Spine Surgery – FAQs

Understanding the spineThe spine is made up of many bones called vertebrae. These are roughly circular and between each vertebra is a disc. The discs are made of strong rubber-like tissue, which allows the spine to be fairly flexible. A disc has a stronger fibrous outer part, and a softer jelly-like middle part called the nucleus pulposus.

The spine protects the spinal cord, which contains the nerves that come from the brain. Nerves from the spinal cord come out from between the vertebrae to take and receive messages to various parts of the body. Strong ligaments attach to the vertebrae. These give extra support and strength to the spine. Various muscles also surround, and are attached to various parts of the spine.

When you have a prolapsed disc (commonly called a slipped disc). A disc does not actually slip. What happens is that part of the inner softer part of the disc (the nucleus pulposes) bulges out through a weakness in the outer part of the disc. A prolapsed disc is sometimes called herniated disc. The bulging disc may press on nearby structures such as a nerve coming from the spinal cord. Some inflammation also develops around the prolapsed part of the disc.

Any disc in the spine can prolapse. However, most prolapsed discs occur in the lumbar part of the spine (lower back). The size of the prolapse can vary. As a rule, the larger the prolapse, the more severe the symptoms are likely to be.

It is not clear why some people develop a prolapsed disc and not others, even when they do the same job or lift the same sort of objects. It seems that some people may have a weakness in the outer part of the affected disc. Various things may trigger the inner softer part of the disc to prolapse out through the weakened outer part of the disc. For example, sneezing, awkward bending, or heavy lifting in an awkward position may cause some extra pressure on the disc. In people with a weakness in a disc this may be sufficient to cause a prolapse. Factors that may increase the risk of developing a prolapsed disc include: a job involving lots of lifting, a job involving lots of sitting (especially driving), weight bearing sports (weight lifting etc), smoking, obesity and increasing age (a disc is more likely to develop a weakness with increasing age).

Back Pain

The pain is often severe, and usually comes on suddenly. The pain is usually eased by lying down flat, and is often made worse if you move your back, cough, or sneeze.

Nerve root pain (usually sciatia)

Nerve root pain is pain that occurs because a nerve coming from the spinal cord is pressed on (trapped) by a prolapsed disc, or is irritated by the inflammation cause by the prolapsed disc. Although the problem is in the back, you feel pain along the course of the nerve in addition to back pain. Therefore, you may feel pain down a leg to the calf or foot. Nerve root pain can range from mild to severe, but it is often worse than the back pain. With a prolapsed disc, the sciatic nerve is the most commonly affected nerve. (The term sciatica means nerve root pain of the sciatic nerve). The sciatic nerve is a large nerve that is made up from several smaller nerves that come out from the spinal cord in the lower back. It travels deep inside the buttock and down the back of the leg. There is a sciatic nerve for each leg.

Other nerve root symptoms

The irritation or pressure on the nerve next to the spine may also cause pins and needles, numbness or weakness in part of a buttock, leg or foot. The exact site and type of symptoms depends in which nerve is affected.

Cauda equine syndrome – rare, but an emergency

Cauda equine syndrome is a particularly serious type of nerve root problem that can be caused by a prolapsed disc. This is a rare disorder where the nerves at the very bottom of the spinal cord are pressed on. This syndrome can cause low back pain plus: problems with bowel and bladder function (usually unable to pass urine), numbness in the saddle area (around the anus), and weakness in one or both legs. This syndrome needs urgent treatment to preserve the nerves to the bladder and bowel from becoming permanently damaged. See a doctor immediately if you develop these symptoms.

Some people do not have symptoms

Research studies where routine back scans have been done on a large number of people have a prolonged disc without any symptoms. It is thought that symptoms mainly occur if the prolapse causes pressure or irritation of a nerve. This does not happen in all cases. Some prolapses may be small, or occur away from the nerves and cause minor, or no symptoms.

In most cases, the symptoms tend to improve over a few weeks. Research studies of repeated MRI scans have shown that the bulging prolapsed portion of the disc tends to get smaller (regress) over time in most cases. In only about 1 in 10 cases is the pain still bad enough after six weeks to consider surgery.

Your doctor will normally be able to diagnose a prolapsed disc from the symptoms and by examining you. (It is the common cause of sudden back pain with nerve root symptoms). In most cases, no tests are needed as the symptoms often settle within a few weeks. Tests such as X-rays or scans may be advised if symptoms persist. In particular, an MRI scan can show the site and size of a prolapsed disc. This information is need if treatment with surgery is being considered.

Exercise and keep going!

Continue with normal activities as far as possible. This may not be possible at first if the pain is very bad. However, move around as soon as possible, and get back into normal activities as soon as you are able. As a rule, don’t do anything that causes a lot of pain. In the past, advice had been to rest until the pain eases. It is now known that this was wrong. You are likely tom recover more quickly and are less likely to develop chronic (persistent) back pain if you keep active when you have back pain rather than rest a lot. Also, sleep in the most naturally comfortable position on whatever is the most comfortable surface. (Advice given in the past used to be to sleep on a firm mattress is better than any other type of mattress for people with back pain).

