Spine Surgery is one of the most commonly performed surgeries worldwide at the moment. Spine surgery has become very safe with the recent advancements like neuromonitoring, C-arm image identifier, O-arm image with intra-operative Ct scans and minimally invasive techniques.
Minimally invasive spine surgery is the latest development in the field of spine surgery. In this , spine surgery is performed through tubes without cutting through the muscles so that recovery is much faster, there is minimal blood loss, incisions are much smaller than the conventional techniques. We advocate minimally invasive spine surgery for all our patients. Also we are equipped with all the latest technology for performing minimally invasive spine surgery.
Spinal fusion is one of the most commonly performed spine surgeries. Spine is meant for motion. When this motion becomes abnormal and starts causing back pain or leg pain due to impingement of nerves, spinal fusion surgery is performed. In this surgery, the two bones are fused together by putting bone graft alongwith fixation with screws and rods. Sometimes, the diseased disc is excised and replaced with cage filled with bone graft for better fusion success rate.
Laser spine surgery is one of the most common reasons for patients to visit me. Laser spine surgery can be performed in early stages of disc degeneration, when the disc is bulging or is protruding but has not slipped from its original position. In this surgery, a radiofrequency probe is inserted into the disc space percutaneous and the disc bulge or protrusion is reduced with the help of radiofrequency probe. The procedure is also known as Disc Fx. The similar surgery can be done for facet joints if facet joints are causing pain.
Though spinal fusion surgery decreases motion at the operated level, but clinically patient does not feel any decreased motion after spinal fusion surgery, especially if fusion has been done only at one or two levels. In fact, clinical motion of the spine increases after spinal fusion surgery because patients usually have decreased movements in the spine before surgery due to pain. After surgery, the pain goes away, and spinal motion actually increases.
Most of our patients (99%) start walking on the first day of surgery and are discharged on 3 rd day of surgery, when they are completely independent. In some minimally invasive spine surgeries, patients are able to walk immediately after surgery and are discharged on the next day of surgery.
We expect our patients to stay for 2 weeks in India after surgery. This period is to make sure that the wound has healed completely and patient is walking independently. Also, it ensures good physiotherapy and rehabilitation.
There is no restriction for sex after spine surgery.
The duration of physiotherapy after spine surgery depends on the underlying disease for which the spine surgery is being done. Patients with spinal cord injury usually require continuous physiotherapy for many months. For patients of degenerative spine disorders like disc disease, there is no special need for physiotherapy. Patients are usually taught exercises when they are in house. They just need to continue with these exercises.
Spinal fusion usually takes 3 months to heal internally i.e. it takes three months for the new bone to form. Similarly, after microscopic discectomies, the annular tears usually take 3 months to heal. Therefor, we advise our patients to take life coolly for 3 months, avoid ground level activities like sitting on ground crosslegged , avoid squatting, avoid household work needing too much of twisting the spine and playing sports.
Patients can resume light work after 3 to 6 weeks of surgery. Patient needs to wait for 3 months before starting heavy manual work.
Patients can start driving for short distances 3 weeks after surgery. Long drives should be avoided for 3 months after surgery.
Scoliosis is abnormal bending of spine in the coronal plane (Anteroposterior plane). Kyphosis is abnormal bending of spine when viewed from one side i.e. lateral aspect or sagittal plane. Both scoliosis and kyphosis can coexist.
Treatment : We measure the angle of scoliosis (Cobb’s angle) on standing xrays. Only observation is done if angle is less than 25 degrees. Bracing ( Corrective Spinal brace to be worn for 16 hours a day) is done for 25 to 40 degrees of curve. Surgery is absolutely necessary for curves greater than 50 degrees. Surgery is considered for curves of 40 to 50 degrees, if the scoliosis is getting worse with time.
IF PRESSURE ON A NERVE OR SPINAL CORD PERSISTS FOR LONG PERIOD OF TIME, THEN THE CHANCE OF COMPLETE RECOVERY AFTER SURGERY BECOMES LESS AND LESS. THEREFORE IF A PATIENT IS HAVING PROGRESSIVE WEAKNESS OR NUMBNESS IN LEGS OR ARMS, HE/SHE SHOULD NOT DELAY THE SURGERY FOR LONG. ALSO, IF PATIENT IS HAVING SPINAL INSTABILITY BECAUSE OF CANCER, INFECTIONS OR TUMOURS, THIS MAY NEED MUCH URGENT ATTENTION
Whenever there is spinal instability or deformity of spine, or there is potential for causing spinal instability by doing decompression surgery, surgeons usually resort to spinal fusion to give the best possible result to their patients
Stages of degeneration:
The degenerative process has been divided into three separate stages with relatively distinct findings.
