Composition of Spine
The Spine is composed of smaller bones called vertebrae. At birth the total number of vertebrae is generally 33 and it is reduced to 26 after attaining adulthood because of fusion of some vertebrae. The various vertebrae are stacked one above the other and the last one on two other bones thus 24 vertebrae and 2 other bones totaling 26. The spine is connected to the skull on the top and shoulders, ribs and pelvis along its length. The spine provides the axis of the human skeleton.
- The Cervical Spine- The neck region and has 7 vertebrae.
- The Thoracic Spine-the upper back area having 12 vertebrae.
- The Lumbar Spine-The lower back area and has 5 larger vertebrae.
- The Base- Comprises of the fused Sacrum and the fused tailbone (Coccyx).
The vertebrae are ring-shaped with the thicker part of the ring facing the front of the body. Each vertebra is separated by an inter-vertebral thick disc made of cartilage. These discs act as shock absorbers for the spine and cushion everyday stresses preventing trauma. The spinal cord- the thick nerve cord, originates from the brain and passes through the spinal canal formed by the vertebrae and the nerve roots pass out through the vertebrae.
Two prominent forward curvatures in the spine in the thoracic and sacral regions are compensated by backward curvatures in the cervical and lumbar vertebrae. These curves make the spine resilient and flexible.
Cervical spine has the maximum range of motion and the lumbar spine bears a lot of weight. This makes both these portions more prone to injury and trauma.
The spine is affected by diseases related to the spine and even other organs of the body resulting in pain and disability. Almost everyone suffers from some form of pain or the other in the spinal region during their lifetime. Generally spinal conditions improve with rest, physiotherapy, OTC or prescribed medications and injection therapy.
Surgery performed on the spinal cord or near the spine is called spine surgery. It is resorted to for alleviation of serious spinal ailments of the back and the neck as also for some specific conditions causing back pain.
Spine surgery will normally be performed for removing pain. There have to be changes noticed in the diagnostic tests like CAT scan and MRI to justify surgery. These changes are accompanied with pain and or weakness. Pain specialists will treat pain and conditions like spine stenosis etc. that can not be treated by conventional non-surgical methods require surgery.
Spinal surgery could be:
Conventional Spine Surgery- Open surgery with a longer incision and longer recovery period.
Arthoscopic or Endoscopic Surgery- Minimally invasive surgery requiring a small incision of 1 to 2 inches in length.
Minimally invasive surgery may not be appropriate in all cases. Spinal surgery has a posterior approach with incision in the back. Only some surgeons use an anterior approach through the abdomen and the neck.
WHAT TYPE OF ABEASTHESIA IS USED FOR SPINE SURGERY?
The type of spine surgery varies as per the underlying condition being treated. Minimally invasive surgeries may be performed under local anesthetic only because it takes lesser time with a very small incision. Conventional surgery will require general anesthesia with hospitalization and post surgery rehabilitation. Pre surgery evaluation to minimize risks and post surgery instructions for quick recovery with less pain, are conducted.
UNDER WHAT CIRCUMSTANCES IS SPINE SURGERY UNDERTAKEN?
Back pains will invariably not necessitate spine surgery. The conditions requiring surgery are:
- Spinal Cord injuries
Any damage caused to the spinal cord due to direct injury to the cord itself or indirect injury from damage to the bones and soft tissues surrounding it will generally need spine surgery. Spinal trauma caused by vehicle accidents, athletics and shallow water injuries and resulting from violent crimes are treated by surgery.
- Inter-Vertebral Disc Conditions
Vertebral discs act as cushions for the spine. The specific situations requiring surgery are:
A situation when the disc protrudes into the spinal canal and may rupture.
Degenerative Disc Disease
A condition caused by degenerative changes due to old age and or injury resulting in pain.
- Spinal Stenosis
Spinal stenosis causes narrowing of the nerve openings along the spinal canal, particularly in the lower(lumbar) back, that may cause debilitating pain. Spinal stenosis pain occurs when the cushioning discs between vertebrae shrink and affect the nerve openings, causing nevrve impingement. It may be associated with numbness, tingling or weakness in the affected area.
