trained to recognize conditions that are more serious and may require interventional care or surgery.
Physical Therapist:
Physical therapists are trained in rehabilitative exercises and therapies. They can design a personalized exercise program to improve strength, flexibility, and reduce pain. Physical therapy is often a key component of lumbar strain treatment.
Chiropractor:
Chiropractors specialize in diagnosis and treatment of injuries to the musculoskeletal system, particularly the spine. Most use manual adjustments to relieve pain and improve spinal function, but many also provide modalities such muscle stimulation, physical therapy, and ultrasound to calm muscle pain. A chiropractor with appropriate credentials and experience will obtain appropriate x-rays and imaging before starting treatment, and avoid aggressive manipulation in the earliest phases of treatment. Most chiropractors that I have worked with are very good at spotting more serious problems and referring patients when interventional therapy or surgery need to be considered.
Pain Management Specialist:
A pain management specialist may be consulted if the pain is persistent. They can offer a variety of interventions, including medications, injections, or other minimally invasive procedures to manage pain. Nerve root blocks or epidural steroid injections are commonly offered in care of ongoing back problems, but have little benefit when muscle injuries cause severe back pain. Injections into the muscles or injured joints can be helpful.
Sports Medicine Specialist:
If the lumbar strain is related to sports or physical activity, a sports medicine specialist can provide specialized care and guidance on rehabilitation.
Occupational Therapist:
Occupational therapists can assist in optimizing daily activities, recommending ergonomic adjustments, and providing strategies to prevent further strain. Patients who have been injured at work will often be directed to an occupational therapy specialist.

It's crucial to communicate openly with your healthcare provider, providing details about your symptoms, medical history, and any relevant activities or events leading to the lumbar strain. Based on the evaluation, the healthcare provider will guide you through an appropriate treatment plan, which may include a combination of therapies or referrals to specialists.

Conclusion:
It can take quite a while for a lumbar strain or sprain to completely heal, and the pain can be intense and disabling. Because these injuries primarily involve muscles and soft tissues that can heal and repair, you have a great chance of getting back to normal, with enough time. Getting back to activity and health is always the goal, but it can take some time and alot of effort to get there.

Because these injuries often occur at work or as the result of an accident, there is often a secondary issue of who's at fault, and who will pay, and that intensifies everything about the healing process. So, be patient, remember that your health care providers are on your side, and don't get depressed when it takes longer than you expected to get back to your old self!

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1/13/2024

Let's Talk about Our Most Common Back and Neck Pain Problems

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Cervical Strain or Sprain: Understanding and Managing a Common Injury

I want to provide you with the general information you need to get good care for these 10 common spine problems, the ones that patients most often inquire about. Specific medical advice should be sought directly from a healthcare professional. Here are ten common spine problems that my patients ask about, and I will be addressing each one individually

Cervical Spine Strain and Whiplash: Pain caused by injury to the muscles and ligaments supporting the neck and facet joints that connect the vertebrae.

2. Lower Sprain: Often caused by muscle strain, injury, or poor posture.

Herniated Disc: When the soft center of a spinal disc pushes through a crack in the tough outer layer.
Sciatica: Pain that radiates along the sciatic nerve, typically caused by compression or irritation.
Scoliosis: An abnormal curvature of the spine, often diagnosed during adolescence.
Spinal Stenosis: Narrowing of the spinal canal, leading to pressure on the spinal cord or nerves.
Degenerative Disc Disease: Wear and tear on the spinal discs over time, causing pain and discomfort.
Tumors and Infections of the Spine: A rare but very serious cause of damage to the spine, often seen as late complication during primary cancer therapy.
Spinal Fractures: Breaks or cracks in the bones of the spine, usually caused by trauma or osteoporosis.
Failed Back Surgery of the Spine: Persistent or worsening pain after a spine surgery treatment. Did the patient FAIL to get better, or did the surgery FAIL to fix the problem?.

If you have specific concerns about your spine health, it's recommended to consult with a healthcare professional for a thorough evaluation and personalized advice. Let's start with one of the most common...

Cervical Strain or Sprain: Understanding and Managing a Common Injury
Cervical strain or sprain refers to an injury affecting the muscles, tendons, or ligaments in the neck, often caused by sudden movements or trauma. This paper provides an overview of the symptoms, treatment options, and healthcare professionals involved in managing cervical strain or sprain.