1) The first stage is dysfunction, which is seen in individuals 15 to 45 years old. It is characterized by circumferential and radial tears in the disc anulus and localized synovitis of the facet joints.
2) Second stage stage is instability. This stage, found in 35- to 70-year- old patients, is characterized by internal disruption of the disc, progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation, and joint erosion.
3) The final stage, present in patients older than 60 years, is stabilization. In this stage, the progressive development of hypertrophic bone around the disc and facet joints leads to segmental stiffening or frank ankylosis.
Each spinal segment degenerates at a different rate. As one level is in the dysfunction stage, another may be entering the stabilization stage. Disc herniation in this scheme is considered a complication of disc degeneration in the dysfunction and instability stages. Spinal stenosis from degenerative arthritis in this scheme is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages.
Radiologically a 4-mm collapse of the disc produces sufficient narrowing of the foramen to threaten the nerve.
Prognosis and treatment : Long-term follow-up studies of lumbar disc herniations documented several principles, the foremost being that generally symptomatic lumbar disc herniation (which is only one of the consequences of disc degeneration) has a favorable outcome in most patients. The primary benefit of surgery was early on in the first year, but that with time the statistical significance of the improvement was lost. The judicious use of epidural steroids also is supported. Nonprogressive neurological deficits (except cauda equina syndrome) ca
n be treated nonoperatively with expected improvement clinically. If surgery is necessary, it usually can be delayed 6 to 12 weeks to allow adequate opportunity for improvement. Some patients are best treated surgically for lumbar disc herniation. Similar principles are valid regarding cervical disc herniations, which also generally can be treated nonoperatively. The important exception is a patient with cervical myelopathy, who is best treated surgically.
The natural history of degenerative disc disease is one of recurrent episodes of pain followed by periods of significant or complete relief. The memory of painful low back episodes was short.
Before a discussion of diagnostic studies, axial spine pain with radiation to one or more extremities must be considered. It is doubtful if there is any other area of orthopaedics in which accurate diagnosis is as difficult or the proper treatment as challenging as in patients with persistent neck and arm or low back and leg pain. Surgical treatment can benefit a patient if it corrects a deformity, corrects instability, relieves neural compression, or treats a combination of these problems. Obtaining a history and completing a physical examination to determine a diagnosis that should be supported by other diagnostic studies is a useful approach; conversely, matching the diagnosis and treatment to the results of diagnostic studies, as often can be done in other subspecialties of orthopaedics (e.g., treating extremity pain based on a radiograph that shows a fracture), is fraught with difficulty.
most patients with nonspecific complaints and findings are best treated by physiotherapy. For patients with significant findings, evaluation and treatment by a specialist is appropriate. For a few patients (although they are responsible for a much more significant portion of health care use), a multidisciplinary approach is best.
The primary indications for operative treatment of cervical disc disease are
(1) failure of nonoperative pain management.
(2) increasing and significant neurological deficit.
(3) cervical myelopathy.
In most patients, the persistence of pain is the primary indication. The intensity of the persistent pain should be severe enough to interfere consistently with the patient's desired activity and greater than would reasonably be expected after operative treatment. The approach chosen should be determined by the location and type of lesion. Soft lateral discs are easily removed with the posterior (back) approach, whereas soft central or hard discs (central or lateral) probably are best treated with an anterior (front) approach. Osteophytes that were not removed at surgery frequently have been shown to be reabsorbed at the level of fusion. The use of a graft also prevents the collapse of the disc space and maintains adequate foraminal size.
AFTER TREATMENT Neurological function is closely monitored after surgery. Discharge is permitted when the patient is ambulatory, which usually is the same day as surgery. Pain should be controlled with oral medication. Radicular pain relief usually is dramatic and prompt, although hypesthesia can persist for weeks or months. The patient is allowed to return to clerical work when comfortable and to manual labor after 6 weeks. As a rule, neither support nor physical therapy is necessary, and the patient's future activity is not restricted. Isometric neck exercises, upper extremity range-of- motion exercises, and posterior shoulder girdle exercises can be useful for patients in whom atrophy or inactivity has been considerable. A soft cervical collar can help relieve immediate postoperative pain. Results Operations in cervical surgery are the results better than after the removal of a lateral herniated cervical disc. Mostly patients recover completely but in some cases neurodeficit persist . few patients continued to have arm pain after operation which settle over time. One patient had a recurrent extrusion at the same level. Two other patients had soft extrusions on the opposite side at another level, also requiring a second operation. Approximately 90% had extremely good results.
The number and variety of nonoperative therapies for back and leg pain are diverse and overwhelming. Treatments range from simple rest to expensive traction apparatus. All of these therapies are reported with glowing accounts of miraculous “cures”; few have been evaluated scientifically. In addition, the natural history of lumbar disc herniation is characterized by exacerbations and remissions with eventual improvement of extremity complaints in most cases. Finally, several distinct symptom complexes seem to be associated with disc disease. Few, if any, studies have isolated the response to specific and anatomically distinct diagnoses.
