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We provide information to help patients and caregivers to understand of anatomy, associated symptoms, and arthroplasty of spine.

Spine Bone

  • The vertebrae are composed of five different sections and 24 bones in total. When we are born, we have 33 bones in the spine but nine of those eventually fuse together.
  • The spine is composed of five different sections: Cervical, Thoracic, Lumar, Sacrum and Coccyx.
    • The cervical area
      • The main function is to support the weight of the head, around 10 pounds. It also has the greatest range of motion (C1-C7).
    • The thoracic area
      • This area protects the organs in the chest by connection to the rib cate. It has a very limited range of movement (T1-T12).
    • The lumbar area
      • The main function is to bear the weight of the body. It is much larger than the other areas on the spine (L1-L5).
    • The sacrum
      • The sacrum provides attachment of the iliac bones and protects the pelvic organs. It is five different bones fused together.
    • The coccyx
      • The coccyx is made up of four bones that are fused together. It doesn’t have an important function. It is a remnant of a tail from our primate ancestors.

Each vertebra consists of

  • At the front - vertebral body
  • At the side - the pedicles
  • At the back - the lamina
  • At the back of each vertebra, there is a pair of facet joints which articulate with the facet joints of the adjacent vertebra. The vertebral bodies are separated by cushions called intervertebral discs. A disc is made of special cartilage and acts like a shock absorber between the bodies.

There are two types of back pain: Acute and Chronic

  • Acute
    • Acute back pain is short-term pain, typically lasting from a few days to a few weeks. Most acute back pain is the result of trauma to the back or from a condition like arthritis. Acute pain symptoms range from shooting or stabbing pain to muscle aches, limited flexibility, range of motion, and inability to stand up straight.
  • Chronic
    • Chronic back pain lasts for three or more months. It is often progressive, meaning it gets worse over time. The cause of chronic pain can be hard to determine and usually requires treatment from a medical professional.
    • The main causes of back pain are:
      • Stress or injury involving the back muscles, including back sprain or strain; chronic overload of back muscles caused by obesity; and short-term overload of back muscles caused by any unusual stress, such as lifting or pregnancy
      • Disease or injury involving the back bones (vertebrae), including fracture from an accident or as a result of the bone-thinning disease osteoporosis
      • Degenerative arthritis, a "wear and tear" process that may be related to age, injury and genetic predisposition
      • Disease or injury involving the spinal nerves, including nerve injury caused by a protruding disc (a fibrous cushion between vertebrae) or spinal stenosis (a narrowing of the spinal canal)

Herniated Disk

When people say they have a “slipped” or “ruptured” disc in their neck or lower back, what they are actually describing is a herniated disc, a common source of pain in the neck, lower back, arms or legs. 

Symptoms

 The symptoms of a herniated disc depend on the exact level of the spine where the disc herniation occurs and whether or not nerve tissue is being irritated. A disc herniation may not cause any symptoms. However, disc herniation can cause local pain at the level of the spine affected. If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the level of the disc herniation. This can cause shooting pain in the distribution of that nerve and usually occurs on one side of the body and is referred to as sciatica. For example, a disc herniation at the level between the fourth and fifth lumbar vertebrae of the low back can cause a shooting pain down the buttock into the back of the thigh and down the leg. Sometimes this is associated with numbness, weakness, and tingling in the leg. The pain often is worsened upon standing and decreases with lying down. This is often referred to as a "pinched nerve."

 If the disc herniation occurs in the cervical spine, the pain may shoot down one arm and cause a stiff neck or muscle spasm in the neck.

  • Pain and numbness, most commonly on one side of the body
  • Pain that extends to your arms and/or legs
  • Pain that worsens at night
  • Pain that worsens after standing or sitting
  • Pain when walking short distances
  • Unexplained muscle weakness
  • Tingling, aching or burning sensations in the affected area

Treatment

If your slipped disc pain does not respond to over-the-counter treatments, your physician may prescribe stronger medications.

  • A physician may recommend surgery if your symptoms do not subside in six weeks or if your slipped disc is affecting your muscle function. Your surgeon may simply remove the damaged or protruding portion of the disc without removing the entire disc. This is called a micro discectomy.
  • In more severe cases, your doctor may replace the disc with an artificial one, or remove the disc and fuse your vertebrae together. This procedure, called a laminectomy, adds stability to your spinal column

Prevention

It may not be possible to prevent a slipped disk, but you can take steps to reduce your risk of developing a slipped disk. Those steps include:

  • Use safe lifting techniques, such as bending or lifting from your knees, not your waist
  • Maintain a healthy weight
  • Do not remain seated for long periods; get up and stretch periodically
  • Do exercises to strengthen the muscles in your back, legs and abdomen

Spondylosthesis

If a stress fracture weakens the bone so much that it is unable to maintain its proper position, the vertebra can start to shift out of place. This condition is called “spondylolisthesis”.
If too much slippage occurs, the bones may begin to press on nerves, and surgery may be necessary to correct the condition. It is found most frequently in the lumbar (lower back) region of the spine.
This is due to the fact that this area is exposed to a great deal of pressure caused by movement associated with lifting heavy objects and twisting the torso.