Introduction:
Cervical strain is a common condition that can result from various activities, including whiplash injuries, improper lifting, or sudden movements. The five most common causes that my patients run into are:

Whiplash Injuries: Sudden acceleration or deceleration of the head - which is heavy relative to the neck -commonly associated with car accidents, and some sports injuries, can lead to a severe cervical sprain or strain, often referred to as whiplash. The forceful movement of the head strains and sometimes tears the neck muscles and ligaments.
Poor Posture: Prolonged periods maintaining the neck and head in an incorrect position, such as slouching while sitting at your desk or spending too much time looking down at your phone, can contribute to cervical strain over time.
Repetitive Strain: Activities that involve repetitive neck movements or sustained positions, such as long hours of computer work, painting, or other manual tasks, can strain the neck muscles and lead to discomfort. Likewise, repeated and prolonged exposure to low-grade impacts or vibration, as seen in construction vehicles, can result in a chronic strain situation.
Lifting Heavy Objects Incorrectly: Lifting heavy objects with improper technique or with sudden, jerky movements can strain the neck and upper back muscles and cause injury.
Sleeping Position: Sleeping in an awkward or unsupportive position can lead to neck strain. Using an unsuitable pillow or sleeping in an uncomfortable posture may contribute to waking up with neck pain (Check out my post on Proper Pillow Selection)..

While most cases can be effectively managed with conservative (nonsurgical) treatments, severe cases may require surgical intervention.

Symptoms:
Symptoms of cervical strain include intense neck pain, muscle spasms, limited range of motion, headaches, tenderness, and swelling. In severe cases, individuals may experience arm pain or numbness, indicating potential nerve compression or a herniated disc.
Treatment:
Conservative Measures:
Treated well with non-operative methods symptoms may resolve over a period of a few weeks or 2 -3 months. However, it is not uncommon for some symptoms, such as stiffness and headache, to linger for a year or more before completely resolving.

Rest: Allow the neck muscles time to heal by avoiding activities that worsen the strain.
Ice and Heat Therapy: Apply ice in the first 48 hours to reduce swelling, followed by episodic heat to relax muscles.
Pain Medications: Over-the-counter pain relievers like ibuprofen or acetaminophen can help manage pain by reducing the inflammation within the injured muscles and ligaments.
Physical Therapy: Exercises and stretches to improve flexibility and strengthen neck muscles can usually be started in two to three weeks when the initial muscle spasm calms down.
Neck Brace or Collar: In some cases, a neck brace may be recommended to limit movement and provide support.
Massage and Relaxation Techniques: Alleviate muscle tension and promote healing.

Surgical Intervention:

Surgery is considered when conservative measures fail or when there is an underlying structural issue, such as:

Severe herniated disc.
Persistent nerve compression.
Trauma or instability requiring stabilization.

Common surgical procedures include discectomy, cervical fusion, foraminotomy, and artificial disc replacement. Approximately one patient in 10 or 20 will need surgery for an acute strain, and some additional patients may later require surgery to address late disc degeneration of instability caused by the initial strain.

Healthcare Professionals:
There are several healthcare professionals that may be consulted during the evaluation and treatment process:

Primary Care Physician: Initial assessment, treatment, and referral to specialists if needed.
Orthopedic Surgeon: Specialist in musculoskeletal conditions for both non-operative and surgical interventions.
Neurologist: Consulted for evaluation and management of neurological symptoms of arm pain, numbness, or weakness, and for any evidence of a more severe neurological problem such as dizziness or loss of balance.
Physical Therapist: Designs rehabilitation exercises for improved neck strength and flexibility and provides some modalities that can relieve spasm and improve function.
Pain Management Specialist: Manages pain through medications, specialized injections, or other interventions.
Chiropractor: Utilizes manual adjustments for musculoskeletal issues.
Rheumatologist: Involved in cases related to inflammatory conditions or autoimmune disorders.
Emergency Room or Urgent Care Physicians/Nurse Practitioners: Address acute trauma or severe symptoms; often obtain the first imaging studies of the injured tissues and may be the first to see fractures or other problems that will need surgery.