The simplest treatment for acute back pain is rest. 2 days of bed rest were better than a longer period. Biomechanical studies indicate that lying in a semi-Fowler position (i.e., on the side with the hips and knees flexed) with a pillow between the legs should relieve most pressure on the disc and nerve roots. Muscle spasm can be controlled by the application of ice, preferably with a massage over the muscles in spasm. Pain relief and antiinflammatory effect can be achieved with nonsteroidal antiinflammatory drugs (NSAIDs). Most acute exacerbations of back pain respond quickly to this therapy. As the pain diminishes, the patient should be encouraged to begin isometric abdominal and lower extremity exercises. Walking within the limits of comfort also is encouraged. Sitting, especially riding in a car, is discouraged.
Numerous medications have been used with various results in subacute and chronic back and leg pain syndromes. The current trend seems to be moving away from the use of strong narcotics and muscle relaxants in the outpatient treatment of these syndromes. This is especially true in the instances of chronic back and leg pain where drug habituation and increased depression are frequent. Oral steroids used briefly can be beneficial as potent antiinflammatory agents. The many types of NSAIDs also are helpful when aspirin is not tolerated or is of little help. Numerous NSAIDs are available for the treatment of low back pain. When depression is prominent, mood elevators such as nortriptyline can be beneficial in reducing sleep disturbance and anxiety without increasing depression. Nortriptyline also decreases the need for narcotic medication. Physical therapy should be used judiciously. The exercises should be fitted to the symptoms and not forced as an absolute group of activities. Patients with acute back and thigh pain eased by passive extension of the spine in the prone position can benefit from extension exercises rather than flexion exercises. Improvement in symptoms with extension indicates a good prognosis with conservative care. Patients whose pain is increased by passive extension may be improved by flexion exercises. These exercises should not be forced in the face of increased pain. This may avoid further disc extrusion. Any exercise that increases pain should be discontinued. Lower extremity exercises can increase strength and relieve stress on the back, but they also can exacerbate lower extremity arthritis. The true benefit of such treatments may be in the promotion of good posture and body mechanics rather than of strength. Hansen et al. compared intensive, dynamic back muscle exercises, conventional physiotherapy (manual traction, flexibility, isometric and coordination exercises, and ergonomics counseling), and placebo-control treatment in a randomized, observer blind trial. Regardless of the method used, patients who completed therapy reported a decrease in pain. Physiotherapy seemed to have better results in men, however, and intensive back exercises gave better results in women. Patients with strenuous physical occupations responded better to physiotherapy, whereas patients with sedentary occupations responded better to intensive back exercises.
Numerous treatment methods have been advanced for the treatment of back pain. Some patients respond to the use of transcutaneous electrical nerve stimulation. Others do well with traction varying from skin traction in bed with 5 to 8 lb to body inversion with forces of more than 100 lb. Back braces or corsets may be helpful to other patients. Ultrasound and diathermy are other treatments used in acute back pain. The scientific efficacy of many of these treatments has not been proved.
Although symptoms may arise from narrowing of the spinal canal, not all patients with narrowing develop symptoms. In general, the natural history of most forms of spinal stenosis is the insidious development of symptoms. Occasionally, there can be an acute onset of symptoms precipitated by trauma or heavy activity. Many patients have significant radiographic findings with minimal complaints or physical findings. 50% of patients treated nonoperatively reported improved back and leg pain after 8 to 10 years. Pain relief was noted after 3 months in most patients regardless of treatment, but took 12 months in a few patients. Results in conservatively treated patients deteriorated over time, however, and at 4 years were excellent or fair in 50% of patients treated nonoperatively; 80% of patients treated operatively still had good results. Results were not worse if surgery was done 3 years after failed conservative treatment, and significant deterioration did not occur during the 6 years of follow-up in any of the three groups of patients. Predictors of poor outcomes could not be identified. These authors concluded that conservative treatment is appropriate for patients with moderate pain, 50% of whom have pain relief in less than 3 months, but operative treatment probably is indicated for patients with severe pain and patients in whom conservative treatment fails.