Causes

The bones in patients' spine come together at several small joints that keep the bones lined up while still allowing them to move. Spondylolisthesis is caused by a problem with one or more of these small joints that allow one bone to move out of line. Spondylolisthesis may be caused by any of a number of problems with the small joints in patients' back.

  • A defective joint that you've had since birth (congenital).
  • A joint damaged by an accident or other trauma.
  • A vertebra with a stress fracture caused by overuse of the joint.
  • A joint damaged by an infection or arthritis.

Symptoms

  • Persistent lower back pain
  • Stiffness in the back and legs
  • Lower back tenderness
  • Thigh pain
  • Tight hamstring and buttocks muscles
  • Other symptoms may include tingling and numbness. Coughing and sneezing can intensify the pain. An individual may also note a "slipping sensation" when moving into an upright position. Sitting and trying to stand up may be painful and difficult.

Treatment

Non-Surgical Treatments

Although nonsurgical treatments will not repair the slippage, many patients report that these methods do help relieve symptoms.

  • Wearing a back brace
  • Physical therapy
  • Taking over-the-counter or prescription anti-inflammatory drugs (such as ibuprofen) to reduce pain
  • Epidural steroid injections

Surgical Treatments

  • Surgical candidates with DS: Surgery for degenerative spondylolisthesis is generally reserved for the patient who does not improve after a trial of nonsurgical treatment for at least 3 to 6 months. In making a decision about surgery, your doctor will also take into account the extent of arthritis in your spine, as well as whether your spine has excessive movement. DS patients who are candidates for surgery often are unable to walk or stand and have a poor quality of life due to the pain and weakness.
  • Surgical candidates with spondylotic spondylolisthesis: Patients with symptoms that have not responded to nonsurgical treatment for at least 6 to12 months may be candidates for surgery. If the slippage is getting worse or the patient has progressive neurologic symptoms, such as weakness, numbness, or falling, and/or symptoms of cauda equina syndrome, surgery may help.
  • Surgical procedures:  Surgery for both DS and spondylotic spondylolisthesis includes removing the pressure from the nerves and spinal fusion. Removing the pressure involves opening up the spinal canal. This procedure is called a laminectomy. Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
  • Surgical recovery: The fusion process takes time. It may be several months before the bone is solid, although your comfort level will often improve much faster. 

Prevention

Since there is no stopping the aging process, spondylolisthesis prevention can be difficult, if not impossible. However, maintaining good physical and cardiovascular fitness is one way to prepare the body to cope with symptoms that sometimes can accompany spondylolisthesis, including pain, tingling, numbness or muscle weakness.

Lumbar Spinal Stenosis

 Lumbar Spinal Stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves at the level of the lumbar vertebrae. This is usually due to the common occurrence of spinal degeneration that occurs with aging. It can also sometimes be caused by spinal disc herniation, osteoporosis, a tumor, or trauma. In the cervical (neck) and lumbar (low back) region, it can be a congenital condition to varying degrees.

 It is also a common symptom for those who suffer from various skeletal dysplasias such as with pseudoachondroplasia and achondroplasia at an early age.

 Spinal stenosis may affect the cervical or thoracic region in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. In some cases, it may be present in all three places in the same patient. Lumbar spinal stenosis can cause low back pain, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet or buttocks, or loss of bladder and bowel control.

Symptoms

Lumbar spinal stenosis may or may not produce symptoms, depending on the severity of your case. The narrowing of the spinal canal itself does not produce these symptoms. It is the inflammation of the nerves due to increased pressure that may cause noticeable symptoms to occur. When present, symptoms may include:

  • Pain, weakness or numbness in the legs, calves or buttocks
  • Pain radiating into one or both thighs and legs, similar to sciatica
  • In rare cases, loss of motor functioning of the legs
  • In rare cases, loss of normal bowel or bladder function
  • Pain may decrease when you bend forward, sit or lie down. Pain may get worse when you walk short distances.
  • As lumbar spinal stenosis symptoms worsen, they may become quite debilitating. It is estimated that 400,000 Americans suffer from leg pain and/or low back pain from lumbar spinal stenosis.
 

Treatment

Non-Surgical Treatments

  • Activity modification
  • Exercise
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Epidural injections

Surgical Treatments

  • Spinal stenosis symptoms often become worse over time, but this may happen slowly. If the pain does not respond to these treatments, or you lose movement or feeling, you may need surgery. Surgery is done to relieve pressure on the nerves or spinal cord. You and your doctor can decide when you need to have surgery for these symptoms. Surgery may include removing a bulging disc, removing part of a vertebra or widening the opening where your spinal nerves are. After some spinal surgery, the surgeon may fuse some of the spine bones to make your spine more stable.