Various types of arthritis may necessitate spine surgery including:
Age related changes cause the breakdown of joint cartilage in people over 45 years of age causing osteoarthritis. In addition to other joints affected by it, its prevalence is noticeable in lumbar region of the spine. Surgery to affect the fusion of two bones is carried out to treat this condition. Osteoarthritis is the most common form of arthritis.
RA causes inflammation of the joints. In some cases it affects the joints in the neck eventually affecting the stability of the spine.
Degenerative changes in old age leads to bony overgrowths in the spine. These overgrowths often cause back and neck pain. Surgery may be required to treat spondylosis in some cases.
In old age or women after menopause start losing bone density. This may cause vertebral fractures requiring surgery.
An abnormal sideways curve of the spine generally in adolescents may require surgery, especially in patients still growing; the spinal curve is more than 45 degrees and further deteriorating.
- Spina Bifida
This is a congenital defect when the backbone and spinal canal do not close before birth. In some situations the spinal cord and the covering membranes may be prominently protruding out of the infant’s back. Spinal surgery is required to correct the abnormality.
A syrinx or a fluid filled cyst formed in the spinal cord enlarges over time and causes damage to the spinal cord. Surgery is carried out to drain the syrinx.
- Pinched Nerves
Nerves impinged between a bone and a ligament or between a bone and a tendon start malfunctioning. Spinal surgery helps in removing scar tissue, an inter-vertebral disc or bone spurs.
A herniated inter vertebral disc impinging upon the sciatic nerve may cause pain, weakness, numbness or tingling that affects one or both legs. In cases where the weakness in limbs deteriorates, surgery may be required. OTC drugs, physiotherapy and exercise will generally help in relieving sciatica.
Sudden jerks to the head and neck cause sever injury to the spine. Rare cases require surgery while generally the condition improves with non invasive treatments.
WHAT ARE THE TYPES OF SPINAL SURGERY AND WHAT ARE THE DISTINCT DIFFERENCES IN EACH?
Spinal surgeries are carried out to correct abnormalities / remove growths in the spine. The surgery may be minimally invasive and require only local anesthesia. Generally, spinal surgeries are carried out under general anesthesia and the patient has to stay in a hospital for a few days. Post surgery rehabilitation, physiotherapy and even occupational therapy may be required.
Some of the more common spinal surgeries include:
To remove a part or whole of the inter-vertebral disc to relieve pain caused by the herniated disc. Pecutaneous disectomy (a minor surgery) uses a small thin tube inserted through a small incision.
- Spinal Fusion
Spinal function is improved by fusing 2 or more vertebrae, by using bone grafts or devices like screws etc, affected by an injury, degenerative disease, arthritis or osteoporosis. It may decrease mobility but strengthens spinal function. Hospitalization is required for this procedure.
The lamina or arched roof of the spinal canal of the vertebra is removed to release nerve pressure by increasing the size of the spinal canal. Prtial removal of the lamina is called laminotomy. The procedure provides relief from pain.
Over age degenerative changes cause thickening of the discs or the joints leading to narrowing of the bony hole (foramen) from where nerve roots exit from the spine. Enlarging of the foramen is carried out by cutting away the blockage. The procedure widens the hole, relieves pressure on the nerve roots. The pain, numbness or weakness or pain gets relived after the procedure.
- Vertebroplasty or Kyphoplasty
Vertebral compression fractures caused by osteoporosis are treated by these minimally invasive procedures. Bone cement is injected in to the affected bone area. In kyphosis, the original height of the vertebra is restored first by using a balloon and subsequently the cementing is done. Recovery time from these is much less as compared to conventional surgery and risk of future fractures is reduced considerably..
- Radio Frequency Lesioning
A needle is inserted in to the affected tissue with the guidance of x-ray. Electric impulses are then transmitted through the needle to interrupt pain signals from the tissues. The procedure heats up the tissues area and interrupts the nerve’s transmissions temporarily- up to 12 months
Under certain conditions the spinal nerve roots are cut to relieve sever chronic pain. The procedure blocks all sensory perceptions from the area.