Reported studies suggest that for most patients with spinal stenosis, a stable course can be predicted, with 15% to 50% showing some improvement with nonoperative treatment. Worsening of symptoms despite adequate conservative treatment is an indication for operative treatment.
back pain and sciatica is present in 95% and claudication present in 91% of patients. Sensory disturbance in the legs was present in 70%, motor weakness was present in 33%, and voiding disturbance was present in only 12% of patients. Despite the coexistent symptoms, back pain had been present for a median duration of 14 years and sciatica for a median duration of 2 years before presentation. Bilateral leg complaints were present in 42%, and unilateral leg symptoms were present in the other 58%. Distribution of symptoms was L5 in 91%, S1 in 63%, L1-4 in 28%, and S2-5 in 5%. 47% had symptoms specific for two nerve roots, and 35% had monoradiculopathy. Three-level and four-level radicular complaints were recorded in 17% and 1%, respectively. In patients with central spinal stenosis, symptoms usually are bilateral and involve the buttocks and posterior thighs in a nondermatomal distribution. With lateral recess stenosis, symptoms usually are dermatomal because they are related to a specific nerve being compressed. Patients with lateral recess stenosis may have more pain during rest and at night, but more walking tolerance than patients with central stenosis.
Vascular symptoms typically are felt in the upper calf, are relieved after a short rest (5 minutes) while still standing, do not require sitting or bending, and worsen despite walking uphill or riding a stationary bicycle. Neurogenic claudication improves with trunk flexion, stooping, or lying, but may require 20 minutes to improve. Patients often report better endurance walking uphill or up steps and tolerate riding a bicycle better than walking on a treadmill because of the flexed posture that occurs. Pushing a grocery cart also allows spinal flexion, which enhances endurance in most patients with neurogenic claudication. The gait and posture after walking may reveal a positive “stoop test.” This test is done by asking the patient to walk briskly. As the pain intensifies, the patient may complain of sensory symptoms followed by motor symptoms. If the patient is asked to continue to walk, he or she may assume a stooped posture, and the symptoms may be eased, or if the patient sits in a chair bent forward, the same resolution of symptoms occurs.
Magnetic Resonance Imaging
Investigators have found abnormal findings in 67% of asymptomatic patients evaluated by MRI. In patients older than 60 years, 57% of MRI scans were abnormal, including 36% of patients with herniated nucleus pulposus and 21% with spinal stenosis. MRI is helpful in identifying other disease processes, such as tumors and infections, and is a good noninvasive study for patients with persistent lower extremity complaints after radiographic screening evaluation. MRI should be confirmatory in patients with a consistent history of neurogenic claudication or radiculopathy, but it should not be used as a screening examination because of the high rate of asymptomatic disease. Sagittal T2-weighted images are a good starting point because they give a myelogram-like image. Sagittal T1-weighted images are evaluated with particular attention focused on the foramen. An absence of normal fat around the root indicates foraminal stenosis. Axial images provide a good view of the central spinal canal and its contents on T1- and T2-weighted images. Far-lateral disc protrusions are identified on axial T1-weighted images by obliteration of the normal interval of fat between the disc and nerve root . The foraminal zone is better evaluated with sagittal T1-weighted sequences, which confirm the presence of fat around the nerve root. Spinal deformity, including scoliosis and significant spondylolisthesis, can result in suboptimal imaging by MRI. This is secondary to the curvature of the spine in and out of the plane of the scanner on sagittal sequences and difficulty obtaining true axial cuts. Another disadvantage of MRI is the cost; nonetheless, MRI has become a useful, noninvasive diagnostic tool for the evaluation of patients with extremity complaints.
Symptoms of spinal stenosis usually respond favorably to nonoperative management. Despite symptoms of back pain, radiculopathy, or neurogenic claudication, conservative management is successful in most patients. Conservative measures should include rest not exceeding 2 days, pain management with antiinflammatory medications or acetaminophen, and participation in a trunk-stabilization exercise program, along with good aerobic fitness. Other methods should be reserved for patients who are limited by pain and should be used to maximize participation in the exercise program. Traction has no proven benefit in the adult lumbar spine. For a patient with unremitting symptoms of radiculopathy or neurogenic claudication, epidural steroid injections may be useful in alleviating symptoms to allow better participation in physical therapy. Epidural steroids can give significant symptomatic relief, although no scientific study has documented long-term efficacy. If spinal stenosis is present with coexistent degenerative arthritis in the hips or knees, some permanent limitation in activity may be necessary regardless of treatment.
All had spinal stenosis documented by CT or MRI and symptoms of disabling back, buttock, or leg pain. Except for a few patients with acute neurological changes who initially were prescribed 1 to 2 weeks of bed rest, patients were given one course of oral corticosteroids on a 7-day tapered schedule. An epidural steroid injection was given if symptoms persisted, with a repeat injection given if necessary by the transforaminal route at the point of most severe constriction. A third injection was administered only at the treating physician's discretion, usually for flare-ups during follow-up. For less severe symptoms, nonsteroidal antiinflammatory medications were used for 4 to 6 weeks, and this occasionally was repeated. All patients participated in physical therapy that included postural exercises, gentle lumbopelvic mobilization exercises, and a daily flexion lumbar stabilization program. Sustained improvement was reported in 24% and mild improvement in 28%, with 13% definitely worse. Regarding walking, 40% reported improvement, 35% reported no change, and 25% reported worsening at final follow-up.