Conclusion:
Cervical strain or sprain is a common yet manageable condition. The pain and stiffness associated with this muscle injury can be remarkably intense and limiting, early on. If arm pain or weakness is part of it, the situation needs to be carefully assessed and imaging obtained by a specialist. Conservative measures are often effective, but surgical intervention may be necessary in severe cases. Collaboration among healthcare professionals is crucial for accurate diagnosis and tailored treatment plans, ensuring optimal recovery for individuals with neck and back injuries.

I hope you find this helpful. In the coming weeks I'm going to address each of the common problems I listed above. If there's something you think I need to address that you don't see, just let me know!!

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5/7/2023

Slips and Falls in the Shower: One Cause that no-one tells you about!

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Slips and falls are among the most common causes of back and neck sprain and injury that I see each year. Falls of one type or another injure about a quarter-million seniors every year.

Falls in the bathroom can cause serious back and neck injuries, and result in fractures, severe sprains, and even death. We all know we need to be careful getting in and out of the tub, to be careful in the shower, yet I get a call about once every month from a patient that needs to be seen because they fell in the shower.

If we all know better, why are falls in the bath or shower so common?

**First: Physics is against you!**

To start with, age or infirmity aren't the only problem. Falls happen to everyone, of every age, and usually for similar reasons:

The floor of the shower or tub starts off with a smooth, slippery surface, which gets much slicker when wet, and can become absolutely treacherous when soap or shampoo spills onto it. Changing position or even leaning just a bit to reach for something can be like slipping on ice: one second you're fine and the next you headed for the floor!

The surface you're going to land on is hard and unforgiving. The shower walls and floor are tiled. They offer no "bounce" or cushion when you land. If you hit on a "meaty" part of your body, the impact will hurt and jar your whole frame. If you hit on an elbow or hip, a fracture can easily occur.

And, if you're in a tub, a fall across that tub edge can break ribs, crack vertebra, or cause a serious head injury.

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.

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2/27/2023

Treat your back better! 10 Risky things You need to Stop doing in 2023.

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Spring is coming but it isn't here yet. Let's review the things you need to avoid/stop doing entirely if you want to have a healthy, pain-free back and neck this summer!

! 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

someone else is driving/flying them home,
they get up or out and walk around a bit every two hours along the way, and
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!

Picture of dog walker from acmecanine 2020

Injuries to older patients while dog-walking have increased dramatically in recent years, and many require medical attention or hospitalization.

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.

Picture of a woman barrel racing in a rodeo

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!

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2/25/2023

How disc replacement surgery will make your neck pain better!

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Disc replacement surgery is growing in popularity, but there is still a lot of misinformation out there, and it’s still hard to figure out which facts are FACTS!

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.

$X-ray of spine fracture due to a malignant tumor. Fusion is absolutely the right thing for this patient.$

X-ray of spine fracture due to a malignant tumor. Fusion is absolutely the right thing for this patient.

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.

Two-year post-operative x-ray showing cervical disc replacement in a patient treated for disc herniation

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.

Picture of artificial disc design and position in the cervical spine

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.

Picture of MobiC artificial disc showing size and placement in the spinePicture

Picture of MobiC artificial disc showing size and placement in the spine (ZimVie)

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.

MRI image showing large cervical disc herniation putting pressure on the spinal cord and the nerve roots going out to the arm.

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

Illustration of cervical disc herniation compressing the spinal cord.

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.

Picture of cervical spine with nerve compression

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).

Picture of fused cervical spine after anterior cervical discectomy and fusion using a specially designed spacer and fixation screws. (Centinel)

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.

Picture of intervertebral space left after cervical discectomy.

Illustration of the intervertebral space left behind after cervical discectomy.

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.

X-ray of cervical spine 4 years after patient had a two-level cervical fusion with a plate and screws used for fixation. the large osteophyte at the level below reveals the severe adjacent level disease.

X-ray of cervical spine 4 years after patient had a two-level cervical fusion with a plate and screws used for fixation. the large osteophyte (bone spur) at the level below reveals the severe adjacent level disease.

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.

Mechanics of the artificial disc allows flexion and extension, rotation and side bending while resisting shifting back and forth that would irritate the small facet joints or cause pain.

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".

Picture of the highly polished metal dome that rotates on the high molecular weight polyethylene dome, creating a very low-friction interface.

Picture of the highly polished metal cup that rotates on the high molecular weight polyethylene dome, creating a very low-friction interface.

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

X-ray of two-level cervical total disc arthroplasty

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.