Patients suffering from cancer undergo this procedure to relieve them from the sensory perception of pain and temperature. Certain pain conductors in the spinal cord are disabled through this.
- Dorsal Root Entry Zone Operation
Generally patients suffering from paraplegia (paralysis below the neck region) or after amputation experience phantom limb pain. Neurons (nerve points) in the spine transmitting pain are permanently destroyed with this surgery.
- Mechanical Pump Implantation
A mechanical pump like device is surgically placed under the skin in the affected area. Patients suffering from severe pain get automatic periodic release of pain medication around the spinal cord from this device.
- Spinal Stimulator Implantation
Cases of diseases like diabetic neuropathy, sciatica etc. having severe nerve pain undergo this procedure to get a spinal cord stimulator to get relief from pain.
- Inter-Vertebral Disc Replacement
Degenerative disc disease is treated by replacing the affected disc with an artificial inter-vertebral disc to restore the separation of two adjacent vertebrae. These discs made of plastic or metals can be used to replace an entire disc, the core (nucleus pulposus) or part thereof. This procedure obviates the necessity of spinal fusion and vertebral range of movement is retained. Five years after performing the first transplants of inter-vertebral discs from humans, Chinese surgeons in 2007 reported long-term success in relieving chronic back pain due to disc degeneration. However, it may take many more years of research before such transplants are approved in the United States.
- Intra-discal Electro-thermal Therapy (IDET)
A catheter is used to insert a special needle in to the affected disc and heat is electrically transmitted to the disc to reduce inflammation. This thermal power, applied for several minutes, seals the disc wall of the bulging or cracked disc. The patient gets adequate pain relief and is not required to undergo the more invasive and limiting spinal fusion.
Like IDET a needle is first used to remove painful disc material and then heated using radiofrequency waves to relieve pain caused by mildly herniated discs. The heat applied shrinks the tissue and seals the disc wall. The procedure for inserting the needle may be repeated several times to remove the material from the herniated disc. This method of radio frequency ablation (heating) is also used to remove benign and cancerous tumors from the spinal cord area.
Spine provides axis to the body and due to its importance alternative ways are being developed to avoid limiting procedures like spinal fusion. Newer devices with better materials are being tried and tested for treating spinal stenosis and other such ailments.
WHAT ALL PRECEDES SPINAL SURGERY?
Spine surgery has certain inherent risks and the surgeon decides for surgery after exploring all other treatment options. He may prescribe:
- Diagnostic Tests
X-ray, Arthrography, CAT scan or MRI are carried out to assess the damage to the spine and to ascertain the possibility of alternative treatment options. Even injections are given to diagnose the condition (discography, selective nerve root injection).
- Surgical Risk Assessment
The surgeon collects all necessary information about the patient’s condition to decide on risks during or after surgery. The physician will:
- Gather facts about the patient’s health (past medical history and any allergies etc).
- Review results of all diagnostic tests conducted.
- Conduct a physical and a neurological examination.
- Some other specialists may be consulted to manage and stabilize the condition before, during or after surgery (Diabtologist, Nephrologist. Cardiologist etc).
Prior to surgery the surgeon will also advise the patient about preparation for the surgery. This could be:
- Procedure details
The surgeon explains specific details about the surgery and the post operative care.
Patients taking blood pressure medication and anticoagulants (medicines that reduce the blood capacity to clot) are advised about stopping the medication or reducing dosage gradually. Certain other medicines may be altogether stopped or their intake revised.
- Food and Liquid Intake
Food and liquid intake is controlled about 12 hours before the surgery is scheduled. Patients being administered general anesthesia are advised accordingly.
- Tobacco Use
Smoking is prohibited weeks or many days before surgery to reduce potential risks of surgery.
A spinal procedure even if it is the minor outpatient case, causes restrictions on the patient for sometime. Driving is strictly prohibited and arrangements are required to be made for to and fro movement of the patient.