Epidural Steroid Injection
Spinal stenosis and the resultant mechanical compression of neural elements can cause structural and chemical injury to the nerve roots. Edema and venous congestion of the nerve roots can lead to further compression and ischemic neuritis. This may result in the leakage of neurotoxins, such as phospholipase and leukotriene B, which can lead to increased inflammation and edema. Corticosteroids are potent antiinflammatory medications and result in a decrease in leukocyte migration, the inhibition of cytokines, and membrane stabilization. These actions coupled with their ability to reduce edema provide the rationale for the use of epidural steroid injections in spinal stenosis. Although epidural steroid injections have been used in the treatment of spinal stenosis for many years, no scientifically validated long-term outcomes have been reported to substantiate their use, and most prospective reports show no statistically significant benefit. A meta-analysis showed that epidural steroids have little short-term advantage over placebo for the treatment of leg pain. Studies also are divided on the long-term results and the avoidance of surgery.
Accurate placement of translaminar injections seems to be equally difficult, with successful placement reported in 70%. Complications are infrequent but can occur and include hypercorticism, epidural hematoma, temporary paralysis, retinal hemorrhage, epidural abscess, chemical meningitis, and intracranial air. The ideal candidate for epidural steroid injection seems to be a patient who has acute radicular symptoms or neurogenic claudication unresponsive to traditional analgesics and rest, with significant impairment in activities of daily living. We have used this technique successfully in our treatment algorithm for neurogenic claudication and radiculopathy.
The primary indication for surgery in patients with spinal stenosis is increasing pain that is resistant to conservative measures. Because the primary complaint often is back pain and some leg pain, pain relief after surgery may not be complete. Most series report a 64% to 91% rate of improvement, with 42% in patients with diabetes, but most patients still have some minor complaints, usually referable to the preexisting degenerative arthritis of the spine. Neurological findings, if present, improve inconsistently after surgery. normally 30% had complete improvement in motor symptoms after laminectomy, with 58% regaining grade 4 strength or better at a mean follow-up of 3 years. Reoperation rates vary from 6% to 23%. Prognostic factors include better results with a disc herniation, stenosis at a single level, weakness of less than 6 weeks' duration, monoradiculopathy, and age younger than 65 years. Reversal of neurological consequences of spinal stenosis seems to be a relative indication for surgery unless the symptoms are acute.
A patient's inability to tolerate the restricted lifestyle necessitated by the disease and the failure of a good conservative treatment regimen should be the primary determining factors for surgery in a well-informed patient. The patient should understand the potential for the operation to fail to relieve pain or to worsen it, especially in regard to the axial component of the symptoms. In addition to the general risks of spinal surgery, the severity of symptoms and lifestyle modifications should be considered. Lumbar spinal stenosis does not result in paralysis, only decreased ambulatory capacity, and conservative management is warranted indefinitely in a patient with good function and manageable symptoms. Cervical and thoracic spinal stenoses are associated with painless paralysis in the form of cervical and thoracic myelopathy and require closer attention and follow-up.
The facet joint can be a source of back pain; the exact cause of the pain is unknown. Theories include meniscoid entrapment and extrapment, synovial impingement, chondromalacia facetae, capsular and synovial inflammation, and mechanical injury to the joint capsule. Osteoarthritis is another cause of facet joint pain; however, the incidence of facet joint arthropathy is equal in symptomatic and asymptomatic patients. As with other osteoarthritic joints, radiographic changes correlate poorly with pain.
Although the history and physical examination may suggest that the facet joint is the cause of spine pain, no noninvasive pathognomonic findings distinguish facet joint–mediated pain from other sources of spine pain. Fluoroscopically guided facet joint injections are commonly considered the “gold standard” for isolating or excluding the facet joint as a source of spine or extremity pain.
Clinical suspicion of facet joint pain by a spine specialist remains the major indicator for diagnostic injection, which should be done only in patients who have had pain for more than 4 weeks and only after appropriate conservative measures have failed to provide relief. Facet joint injection procedures may help to focus treatment on a specific spinal segment and provide adequate pain relief to allow progression in therapy. Either intraarticular or medial branch blocks can be used for diagnostic purposes. The only controlled study on the use of intraarticular corticosteroids in the cervical spine found no added benefit from intraarticular betamethasone over bupivacaine.
Epidural injections in the cervical, thoracic, and lumbosacral spine were developed to diagnose and treat spinal pain. Information obtained from epidural injections can be helpful in confirming pain generators that are responsible for a patient's discomfort. Structural abnormalities do not always cause pain, and diagnostic injections can help to correlate abnormalities seen on imaging studies with associated pain complaints. In addition, epidural injections can provide pain relief during the recovery of disc or nerve root injuries and allow patients to increase their level of physical activity. Because severe pain from an acute disc injury with or without radiculopathy often is time limited, therapeutic injections help to manage pain and may alleviate or decrease the need for oral analgesics.