Picture of full cervical range of motion

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.

Picture of x-ray of patient with poor fusion and excellent result from disc replacement

X-ray of two-level cervical fusion with marginal success at both levels. This patient developed adjacent level disease above and below the fused segments and need disc replacement 3 years after the fusion.

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!

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2/19/2023

Disc Replacement is an Excellent Solution for Adjacent Level Disc Disease: Five Things to Know

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One of the most concerned groups of patients I see are those who've had a previous cervical fusion - sometimes quite recently -

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.

X-ray of single level disc herniation treated by fusion, showing the plate and screws used to hold the spine still as it heals.

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.

Dr. McLain drawing of cervical spine anatomy

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.

X-ray of patient with a two level cervical fusion (ACDF) just two years before

This patient had a two level cervical fusion (ACDF) just two years before herniating the disc below. You can already see bone spurs at the level above, so more fusion will cause even greater problems.

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.

X-ray 2 years after disc replacement at lower level to preserve motion while treating the herniation. Neck pain and arm pain both resolved.

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.

Dr. McLain drawing of anterior cervical discectomy

This drawing of anterior cervical discectomy illustrates the technique used for any anterior decompression surgery.

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.

Picture of M6 cervical disc arthroplasty implant

This M6 cervical disc arthroplasty implant can be applied at an adjacent level without having to take out old hardware or dissect away adjacent level scar.

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.

Picture of MobiC implant showing size.

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.

Photograph of implant showing the articulating dome and polyethylene spacer that allow controlled motion

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!

X-ray of patient prior to surgery, with old two-level fusion and new disc herniations at adjacent levels. Patient was told he would have to have a new fusion from C3 to C6.

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.

The patient is now three years post two-level disc replacement and thrilled with his result.

The patient is now three years post-op and thrilled with his result. Although bone spurs formed in front of the implants, motion is preserved and pain relieved.

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.

Picture of older disc replacement implant design.

This older disc replacement implant design was later revised to eliminate the large screws and anterior surface.

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?

Picture of single level total disc replacement x-ray

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.

Picture of two-level total disc replacement x-ray

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!

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2/18/2023

Prehistoric vs. Modern Man: When did our Back Start to Hurt so Bad?

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Paleopathology: Musculoskeletal Disease in Early Man
The Paleo Diet might be healthy, but the Paleo Life was hard!

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.

$Picture of Iron Age pelvis following a severe injury which fractured and displaced the pelvic ring and sacroiliac joint and fractured the left hip socket.$

Iron Age pelvis following a severe injury which fractured and displaced the pelvic ring and sacroiliac joint and fractured the left hip socket. This sort of injury is seen in patients who've been hit by a car and are often fatal today. But this pelvis has healed!

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.

Picture of dinosaur bones showing spinal disc degeneration and fusion

Paleontologists have found many examples of dinosaur bones showing spinal disc degeneration and spontaneous fusion similar to the severe disc disease we see today.

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

Picture of preColumbian miner found in a cave

This preColumbian miner was mummified by the natural chemicals found in the cave where he died.

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 Tolund Man bog body was startlingly well preserved, an effect of the peat swamp he was deposited in after what is thought to be ritual execution or sacrifice.

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.

Picture of Inca mummy with Hookworm specimens

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.

Picture of spine with osteomyelitis due to tuberculosis causing severe deformity

European spine with osteomyelitis due to tuberculosis causing severe bone destruction and deformity.

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.

Graph showing average age at death of people throughout history

Graphic illustration showing average age of people throughout history and prehistory, at the time of death. Age at death of prehistoric men and women is based on skeletal examination of fossil remains throughout the world and recovered subjects from European burial sites.

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!.

X-ray of knees of Pharaoh Thutmose showing clearly seen growth lines, which typically disappear at the end of adolescence or early adulthood

Only recently did man start living beyond his sixth decade with any frequency. Prior to the 1700's, the odds of living to the age of 40 had not changed much in about 200,000 years - and they were universally poor. In the last 300 years, however, mans' longevity has increased significantly, and continues to increase to this time.

Graph depicting the percentage of people that survive birth living to a given age. For instance, among older humans, only 5%, roughly, of individuals would live to be 60 years of age, compared to modern mankind, where more than 15% will live beyond 80!

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.

X-ray showing common findings of degenerative joint disease seen today, present in an Egyptian mummy

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.