In certain cases specialized care may be necessitated at home and the patient may be required to arrange for the same prior to surgery.
WHAT WILL I EXPERIENCE DURING SPINAL SURGERY?
The experience will vary according to the type of surgery undertaken. Some arthroscopic or minimally invasive procedures are carried out without hospitalization under local anesthesia only. The patient after such procedure goes home with certain prescribed for duration depending on the typical ailment.
More serious surgeries not only require general anesthesia being administered but also few days stay in the hospital. There may even be need for specific home care.
During the surgical incision may be made in the back or in the front of the body, in the back or neck region. One or several incisions may be made depending on the requirements of the surgery. Special instruments are used for removing the growth, disc or parts of the vertebrae. Some procedures realign or reposition portions of the spine or the nerves running through the spinal cord.
Bone grafts, bone screws or bone cement may be used to strengthen the specific portion of the spine damaged due to a fracture or degenerative changes.
WHAT INSTRUCTIONS ARE GIVEN AFTER SURGERY?
Spine surgery is a complex procedure in most cases and the success of the same is dependant to a large extent in following the post operative instructions. These help in quick healing and reducing pain and could be:
- Post Operative Devices
Some devices are necessarily used to limit pain and prevent recurrence of the problem / injury especially in cases like spinal fusion. These devices could be a brace or a collar.
- Care of bandages, sutures etc.
Sutures, staples and bandages applied after surgery may remain in place for a few days even after leaving the hospital. These may restrict some daily activities like bathing etc. The physician will require a revisit to the hospital for removing the sutures etc. and may advise frequent change of bandage or application of some medicine.
Opioids may be prescribed on need bases to relieve pain. OTC drugs (analgesics) may also be advised.
These drugs are used to prevent infection of any kind in the incision wound. Care must be taken to follow the doctor’s instructions even if you feel better after taking only part of the medicine.
- Change of dressing
Frequent- daily or alternate day- inspection of the wound may be carried out to check for any infection and apply medicine.
- Exercise and rehabilitation
The type of surgery may determine the need for physiotherapy, exercise therapy, posture and ergonomics and at times even occupational therapy.
- Sleeping posture
The physician may advice about adopting certain sleeping positions only to aid recovery and recurrence of injury. Certain positions will also help in reducing pain after the surgery.
- Lifting weights
Objects weighing more than 5- 6 kilos should not be lifted after the spine surgery. These restrictions may remain for a few weeks after surgery.
Driving an automobile is generally not allowed immediately after surgeries- at least for a few days. Even traveling in a vehicle in a sitting position may not be allowed or the duration of travel time may be specified/restricted to prevent stiffness and pain.
The physician may restrict sex for sometime after spinal surgery.
WHAT ARE THE RISKS AND BENEFITS OF SPINAL SURGERY?
Spine injury is resorted to only after other treatment options have been used and found ineffective or can not be used like in an accident case. Not all patients suffering from some type of back pain / spinal disease will require surgery. Spinal surgery in most case will provide following benefits to the patient:
- Restoration of normal alignment of the spine.
- Removal of overgrown, diseased or damaged areas (inter-vertebral discs, joints or nerves)
- Repair and protection from potentially serious complication / injury- in trauma or accident injury cases.
- Relief from pain, weakness, numbness or tingling from compressed nerves
- Spinal stabilization
Spinal cord and most of the nervous system passes through the spinal canal. These are the sensory perception instruments and receive and transmit messages to and from all parts of the body to the brain. Spinal surgery because of proximity of the important central nervous system carries potential risks. Some of these potential risks are:
Spine surgery may not provide the desired results in all cases and only temporary relief may appear with recurrence of the pain / symptoms after sometime. In some cases healing may not be proper after surgery and spinal fusion, implants or fracture may not heal. In rare cases there may be deterioration in the patient’s condition.