The efficacy of epidural injections is not reliably known because of the lack of well- controlled studies. Kepes and Duncalf calculated the average favorable response rate obtained with lumbar epidural steroid injections to be 60%, whereas White calculated the favorable response rate to be 75%. Several studies reported the usefulness of transforaminal epidural corticosteroid injections (selective epidural or selective nerve root block) to identify or confirm a specific nerve root as a pain generator when the diagnosis is unclear based on clinical evidence.
Risks associated with the procedure:
Few serious complications occur in patients receiving epidural corticosteroid injections; however, epidural abscess, epidural hematoma, durocutaneous fistula, and Cushing syndrome have been reported as individual case reports. The most adverse immediate reaction during an epidural injection is a vasovagal reaction. Dural puncture has been estimated to occur in 0.5% to 5% of patients having cervical or lumbar epidural steroid injections. The anesthesiology literature reported a 7.5% to 75% incidence of postdural puncture (positional) headaches, with the highest estimates associated with the use of 16-gauge and 18-gauge needles. Headache without dural puncture has been estimated to occur in 2% and is attributed to air injected into the epidural space, increased intrathecal pressure from fluid around the dural sac, and possibly an undetected dural puncture. Some minor, common complaints caused by corticosteroid injected into the epidural space include nonpositional headaches, facial flushing, insomnia, low-grade fever, and transient increased back or lower extremity pain. Epidural corticosteroid injections are contraindicated in the presence of infection at the injection site, systemic infection, bleeding diathesis, uncontrolled diabetes mellitus, and congestive heart failure.
How is it given:
We do epidural corticosteroid injections in a fluoroscopy suite equipped with resuscitative and monitoring equipment. Intravenous access is established in all patients with a 20-gauge angiocatheter placed in the upper extremity. Mild sedation is achieved through intravenous access. We recommend the use of fluoroscopy for diagnostic and therapeutic epidural injections for several reasons. Epidural injections performed without fluoroscopic guidance are not always made into the epidural space or the intended interspace. Even in experienced hands, needle misplacement occurs in 40% of caudal and 30% of lumbar epidural injections when done without fluoroscopic guidance. Accidental intravascular injections also can occur, and the absence of blood return with needle aspiration before injection is an unreliable indicator of this complication. In the presence of anatomical anomalies, such as a midline epidural septum or multiple separate epidural compartments, the desired flow of epidural injectants to the presumed pain generator is restricted and remains undetected without fluoroscopy. In addition, if an injection fails to relieve pain, it would be impossible without fluoroscopy to determine whether the failure was caused by a genuine poor response or by improper needle placement.
When should be given:
Cervical epidural steroid injections have been used with some success to treat cervical spondylosis associated with acute disc disruption and radiculopathies, cervical strain syndromes with associated myofascial pain, postlaminectomy cervical pain, reflex sympathetic dystrophy, postherpetic neuralgia, acute viral brachial plexitis, and muscle contraction headaches.
The best results with cervical epidural steroid injections have been in patients with acute disc herniations or well-defined radicular symptoms and in patients with limited myofascial pain. At this time, we do not do cervical transforaminal injections. Of greatest concern are the increasing case reports involving injury to the spinal cord and brainstem after cervical transforaminal injections. These injuries are the result of intraarterial injection into either a reinforcing radicular artery or the vertebral artery, the latter of which is the most common basis of complication. Injection into a radicular artery is an unavoidable complication, but one that can be recognized by using real-time monitoring of a test dose of contrast medium. In the case of intraarterial injection, the procedure should be aborted to avoid injury to the spinal cord.
Herniation of the cervical intervertebral disc with spinal cord compression has been identified since Key detailed the pathological findings of two cases of cord compression by “intervertebral substance” in 1838. Mixter and Barr reported lumbar disc herniation in 1934 and included four cervical disc protrusions.
In an epidemiological study of cervical disc rupture, it was more common in men by a ratio of 1.4 : 1. Factors associated with the injury were frequent heavy lifting on the job, cigarette smoking, and frequent diving from a board. The use of vibrating equipment and time spent in motor vehicles were not positively associated with this problem. Studies reported that 40% of people in Sweden were sometimes affected by neck pain during their lives. Patients with cervical disc disease also are likely to have lumbar disc disease. MRI has shown increasing cervical disc degeneration with age.