$Picture of skull of Shanidar 1, a 50,000 year old Neanderthal who survived skull fracture, amputation of an arm and injuries to knees, ankles and feet, that would have left him nearly defenseless and unable to hunt or protect himself..$

Picture of skull of Shanidar 1, a 50,000 year old Neanderthal who survived skull fracture, amputation of an arm and injuries to knees, ankles and feet, that would have left him nearly defenseless and unable to hunt or protect himself.

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.

$Remnants of the shattered and amputated humerus, an infected clavicle and fractured scapula of Shanidar 1. Trinkaus, E.: The Shanidar Neanderthals. Academic Press, New York, 1983$

Remnants of the shattered and amputated humerus, an infected clavicle and fractured scapula of Shanidar 1. Trinkaus, E.: The Shanidar Neanderthals. Academic Press, New York, 1983

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.

Picture of eroded and possibly infected femur Shanidar 1.

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.

$Picture of arthritic joints of the foot and a long-healed fracture of the fifth metatarsal bone showing an older fracture of the foot that healed completely.$

Arthritic joints of the foot and a long-healed fracture of the fifth metatarsal bone showing an older injury of the foot of Shanidar 1 that had healed completely.

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.

Picture of spine and pelvis of tuberculosis victim showing vertebral destruction (Pott's deformity) and cavity in the pelvic wing due to a large psoas muscle abscess.

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.

Picture of An enormous destructive lesion was found in the lower extremity of an Iron Age saxon youth buried in an English cemetery. A radiograph through a peripheral portion of the lesion showed a classic

An enormous destructive lesion was found in the lower extremity of an Iron Age saxon youth buried in an English cemetery. A radiograph through a peripheral portion of the lesion showed a classic "sunburst" of ossifying soft tissue similar to that seen in advanced osteosarcoma today.

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.

$Picture of dinosaur bones with fractures$

Trauma, infection, neoplasia, endocrinopathies, and congenital and acquired deformities are all represented in the fossil and prehistoric record. However, the disease profile of ancient society differs from that of modern society in significant ways. Specifically, three disease processes are underrepresented in early populations when compared to modern society:

1.         Slowly progressive diseases of adulthood, requiring years to reach a level of significant severity.

2.         Diseases occurring in advanced age because of repeated exposure to trauma or stimuli.

3.         Diseases associated with age related hormonal or physical changes.

Hence, degenerative joint and spinal disease occurred in primitive man primarily because of a single traumatic or infectious insult which altered the mechanics or health of the joint, not because of cumulative micro-trauma, progressive degeneration, or genetic predisposition.

It is likely that the environmental and pathologic conditions responsible for orthopaedic disease have existed relatively unchanged for eons. It's likely, in fact that modern humans face consistently lighter strains and loads than our predecessors (fewer bears to fight, no pyramids to build). And, we haven't seen a change in the virulence of a pathogen, or an altered susceptibility or response to disease of the host. (Tuberculosis still does what tuberculosis has always done if we don't treat it).

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!

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2/5/2023

Eight Great Questions about Lumbar Disc Herniation, Leg Pain, and Microdiscectomy

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Herniation of the lumbar intervertebral disc is one of the most common, and most painful, problems that normal, healthy adults can encounter. Microdiscectomy is one solution.

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!

Picture illustrating lumbar disc herniation

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.

Picture illustrating lumbar disc anatomy

Cross section of the spine showing the fibers of the annulus surrounding the central nucleus pulposus and their surrounding blood supply

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.

Picture McLain drawing of nerve roots exiting the spinal canal just behind the lumbar discs

Drawing of the lumbar nerve roots exiting the spinal canal through the neural foramena just behind the lumbar discs

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.

McLain illustration of five types of disc herniation in the lumbar spine

Patients may several types of disc herniation in the lumbar spine; Disc degeneration with a bulge (top), Disc protrusion (Top right), Subligamentous disc extrusion (Middle left), Full disc extrusion (Bottom right), and Sequestered disc fragment (Bottom)

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.

Picture of Dr. McLain Illustration of subligamentous lumbar disc herniation with nerve root compression

Illustration of extruded lumbar disc herniation with nerve root compression

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.

Sequestered disc fragment compressing the lumbar spinal nerve and causing radiculopathy

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.