Prevention

Because almost everyone has some osteoarthritis of the spine by age 50, you can’t really prevent lumbar spinal stenosis. However, you may be able to lower your risk. Following are some ways to keep your spine healthy:

  • Get regular exercise. Exercise strengthens the muscles that support your lower back and helps keep your spine flexible. Aerobic exercises like walking, swimming, cycling, and weight training are all good for your back
  • Maintain good posture. Learn how to safely lift heavy objects. Also, sleep on a firm mattress and sit in a chair that supports the natural curves of your back
  • Maintain a healthy weight. Excess weight puts more stress on your back and can contribute to developing symptoms of lumbar spinal stenosis

Surgical Treatments for Back Pain

  • Lumbar Discectomy: Minimally Invasive Spine Surgery
    • Minimally invasive spine surgery (MISS) is sometimes called less invasive spine surgery. In these procedures, doctors use specialized instruments to access the spine through small incisions. 
      • In a traditional, open surgery, the doctor makes an incision that is 5 to 6 in. long and moves the muscles to the side in order to see the spine. With the muscles pulled to the side, the surgeon can access the spine to remove diseased and damaged bone or intervertebral disks. The surgeon can also easily see to place screws, cages, and any bone graft materials necessary to stabilize the spinal bones and promote healing. 
      • One of the major drawbacks of open surgery is that the pulling or "retraction" of the muscle can damage the soft tissue. Although the goal of muscle retraction is to help the surgeon see the problem area, it typically affects more anatomy than the surgeon requires. As a result, there is greater potential for muscle injury, and patients may have pain after surgery that is different from the back pain felt before surgery. This can lead to a lengthier recovery period. 
      • Minimally invasive spine surgery was developed to treat spine problems with less injury to the muscles and other normal structures in the spine. It also helps the surgeon to see only where the problem exists in the spine. Other advantages to MISS include smaller incisions, less bleeding, and shorter stays in the hospital.
    • Procedure
      • MISS fusions and decompression procedures are performed with special tools called tubular retractors. During the procedure, a small incision is made and the tubular retractor is inserted through the skin and soft tissues down to the spinal column. This creates a tunnel to the small area where the problem exists in the spine. The tubular retractor holds the muscles open and is kept in place throughout the procedure.
      • The surgeon accesses the spine using small instruments that fit through the center of the tubular retractor. Any bone or disk material that is removed exits through the retractor, and any devices necessary for fusion — such as screws or rods — are inserted through the retractor. Some surgeries require more than one retractor.
      • The surgeon accesses the spine using small instruments that fit through the center of the tubular retractor. Any bone or disk material that is removed exits through the retractor, and any devices necessary for fusion — such as screws or rods — are inserted through the retractor. Some surgeries require more than one retractor.
      • At the end of the procedure, the tubular retractor is removed and the muscles return to original position. This limits the muscle damage that is more commonly seen in open surgeries.
    • Recovery
      • Minimally invasive procedures can shorten hospital stays. The exact length of time needed in the hospital will vary with each patient and individual procedure, but generally, MISS patients go home in 2 to 3 days.
  • Foraminotomy
    • A foraminotomy is also a procedure used to relieve pressure on a nerve, but in this case, the nerve is being pinched by more than just a herniated disc.
    • The surgery may be considered if a patient has severe symptoms that interfere with your daily life. Symptoms include:
      • Pain that may be felt in your thigh, calf, lower back, shoulder, arms or hands. The pain is often deep and steady
      • Pain when doing certain activities or moving your body a certain way
      • Numbness, tingling, and muscle weakness
    • Procedure
      • Lying face down or sitting up on the operating table. A cut (incision) is made in the middle of the back of your spine. The length of the incision depends on how much of your spinal column will be operated on.
      • Skin, muscles, and ligaments are moved to the side. The surgeon may use a surgical microscope to see inside patient's back.
      • Some bone is cut or shaved away to open the nerve root opening (foramen). Any disk fragments are removed.
      • Other bone may also be removed at the back of the vertebrae to make more room.
      • The surgeon may do a spinal fusion to make sure your spinal column is stable after surgery.
      • The muscles and other tissues are put back in place. The skin is sewn together.
  • Laminectomy
    • Lumbar laminectomy (open decompression) is a surgical procedure that is performed to alleviate pain caused by neural impingement (pressure on the nerves). The surgery removes a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the nerve root more space and an opportunity to heal.
    • A laminectomy is effective for decreasing pain and improving function for patients with lumbar spinal stenosisSpinal stenosis is a condition that usually occurs in elderly patients, and is caused by degenerative changes that result in enlargement of the facet joints. The enlarged joints then place pressure on the nerves, and this pressure may be effectively relieved with a lumbar laminectomy.
    • Procedure