Cause of pain: The pathophysiology of cervical disc disease is the same as degenerative disc disease in other areas of the spine. Physiological changes in the nucleus are followed by progressive annular degeneration. Frank extrusion of nuclear material can occur as a complication of this normal degenerative process. Studies postulated that hydraulic pressure on the disc rather than excessive motion produces traumatic disc herniation. As the disc degeneration proceeds, hypermobility of the segment can result in instability or degenerative arthritic changes or both. In contrast to those in the lumbar spine, these hypertrophic changes are predominantly at the uncovertebral joint (uncinate process). Hypertrophic changes eventually develop around the facet joints and vertebral bodies. As in lumbar disease, progressive stiffening of the cervical spine and loss of motion are the usual result in the end stages. Hypertrophic spurring anteriorly occasionally results in dysphagia. Studies identified the production of increased amounts of matrix metalloproteinases, nitric oxide, prostaglandin E 2 , and interleukin-6 in disc material removed from cervical disc hernias. They suggested that these products are involved in the biochemistry of disc degeneration. These substances also are implicated in pain production. These findings are similar to findings in the lumbar spine. Error! Filename not specified.
The classic approach to discs in this region has been posteriorly (from the back) with laminectomy. Surgery showed that simple anterior disc excision without fusion can give results similar to anterior cervical disc excision with anterior interbody fusion. More recently, Yamamoto et al. reported the long-term (2 to 13 years) results of anterior cervical disc excision without fusion. They noted 81% improvement in patients with soft disc hernias, but only 47% improvement in patients with spondylosis; 49% had neck and scapular pain as new postoperative symptoms for the first 4 weeks after surgery . Spontaneous fusion was noted in 79% at 29 months. Currently, anterior cervical discectomy with fusion is the procedure of choice when the disc is removed anteriorly to avoid disc space collapse, prevent painful and abnormal cervical motion, and speed intervertebral fusion. Foraminotomy is the procedure of choice when the disc fragment can be removed posteriorly.
Signs and Symptoms
The signs and symptoms of intervertebral disc disease are best separated into symptoms related to the spine itself, symptoms related to nerve root compression, and symptoms of myelopathy.
Several authors reported that when the disc is punctured anteriorly for the purpose of discography, pain is noted in the neck and shoulder. Complaints of neck pain, medial scapular pain, and shoulder pain are probably related to primary pain around the disc and spine. Anatomical studies have indicated cervical disc and ligamentous innervations. This has been inferred to be similar in the cervical spine to that of the lumbar spine with its sinu- vertebral nerve. Tamura noted cranial symptoms, such as headache, vertigo, tinnitus, and ocular problems, associated with C3-4 root sleeve defects on myelography.
Symptoms of root compression usually are associated with pain radiating into the arm or chest with numbness in the fingers and motor weakness. Cervical disc disease also can mimic cardiac disease with chest and arm pain. Usually the radicular symptoms are intermittent and combined with more frequent neck and shoulder pain.
The signs of midline cervical spinal cord compression (myelopathy) are unique and varied. The pain is poorly localized and aching in nature; pain may be only a minor complaint. Occasional sharp pain or generalized tingling may be described with neck extension. The pain can be in the shoulder and pelvic girdles; it is occasionally associated with a generalized feeling of weakness in the lower extremities and a feeling of instability.
In patients with predominant cervical spondylosis, symptoms of vertebral artery compression also may be found, including dizziness, tinnitus, intermittent blurring of vision, and occasional episodes of retroocular pain. The signs of lateral root pressure from a disc or osteophytes are predominantly neurological . By evaluating multiple motor groups, multiple levels of deep tendon reflexes, and sensory abnormalities, the level of the lesion can be localized as accurately as any other lesion in the nervous system. The multiple innervation of muscles sometimes can lead to confusion in determining the exact root involved. For this reason, MRI or other studies done for imaging confirmation of the clinical impression usually are helpful Care should be taken in the examination of the extremity when radicular problems are encountered to rule out more distal compression syndromes in the upper extremities, such as thoracic outlet syndrome, carpal tunnel syndrome, and cubital tunnel syndrome. The lower extremities should be examined with special attention to long tract signs indicating myelopathy. Cervical paraspinal spasm and limitation of neck motion are frequent findings of cervical spine disease, but do not indicate a specific pathological process. Special maneuvers involving neck motion can be helpful in the selection of conservative treatment and identification of pathological processes. The distraction test, which involves the examiner placing the hands on the occiput and jaw and distracting the cervical spine in the neutral position, can relieve root compression pain, but also can increase pain caused by ligamentous injury. Neck extension and flexion with or without traction can be helpful in selecting conservative therapies.
Patients relieved of pain with the neck extended, with or without traction, usually have hyperextension syndromes with ligamentous injury posteriorly, whereas patients relieved of pain with distraction and neck flexion are more likely to have nerve root compression caused by a soft ruptured disc or more likely hypertrophic spurs in the neural foramina. Pain usually is increased in any condition with compression.