Dr. McLain's drawing of spinal anatomy showing the dorsal root ganglion which is exquisitely sensitive to pressure and inflammation

spinal anatomy showing the The dorsal root ganglion is a thickened part of the spinal nerve containing the actual nerve cell bodies, which is exquisitely sensitive to pressure and inflammation

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.

Dr. McLain's drawing of normal lumbar spine

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.

Microdiscectomy

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!"

Hemilaminotomy and microdiscectomy at L4-L5

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.

Specialized retractor allows access to spine through small incision, the key to microdiscectomy

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.

Lumbar spinal stenosis requires a laminectomy instead of laminotomy.

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.

Picture of inflammed nerve seen through laminotomy, with extruded disc fragment pressing up underneath the nerve

As seen through the laminotomy defect, the inflammed nerve is tented over an extruded disc fragment pressing up from underneath the nerve

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.

Example of a tubular retractor used for microdiscectomy

The surgeon then removes the dense tissue that covers the nerve roots (ligamentum flavum) and removes enough bone around the edges of the interlaminar space to create a window (more like a sky-light) called a laminotomy, allowing us to introduce specialized instruments into the spinal canal.

Picture of disc fragment being removed

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.

Picture of the nerve protected by a retractor, the disc fragment is removed.

With nerve protected by a retractor, the disc fragment is removed.

The nerve root is gently moved to the side with specially designed instruments, allowing the surgeon to get under the nerve root and remove the extruded fragments of disc material that are compressing the nerve. Depending on the situation, specially designed instruments are passed into the disc itself to remove any loose fragments of disc that might herniate later. Any healthy, well attached disc material is left in place.

Picture after the disc fragment is removed demonstrating the decompressed nerve free of pressure.

After the disc fragment is removed a fine instrument is passed through the foramen demonstrating that the decompressed is nerve free of residual pressure.

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.

Picture of patient being discharge from outpatient care

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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2/4/2023

Five Things You Should Know About Osteoporotic Compression Fractures:

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Osteoporotic compression fractures are the most common spinal fractures we see, and have gotten more common as we live longer and experience more problems with bone strength and health. If left untreated, vertebral body compression fractures can lead to progressive kyphosis, cord compromise, and intractable pain.

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".

$Picture of vertebral compression fracture$

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.

$Picture of minimally displaced vertebral compression fracture$

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.

$Drawing by Dr. McLain of vertebral compression fracture$

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.

Picture of osteoporotic bone and normal bone

Normal bone compared to Osteoporotic Bone

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.

$Picture of Patient with multiple myeloma being treated for three adjacent compression fractures$

Patient with multiple myeloma being treated for three adjacent compression fractures

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.

$X-ray image of vertebral compression fracture$

This patient fractured her spine when her chair slipped out from under her

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!

$Dr. McLain illustration of minor fracture$

A fracture that looks like this in the ER...

$Dr. McLain illustration of more severe fracture$

may progress to this in just a few weeks! If it keeps getting worse it will be hard to treat.

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.

Diagram showing the forces that are applied to an injured vertebra during daily activities

Diagram showing the forces applied to an injured vertebra during daily activities

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.

$Photographs of a patient with multiple compression fractures$

Photographs of a patient with multiple untreated compression fractures shows loss of height and painful deformity of the spine

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.

$Picture of compression fracture prior to treatment$

Thoracic compression fracture prior to treatment

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

Photo of needle placement for vertebroplasty

Typical needle placement for vertebroplasty

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.

Picture Of Operating Room set-up for Kyphoplasty procedure

Operating Room set-up for Kyphoplasty procedure. Patient is anesthetized, laying face-down on the operating table

In just a few minutes, before the patient is even off of the operating table, the cement has hardened and become rock-solid. Once the cement hardens the fracture stops collapsing, and bone healing will go ahead and permanently repair the fracture. And once the bone fragments stop moving, back pain gets better quickly and the patient can get up and around and start getting healthier.

Kyphoplasty is somewhat more complex, but the principles are the same.

$Picture of balloon cannula placement in fractured vertebra$

After the needle creates a pathway the balloon cannula is placed in fractured vertebra

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.

$Picture of dilated kyphoplasty balloon in fractured vertebra$

The inflated/dilated kyphoplasty balloon creates a void in fractured vertebra and elevates the compressed bone

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.