- Anesthesia complications
In some case the patient may develop a reaction to the drug or agent used by the anesthetist to eliminate pain and sensation during surgery. Reaction may arise to any other drug used or any known or unknown previous medical complaints that the patient may have. During pre surgery consultation patients are explained about all possible complication before, during or after spine surgery.
- Excessive blood loss
The patient may suffer unexpected bleeding during surgery due to any reason. Large blood vessels may be temporarily moved during surgery to prevent damage. Blood loss may become life-threatening in some cases.
- Formation of blood clots
After spine surgery there is possibility of increased risk of blood clots getting formed in the blood stream. These clots may travel and get lodged in certain areas causing serious medical complications. In the lungs they may block oxygen supply or in the brain a stroke may result. Anticoagulants (medications that reduce the ability of blood to clot) may be administered to reduce this risk. Walking or other activity may be advised after surgery to help prevent blood clots and deep vein thrombosis.
- Dural Tear and additional surgery
Dura mater is a small sac of tissue that covers the spinal cord and surrounding nerves. During spine surgery, a tear of this sac may occur. It is usually repaired during surgery, but an unrecognized tear may not heal properly, increasing the risk for conditions such as meningitis. Additional surgery may be necessary to repair a tear that does not heal naturally.
- Breathing disorders
The patient may suffer from lung infection after surgery due to prolonged bed rest causing pneumonia or collection of fluids in the lungs. Pleural tapping may be required in such cases. The physician may be advised to take preventive measures like taking deep breaths and sitting upright to keep the lungs working properly.
- Bacterial infection
In rare cases infection of the incision area may occur. Depending on the seriousness of the infection antibiotics may be administered for longer periods or even some form of surgery may be repeated.
- Permanent nerve or spine damage
In exceptionally rare cases the spinal cord or connecting nerves may suffer trauma / injury during surgery. This may cause some very serious conditions like sexual dysfunction or paralysis.
WHAT STEPS SHOULD BE TAKEN TO PREVENT SPINAL AILMENTS?
Adopting a healthy life style can help keeping the spine healthy. Obesity, improper posture, not being careful in daily activities and a sedentary lifestyle are preventable causes of spine disease. Spine surgery is a last resort option to treat spine conditions after other options have been explored. To keep the spine in a healthy condition following is advised:
- Regular exercise
A well planned regular exercise regime helps in maintaining the spine, joints and surrounding ligaments and muscles. Yoga, walking, stretching and weight training are all good for reducing pain and spinal pressure with increased strength and flexibility. Exercise also helps in maintaining proper weight thereby reducing unnecessary pressure on the joints due to excess body weight.
- Proper body mechanics
Adopting proper technique to perform daily activities like sitting, standing, lifting, sleeping etc. can affect spinal health significantly. Proper body mechanics may reduce pain and the need for spinal surgery.
- Proper BMI
Excess weight negatively affects the bones and joints of the spine and back area by exerting undue pressure. Keeping the Body Mass Index at manageable levels may reduce the risk of spinal complications requiring surgery.
- Avoiding Trauma / Injury
Practicing safety habits such as wearing seatbelts and not diving in shallow water can reduce the risk of injuries that may require spinal surgery.
WHAT ARE THE BASIC DIFFERENCES IN VERTEBROPLASTY AND KYPHOPLASTY?
Both procedures are minimally invasive and used to treat pain caused by fractures due to osteoporosis. Vertebral fractures cause limited mobility, reduced height, stooped posture, reduced breathing capacity and back pain due to kyphosis or an exaggerated forward curve in the upper portion of the back.
Both procedure entail insertion of a special needle through a catheter in to the damaged vertebra. A special cement-like material is injected into a collapsed vertebra with bone cement. The cement fills hollow spaces and cracks in the bone and solidifies the pieces into one hard structure. This stabilizes and strengthens the area, reducing or eliminating a patient’s pain and improving mobility. The cement used in a vertebroplasty is generally less dense (more runny) than that used in kyphoplasty. This allows easier diffusion of the material, allowing it to get into all areas around the crushed bones. The cement essentially forms an internal cast, stabilizing fractured bones.