The signs of midline disc herniation are those of spinal cord compression. If the lesion is high in the cervical region, paresthesias, weakness, atrophy, and occasionally fasciculations may occur in the hands. A Hoffman sign (upper cervical spinal cord) or the inverted radial reflex (typically indicating C5-6 pathology) also may be present.
The differential diagnosis of cervical disc disease is best separated into extrinsic and intrinsic factors. Extrinsic factors generally include disease processes extrinsic to the neck resulting in symptoms similar to primary neck problems. Included in this group are tumors of the chest; nerve compression syndromes distal to the spine; degenerative processes, such as shoulder and upper extremity arthritis; temporomandibular joint syndrome; and lesions around the shoulder, such as acute and chronic rotator cuff tears and impingement syndromes. Intrinsic problems primarily consist of lesions directly associated with the cervical spine, the most common being cervical disc degeneration with concomitant disc herniation or later development of hypertrophic arthritis. Congenital factors, such as spinal stenosis in the cervical region, also may produce symptoms. Primary and secondary tumors of the cervical spine and fractures of the cervical vertebrae also should be considered as intrinsic lesions. Cervical disc disease is devided into four groups:
(1) unilateral soft disc protrusion with nerve root compression
(2) foraminal spur, or hard disc, with nerve root compression
(3) medial soft disc protrusion with spinal cord compression
(4) transverse ridge or cervical spondylosis with spinal cord compression.
Soft disc herniations usually affect one level, whereas hard disc herniations can affect multiple levels. Central lesions usually result in cord compression symptoms, and lateral lesions usually result in radicular symptoms.
The soft disc herniations occurred at the C6 interspace (70%) , C5 interspace (24%). Only six occurred at the C7 interspace. Foraminal spurs also were found predominantly at the C6 interspace (48%). The C5 interspace (39%) and C7 interspace (13%) accounted for the remaining levels where foraminal spurs were found. Investigators also noted the incidence of medial soft disc protrusion with myelopathy to be rare (14 of 246 patients).
Radiographic evaluation of the cervical spine frequently shows loss of normal cervical lordosis. Disc space narrowing and hypertrophic changes frequently increase with age, but are not indicative of cervical disc rupture. Usually radiographs are most helpful to rule out other problems. Oblique radiographs of the cervical spine may reveal foraminal encroachment.
MRI of the cervical spine has rapidly become the major diagnostic procedure for neck, arm, and shoulder symptoms. MRI should confirm the objective clinical findings. Asymptomatic findings should be expected to increase with the age of the patient. Cervical myelography usually is indicated only after noninvasive evaluation by MRI fails to reveal the cause or level of the lesion. If MRI is inconclusive, electromyography or nerve conduction velocity may be indicated to show active radiculopathy before proceeding with myelography, especially if the history and physical examination are not strongly supportive of the presence of radiculopathy. Cervical myelography usually is more precise than lumbar myelography, regardless of the contrast medium used. Postmyelography CT with block imaging and thin cuts is very helpful.
When a component of dynamic cord compression is present, myelography remains a valuable tool, although dynamic MRI has reduced the role of myelography. Myelography is performed in the same way as for ruptured lumbar discs except that considerable attention must be paid to the flow of the column of contrast medium with the neck in hyperextended, neutral, and flexed positions. One cannot conclude that spinal cord compression is not present until one is certain that the cephalad flow of the medium is not obstructed with the neck acutely hyperextended. The neck should be hyperextended carefully because of the danger of further damage to the spinal cord. Because symptoms from cervical instability tend to be gradually progressive, they can be suggestive of spinal cord tumor, amyotrophic lateral sclerosis, posterolateral sclerosis, or multiple sclerosis. Cervical dynamic instability can be shown because the cephalad flow of contrast material is blocked between the lamina of the cephalad level and the disc or body of the caudal level. In view of the disturbances of the spinal fluid dynamics, jugular compression should be done during lumbar puncture with the cervical spine in flexed, neutral, and hyperextended positions.
Axial back/lumbar pain occurs at some point in the lives of most people. Appropriate treatment for what can be at times excruciating pain generally should begin with evaluation for significant spinal pathology. This pathology being absent, a brief (1 to 3 days) period of bed rest with institution of an antiinflammatory regimen and rapid progression to an active exercise regimen with an anticipated return to full activity should be expected and encouraged. Generally, patients treated in this manner improve significantly in 4 to 8 weeks. Diagnostic studies, including radiographs, often are unnecessary because they add little information. More sophisticated imaging with CT scans and MRI or other studies have even less utility initially. An overdependence on the diagnosis of disc herniation occurred with early use of these diagnostic studies, which show disc herniations in 20% to 36% of normal volunteers.