CLINICAL CONDITIONS

Anatomy of the Spine

The spinal vertebrae are stacked in a column separated by discs and linked by facet joints. Strong ligaments, joint capsules and muscle bundles provide support and flexibility to the vertebral column. The spinal cord passes vertically through ring-shaped openings in the vertebrae (vertebral canal). Nerve roots emerge from the spinal cord and exit the vertebral canal sideways through small bony tunnels (foraminae) between the vertebrae. The spinal cord and nerve roots lie adjacent to the disc spaces and facet joints.

Cervical Disc Prolapse

Spinal Disc

Spinal discs act as shock absorbers and provide flexibility and some rotation between the vertebrae to which they are bonded. The disc comprises of a soft central component (nucleus pulposus) which is circumferentially contained by a tough collagen capsule called the annulus.

Herniated Disc

The term ‘herniated’ or ‘slipped’ disc is used when part of the soft disc content squeezes out under pressure through a tear in the capsule (annulus). The protruded disc material may compress an adjacent nerve root or rarely, the spinal cord. Nerve compression may cause arm, forearm, hand or finger pain (brachialgia). This may be asoociated with weakness, numbness and/or paraesthesia (tingling). Spinal cord compression can lead to leg weakness and disturbances in bladder and bowel function.

Investigations

A suspected herniated disc is confirmed with a Magnetic Resonance Imaging (MRI) scan.

Symptoms

A cervical disc prolapse usually presents with sudden or gradual onset neck pain radiating into the arm, forearm or fingers (brachialgia). This may be associated with numbness, tingling or weakness. Patients usually complain of neck stiffness. If the disc prolapse is also compressing the spinal cord, the patient may experience leg weakness, numbness and /or urinary or bowel disturbances.

Treatment

Cervical herniated discs may be treated conservatively or by surgery. Depending on the symptoms and examination findings, your doctor may decide to initially recommend conservative treatment with analgesia, rest, and physiotherapy which can lead to full recovery in up to 80% of patients within 4-8 weeks. There are several situations where your doctor may recommend a consultation with a Spine Specialist for further advice:

1. Persistent pain despite conservative management for 4-6 weeks
2. Incapacitating or worsening pain
3. Significant arm or leg weakness
4. Bowel or Bladder disturbances

There are several situations where your doctor may recommend a consultation with a Spine Surgeon for further advice:

1. Failure to improve or worsening symptoms despite conservative management for 4-6 weeks
2. Limb weakness due to reduced muscle power
3. Clinical evidence of spinal cord compression (leg weakness, urinary or bowel disturbances)
4. Severe intractable pain

Surgery for Cervical Disc Prolapse

The aim of surgery is to remove the herniated portion of the disc through a minimally invasive ‘open’ operation to alleviate the symptoms and improve neurological function.

There are two main types of operations. A Posterior Foraminotomy and discectomy is carried out through a small (3cm) incision in the back of the neck. Anterior Cervical Discectomy is performed through a small (4cm) incision at the front of the neck just off the midline to the right.

The procedure recommended by your surgeon will depend on several factors including the size and location of the herniated disc, the presence of spinal cord compression, the overall appearances of the cervical spine on the MRI scan, and also surgeon preference.

The procedure is performed under general anaesthesia and takes approximately one hour to complete. The herniated disc material is carefully removed under the magnification and strong light of a surgical microscope. If the anterior approach is used, part of the disc space will be entered to remove the herniation. This space will fill with scar tissue over a few weeks following the operation. This preserves motion across the disc space.

Occasionally, it is necessary to remove the entire disc to complete the operation. In this case, the gap created is filled with a carbon-fibre block (spacer) filled with bone graft that will eventually fuse the adjacent vertebrae together.

Following the operation, the patient is usually allowed mobilise out of bed within 12 hours. Most patients experience relief of arm pain immediately or soon following surgery. The patient is usually discharged from hospital on the first or second day following surgery with a neck brace which is to be worn for one week. An out-patients clinic review is arranged approximately 4 weeks following surgery. The patient typically returns to work thereafter.

Lumbar Disc Prolapse

Spinal Discs

Spinal discs act as shock absorbers and provide flexibility and some rotation between the vertebrae to which they are bonded. The disc comprises of a soft central component (nucleus pulposus) which is circumferentially contained by a tough collagen capsule called the annulus.

Herniated Disc

The term ‘herniated’ or ‘slipped’ disc is used when part of the soft disc content squeezes out under pressure through a tear in the capsule (annulus). The protruded disc material may compress an adjacent nerve root or rarely, the spinal cord. Nerve compression may cause leg pain (sciatica), weakness, numbness and/or paraesthesia (tingling). Spinal cord compression can lead to leg weakness and disturbances in bladder and bowel function.