$Picture of void within bone of fractured vertebra prior to cement placement during kyphoplasty$

Picture of void within bone of fractured vertebra prior to cement placement

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.

Picture of cement fills the space created by the balloon and fixes the broken bone in place.

Picture of cement filling the space created by the balloon and fixes the broken bone in place.

X-ray of dilated balloon shows size of space created.

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.

Picture of fluoroscopy imaging system used in proper balloon kyphoplasty procedure.

Intraoperative fluoroscopy is crucial to accurate and safe placement of the bone cement, and should be used in any balloon kyphoplasty procedure.

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.

$Picture of happy patient after kyphoplasty procedure for thoracic vertebral fracture$

Patient is awake and alert soon after surgery and can often go home without a brace or walker within a few hours of the operation.

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.

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BAck Pain? Neck Pain? Ask Dr. McLain

Lumbar Disc Herniation: A Problem that Causes Back and Leg Pain

Next in my series of ten common problems - Lumbar Disc Herniation and the leg pain, or radiculopathy, that often causes the most frightening concerns.

Lumbar Back Sprain: One of Our Most Common Back Pain Problems

Lumbar Back Strain: Understanding and Managing a Common, Painful Injury

Let's Talk about Our Most Common Back and Neck Pain Problems

Cervical Strain or Sprain: Understanding and Managing a Common Injury

I hope you find this helpful. In the coming weeks I'm going to address each of the common problems I listed above. If there's something you think I need to address that you don't see, just let me know!!

Slips and Falls in the Shower: One Cause that no-one tells you about!

Slips and falls are among the most common causes of back and neck sprain and injury that I see each year. Falls of one type or another injure about a quarter-million seniors every year.

Treat your back better! 10 Risky things You need to Stop doing in 2023.

Spring is coming but it isn't here yet. Let's review the things you need to avoid/stop doing entirely if you want to have a healthy, pain-free back and neck this summer!

How disc replacement surgery will make your neck pain better!

Disc replacement surgery is growing in popularity, but there is still a lot of misinformation out there, and it’s still hard to figure out which facts are FACTS!

Disc Replacement is an Excellent Solution for Adjacent Level Disc Disease: Five Things to Know

One of the most concerned groups of patients I see are those who've had a previous cervical fusion - sometimes quite recently -

Prehistoric vs. Modern Man: When did our Back Start to Hurt so Bad?

Paleopathology: Musculoskeletal Disease in Early Man
The Paleo Diet might be healthy, but the Paleo Life was hard!

Eight Great Questions about Lumbar Disc Herniation, Leg Pain, and Microdiscectomy

Herniation of the lumbar intervertebral disc is one of the most common, and most painful, problems that normal, healthy adults can encounter. Microdiscectomy is one solution.

Five Things You Should Know About Osteoporotic Compression Fractures:

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BAck Pain? Neck Pain? Ask Dr. McLain

Next in my series of ten common problems - ​Lumbar Disc Herniation and the leg pain, or radiculopathy, that often causes the most frightening concerns.

Lumbar Back Strain: Understanding and Managing a Common, Painful Injury

Cervical Strain or Sprain: Understanding and Managing a Common Injury

I hope you find this helpful. In the coming weeks I'm going to address each of the common problems I listed above. If there's something you think I need to address that you don't see, just let me know!!

Slips and falls are among the most common causes of back and neck sprain and injury that I see each year. Falls of one type or another injure about a quarter-million seniors every year.

Spring is coming but it isn't here yet. Let's review the things you need to avoid/stop doing entirely if you want to have a healthy, pain-free back and neck this summer!

Disc replacement surgery is growing in popularity, but there is still a lot of misinformation out there, and it’s still hard to figure out which facts are FACTS!

One of the most concerned groups of patients I see are those who've had a previous cervical fusion - sometimes quite recently -

Paleopathology: Musculoskeletal Disease in Early ManThe Paleo Diet might be healthy, but the Paleo Life was hard!

Herniation of the lumbar intervertebral disc is one of the most common, and most painful, problems that normal, healthy adults can encounter. Microdiscectomy is one solution.

Author

Archives

Categories

Next in my series of ten common problems - Lumbar Disc Herniation and the leg pain, or radiculopathy, that often causes the most frightening concerns.

Paleopathology: Musculoskeletal Disease in Early Man
The Paleo Diet might be healthy, but the Paleo Life was hard!