      • A two-inch to five-inch long incision is made in the midline of the back.
      • The left and right back muscles (erector spine) are dissected off the lamina on both sides and at multiple levels, allowing the surgeon access to the nerves.
      • The facet joints, which are directly over the nerve roots, may then be trimmed to give the nerve roots more room.
      • Following the operation, patients are in the hospital for one to three days. The patient's ability to return to normal activity is largely dependent on his or her pre-operative condition and age. Patients are encouraged to walk directly following the procedure. It is recommended that patients avoid excessive bending, lifting or twisting for six weeks in order to avoid pulling on the suture line before it heals.
  • Spinal Fusion
    • Spinal fusion is a surgical procedure used to correct problems with the small bones of the spine (vertebrae). It is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
    • Spine surgery is usually recommended only when your doctor can pinpoint the source of your pain. To do this, your doctor may use imaging tests, such as x-rays, computed tomography (CT), and magnetic resonance imaging (MRI) scans.
    • Spinal fusion may relieve symptoms of many back conditions, including:
      • Degenerative disk disease
      • Fracture
      • Spondylolisthesis
      • Spinal stenosis
      • Tumor
      • Scoliosis
    • Procedure
      • Adding bone graft to a segment of the spine.
      • Set up a biological response that causes the bone graft to grow between the two vertebral elements to create a bone fusion.
      • The boney fusion - which results in one fixed bone replacing a mobile joint - stops the motion at that joint segment.
    • Recovery
      • Pain Management
        • After surgery, the patient will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
        • Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. 
      • Rehabilitation
        • The fusion process takes time. It may be several months before the bone is solid, although your comfort level will often improve much faster. During this healing time, the fused spine must be kept in proper alignment. The patient will be taught how to move properly, reposition, sit, stand, and walk.
        • Maintaining a healthy lifestyle and following the doctor's instructions will greatly increase chances for a successful outcome.
  • Spinal Disc Replacement
    • In artificial disk replacement, worn or damaged disk material between the small bones in the spine is removed and replaced with a synthetic or "artificial" disk. The goal of the procedure is to relieve back pain while maintaining more normal motion than is allowed with some other procedures, such as spinal fusion.
    • Procedure
      • Most spinal disc replacement surgeries take from 2 to 3 hours.
      • During the procedure, a surgeon will remove the problematic disk and then insert an artificial disk implant into the disk space.
      • Disk Design
        • Some disk replacement devices comprise the nucleus (center) of the intervertebral disk while leaving the annulus (outer ring) in place, although this technology is still in an investigative stage.
        • In most cases, total artificial disk replacements substitute both the annulus and nucleus with a mechanical device that will simulate spinal function.
    • Recovery
      • In most cases, patients will stay in the hospital for 1 to 3 days following artificial disk replacement. 
      • Patients are encouraged to stand and walk on the first day after surgery. Because bone healing is not required following artificial disk replacement, the typical patient is encouraged to move through the midsection. Early motion in the trunk area may lead to quicker rehabilitation and recovery.
      • Also, patients will perform basic exercises, including routine walking and stretch, during the first several weeks after surgery. 
  • Dynamic Stabilization
    • Dynamic stabilization is another option for those trying to avoid spinal fusion but in need of some stability of the spine. It is a technology that is being developed to provide stability to a lumbar spine that is exhibiting instability causing intolerable and intractable low back pain. The source of back pain is most commonly associated with degenerative disc disease but can be also associated with lumbar facet disease. The facets are a paired set of joints that are present at every level in the spine between the vertebrae. Dynamic stabilization devices treat pain caused by both degenerative disc and facet disease by supporting and controlling the motion around the painful segment.
    • Procedure
      • The procedure is performed in the operating room and typically requires a two to three-day hospitalization. During the surgical procedure, screws are inserted into the pedicle and vertebral bodies above and below the diseased level. Non-rigid devices are then inserted into or onto these screws. The flexible connections between the screws allow some motion to take place at the diseased level. However, due to the stabilizing effect of these devices the individual treated with this procedure should have less pain.
      • These devices are most useful for younger patients by maintaining flexibility in their backs. The treatment has the greatest success in treating back pain, particularly disco-genic back pain but can also treat leg pain in select cases. One final advantage of this treatment is that if these devices fail to support a diseased and degenerated lumbar spine, the patient and physician continue to have the surgical option of a lumbar fusion.
  • The information on this page is intended only for patients and caregivers
  • Trademarks appearing on the website are owned, licensed and distributed by Corentec Co., Ltd.
  • Reference : American Academy of Orthopaedic Surgeons (AAOS)