Kyphoplasty is similar, but before the cement is injected, a un-inflated balloon-like device is introduced into the areathrough the same catheter and inflated within the damaged vertebra. This helps to restore the height of the damaged vertebra. How much height can be restored may depend on the age of the fracture. The balloon is then removed and the cavity is filled with the cement. The advantage of kyphoplasty over vertebroplasty is that it can restore vertebral height, helping a patient to regain lost height and/or lessen spinal deformity due to the compression fracture.
Vertebroplasty is conducted on patients with vertebral compression fractures who are experiencing while Kyphoplasty is for patients who also have spinal deformities such as a significantly stooped posture or kyphosis.
Vertebroplasty and kyphoplasty are most often performed as outpatient procedures. The procedure can take a few hours, before a patient is allowed to leave the healthcare facility. Many patients experience immediate pain relief. Follow-up spinal x-rays are usually performed to check the status of the repaired and neighboring vertebrae.
WHAT IS A VERTEBRAL COMPRESSION FRACTURE?
A compression fracture occurs when weakened vertebrae break and collapse. This crushing of bone tissue causes the affected vertebrae to be shorter than others, and puts additional pressure on other vertebrae. When the front of the vertebrae collapse, the length of the spine gets reduced and the spine falls forward. The vertebrae in the chest area and lower spine tend to be most affected by compression fractures.
Vertebral compression fractures usually result from the loss of bone mass and density due to osteoporosis. As osteoporosis progresses, the weight of the head, neck and chest may be enough to cause the bones in the back to fracture during daily activities, such as getting out of a car or turning over in bed. Other possible causes of vertebral compression fractures include tumors and physical trauma to the spine.
Vertebral compression fractures can have varying signs and symptoms. A patient may experience acute back pain. The pain is likely to be worse when standing due to added pressure on the vertebrae. In addition, touching the area can cause pain. Other possible indicators of vertebral fractures include limited mobility, a reduction in the patient’s height, stooped posture, kyphosis (exaggerated forward curve in the upper back) and reduced breathing capability. If the vertebral compression fracture puts pressure on the nerves, it may also cause leg pain. Pressure on the lungs can cause breathing problems.
Vertebroplasty is often recommended for patients with vertebral compression fractures who are experiencing pain that is not responsive to conservative treatment methods. Kyphoplasty is usually reserved for patients who also have spinal deformities such as a significantly stooped posture or kyphosis.
WHAT ARE THE BENEFITS AND RISKS OF VERTEBROPLASTY AND KYPHOPLASTY?
Vertebroplasty and kyphoplasty procedures are basically conducted to relieve back pain, there is no guarantee, however, that they will reduce or eliminate the pain. Patients may no longer be required to take pain medication and may experience a return of lost mobility. A kyphoplasty may also help restore a patient’s height or lessen spinal deformities due to vertebral compression fractures.
Both procedures are generally safe from any complications, but like any other medical procedure, certain inherent risks exist, which may be:
- Cement leakage
If the cement-like material leaks outside the area repaired, it may irritate nerves and cause pain. If the material gets into the spinal canal, it may require an additional procedure to protect the nerves. Cement leakage is more likely during a vertebroplasty due to the less dense (runnier) nature of the cement used.
- Blood loss
Bleeding may occur if a blood vessel is punctured during the procedure. This may occur during either procedure.
- Formation of blood clots
During a vertebroplasty, there is a risk that the cement may get into the bloodstream and create a blockage. This can take the form of a potentially fatal pulmonary embolism that compromises a patient’s ability to breathe. However, this complication is rare.
- Reaction to fusion cement
Pain and fever may appear due to body’s reaction to the cement used during the procedures. Pain and fever may also occur for several hours after the procedure due to heat generated by the cement curing process.
- Additional fractures
The old existing osteoporosis may cause fractures in the adjoining vertebrae that are at a higher risk after the fusion. Fractures may also occur due to any other condition or as a change in body mechanics or increased activity following the procedure rather than the procedure itself.