Symptoms

Lumbar disc prolapse is most commonly seen between the age of 30 and 50. The episode may be caused by heavy lifting, bending or twisting of the spine, or may even occur during mild activity or rest. Patients usually experience acute onset low back pain radiating through the buttock or hip into the lower leg (sciatica), usually in the calf or the side of the shin. The patient may experience numbness, tingling and/or leg muscle weakness. The pain is initially severe and is often described as a dull aching pain with occasional sharp shooting sensations. It is typically aggravated by coughing, sneezing, bending or prolonged sitting.

Investigations

A suspected herniated disc is confirmed with a Magnetic Resonance Imaging (MRI) scan.

Treatment

The symptoms usually improve slowly over a period of 4 to 8 weeks. Physiotherapy, rest, analgesic and anti-inflammatory medication may help to alleviate the symptoms. If the pain fails to resolve or worsens, further treatment may be necessary under the guidance of a Spinal Specialist. Depending on several factors, the specialist may recommend a nerve injection (Nerve Root Block) or surgery to remove the prolapsed disc material (Lumbar Microdiscectomy). Patients with moderate or severe muscle weakness, or disturbances of urinary or bowel function, are usually referred urgently to a specialist for early surgical treatment.

Nerve Root Block

A nerve root block is an X-Ray guided injection of the nerve root with a mixture of local anaesthetic and steroids. The root block is performed as a day-case procedure under local anaesthetic by a Consultant Pain Clinican or Radiologist. The root block is intended to improve pain control and works by reducing nerve inflammation. It is successful in up to 30% of selected patients.

Lumbar Microdiscectomy

A lumbar microdiscectomy is a routine and commonly performed procedure. The procedure has a 80-90% success rate in alleviating sciatic pain. This operation is not usually recommended for back pain alone as this does not respond to this type of surgery. Patients are usually mobile within 24 hours of the operation and discharged home at 48 hours.

The operation is performed under general anaesthesia and takes approximately one hour. A 2 cm skin incision is placed in the midline at the base of the spine. Special retractors are introduced to retract the fat and muscle layers to reach the spine. X-Rays are taken to identify the correct disc level. With the aid of a surgical microscope, a small window (8-10mm) is created in the spine casing (consisting of ligament and bone) to expose the disc prolapse which is seen to be protruding from the disc space and compressing the nerve. The nerve is gently manoeuvred off the prolapsed disc which is then carefully removed to release the nerve. The disc space is then entered to remove any other loose disc fragments which may cause a further prolapse in the future. The wound is closed with dissolving sutures and special sticky paper tapes (Steristrips) applied to the skin. The tapes are peeled off a week later when the skin has healed.

During the first 2 – 3 days, the patient will experience some wound pain which is usually managed with regular analgesia. Most patients report complete relief of sciatica. Patients are encouraged to mobilise out of bed within 12 –24 hours with help from a nurse or physiotherapist. Once the patient is independent with activities of daily living (i.e dressing, feeding, showering etc), they will be discharged home with advice from a physiotherapist.

Cervical Spondylopathy

Cervical spondylopathy is a term applied to degenerative inflammatory changes (wear and tear) in the cervical spine causing arm or neck pain and/or neurological symptoms. The degeneration around the disc space and facet joints slowly causes disc bulging and formation of bony spurs (osteophytes) around the joints. The bulging disc and osteophytes eventually impinge upon the spinal cord or nerve roots with consequent symptoms.

Symptoms

Degenerative changes start causing symptoms from the age 40 onwards. As degenerative changes tend to occur slowly, the symptoms typically develop over a period of several months or years

Nerve root compression may cause arm or hand pain (Brachialgia), weakness, numbness, and/or paraesthesia (tingling). A trapped nerve may not cause any symptoms at all. The arm pain usually a dull tooth-ache like pain, sometimes with a shooting electric sensation. The area of the arm affected depends on the territory of the compressed nerve root. Spinal cord compression may cause gradual onset leg weakness, stiffness or heaviness, poor balance, leg numbness and gradual loss of mobility. Patients may also experience general fatigue and/or disturbances in urinary or bowel. In the arms, patients may develop difficulty with simple tasks requiring fine dexterity e.g. writing, buttoning up, closing zips and using the knife and fork.

Investigations

Cervical spondylopathy is best investigated with a Magnetic Resonance Imaging (MRI) scan.

Treatment

Depending on the severity of symptoms, MRI scan findings and other factors, your doctor may recommend a consultation with a Spine Surgeon for further advice. In the presence of spinal cord or nerve root compression with significant symptoms and/or clinical findings on examination, the surgeon may recommend an Anterior Cervical Discectomy and Fusion (ACDF) procedure or a Posterior foraminotomy.

Anterior Cervical Discectomy and Fusion (ACDF)

This is an minimally invasive "open" operation which is performed under general anaesthesia and takes approximately one hour to complete. Two or three disc can be removed through the same incision if necessary. A small incision is made in a skin crease at the front of the neck slightly to the right of the midline. Using an operating microscope to provide strong light and magnification, the disc and/or bone spurs are gently removed to release the nerve roots and spinal cord. At the end of the procedure, the empty disc space is filled with a synthetic spacer filled with bone graft to allow fusion of the adjacent vertebrae. A titanium plate may be used to reinforce the fusion.

Postoperative Foraminotomy

A posterior foraminotomy involves a 3cm short skin incision at the back of the neck to gain access to the nerve roots from behind. A small opening is made in part of the facet joint to remove the bone spurs compressing the nerve root.

Postoperative Course

Following the operation, the patient is usually allowed to get up and walk within 12 hours. The majority of patients experience relief of arm pain immediately or soon following surgery. The patient is usually discharged from hospital on the first or second day and is prescribed a neck collar to be worn for one week. The patient is reviewed in the surgical clinic at approximately 4 weeks following surgery and typically returns to work thereafter.

Lumbar Spinal Stenosis

Lumbar stenosis is caused by a degenerative (wear and tear) narrowing of the lumbar spinal canal leading to compression of one or more nerve roots. Patients tend to present after the age of 60. The narrowing of the spinal canal is due to facet joint and ligament thickening, disc bulging, or spondylolisthesis (vertebral slippage).

Symptoms

Patients classically present with buttock and leg pain or leg weakness brought on by walking, standing, or lying flat on their back. The leg pain in lumbar stenosis is gradual in onset, and worsens over a period of several months. The pain may be accompanied by leg numbness, paraesthesia, and sometimes, bladder or bowel disturbances or impotence.

Investigations

MRI scanning is the investigation of choice in lumbar stenosis. CT or CT myelography is useful where MRI scanning is either unavailable or contraindicated.

Treatment

Mild symptoms may be managed conservatively with rest, analgesia and physiotherapy. A few patients may obtain long term pain relief from a course of epidural steroid and local anaesthetic injections. Physiotherapy for postural advice and trunk muscle strengthening exercises may also be beneficial. Unfortunately, many patients with lumbar stenosis experience recurrent symptoms as soon as they resume normal activities following a period of conservative management. Indications for surgical intervention are:

1. Failure of conservative treatment
2. Incapacitating or permanent pain
3. Progressive leg weakness and problems with balance
4. Bowel or Bladder disturbances

Decompressive surgery for lumbar stenosis involves carefully shaving back the thickened facet joint and ligaments adjacent to the spinal nerves. In the presence of spondylolisthesis or lumbar instability, a fusion procedure may also be necessary at the same time. Lumbar decompression for stenosis has an 80–90% chance of success.

Spinal Tuomours

Tumours which spread to the spine (metastases) from other parts of the body – for example prostrate,lung,breast, and colon - are the most frequently occurring tumours of the spine.

Symptoms

Spinal pain is the most common initial symptom in patients with a spinal tumour. The pain is constant and may be worsened by spinal movements. It may be worse at night. Patients may eventually develop limb weakness, numbness or tingling as a consequence of nerve or spinal cord compression.

Investigations

Plain X-Ray tests may detect evidence of bone destruction. MRI has become the imaging modality of choice for spinal tumours. CT scan provides more detailed information on the bone structure and joints.

Treatment

The effective treatment of spinal tumour disease depends upon early detection and subsequent management by a multidisciplinary team of Oncologists, Physicians and Spinal Surgeons.

Benign spinal tumours are usually treated by surgical removal. In many cases benign tumours can be removed completely with the likelihood of permanent cure. Malignant spinal tumours cannot usually be removed completely. Surgery may be recommended for severe spine or nerve pain, spinal cord compression with limb weakness, or for structural weakening of the spine. Surgery may also be recommended in patients not responding to radiotherapy and/or chemotherapy. Surgery involves decompression of the spinal cord and nerves by removing as much of the tumour as possible. This is usually followed by stabilisation of the spine with special screws and metal rods (Instrumented Fusion/Stabilisation). The technique and surgical approach used depends on the location of the tumour, the degree of spine destruction/instability, and the access required to allow adequate decompression.

Spondylolisthesis: Lumbar fusion

This section will follow shortly.

Spinal Rheumatoid Arthritis

This section will follow shortly.