Medication

If you need painkillers, it is best to take them regularly. This is better than taking them no and again just when the pain is very bad. If you take them regularly the pain is more likely to be eased for much of the time and enable you to exercise and keep active.

Physical treatments

Some people visit a physiotherapist, chiropractor, or osteopath for manipulation and/or other physical treatments. It is debatable whether physical treatments would help all people with a prolapsed disc. However, physical treatments provide some short-term comfort and hasten recovery in some cases.

Surgery

Surgery may be an option in some cases. As a rule, surgery may be considered if the symptoms have not settled after about six weeks or so. This is the minority of cases as in about 9 in 10 cases; the symptoms have eased off and are not bad enough to warrant surgery within about six weeks. The aim of surgery is to cut out the prolapsed part of the disc. A specialist will advise on the pros and corns of surgery, and the different techniques that are available.

You may be able to avoid back pain by improving your physical condition and learning and practicing proper body mechanics. How can you keep your back healthy and strong?

Exercise

Regular low-impact aerobic activities – those that don’t strain or jolt your back – can increase strength and endurance in your back and allow you muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities are best for you.

Build muscle strength and flexibility

Abdominal and back muscle exercises (core-strengthening exercises) help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels.

Quit smoking

Smokers have diminished oxygen levels in their spinal tissues, which can hinder the healing process.

Maintain a healthy weight

Being overweight puts strain on your back muscles. If you’re overweight, trimming down can prevent back pain.

Use proper body mechanics

• Stand smart. Maintain a neutral pelvic position. If you must stand for long periods of time, alternate placing your feet on a low footstool to take some of the load off your lower back.
• Sit smart. Choose a seat with good lower back support, armrests and swivel base. Consider placing a pillow or rolled towel in the small of your back to maintain its normal curve. Keep your knees and hips level.
• Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lifting and twisting simultaneously. Find a lifting partner if the object is heavy or awkward.
• Sleep smart.People with back pain have commonly been told to use a firm mattress, but recent studies indicate that a medium-firm mattress might be better. Use pillows for support, but don’t use a pillow that forces your neck up at a severe angle.

(Article written byDr. Sajan K Hegde, Sr. Consultant Spine Surgeon, Apollo Hospitals Chennai)

Currently scoliosis is defined as a lateral deviation of the normal vertical spine. But in fact, the curve is three-dimensional resulting in a complex deformity. Scoliosis is broadly classified into three major groups:

• Congenital scoliosis – a structural anomaly in the vertebrae.
• Neuromuscular – in which there is an imbalance of the function of the muscles leading on to structural deformity of spine.
• Idiopathic – in which the cause is not yet known.

Idopathic scoliosis is the most common form of spinal deformity seen. By definition, it is lateral curvature of the spine occurring in an otherwise healthy child, for which no recognizable cause exists. It is divided into three categories depending on the age at which the curve is first detected:

• Infantile idiopathic scoliosis – when the cure occurs before the age of 3 years.
• Juvenile idiopathic scoliosis – first appears between the age 3 and 10 years.
• Adolescent idiopathic scoliosis – the most common type and is first detected after puberty i.e. after 11 years.

Adolescent idiopathic scoliosis is the most common type of spinal curvature. It occurs around the onset of puberty in otherwise healthy boys and girls. It is more common in girls.

For curves between 20 to 30 degrees in very young skeletally immature patients, it is standard that a non-surgical treatment is instituted. Bracing has proved to be an effective form of treatment to prevent curve progression in about 80% of the patients in this group. The patients on brace treatment also are observed for curve progression as described before. The main disadvantage of bracing is the patients’ compliance, as the brace has to be worn almost for the entire day, on all days till skeletal maturity.

Surgical treatment of scoliosis is employed if the cure at detection is of greater magnitude (> 40). The aim of surgical correction is to achieve a well-balanced spine in which the patient’s head, shoulders and trunk are centered over the pelvis. This is done by using instrumentation to reduce the magnitude of the deformity and obtaining fusion in order to prevent future curve progression. When fusion is done in skeletally immature patients, Crank shafting and flat back syndromes occur producing more severe deformity and these also severely retard growth. A more recent development in the treatment of such patients is the use of staples on the convex side of the curve, which correct and maintain the curve till the patient is skeletally mature. These staples allow differential growth to take place i.e. less growing speed on the stapled side than the conclave side thereby correcting the curve as the child grows. This principle has long been used in the correction of long bone deformity in the skeletally immature.

Special spinal implants made from Nitinol – a titanium based alloy – have been studied extensively and are being employed clinically in a few centres in USA and Europe. Two well-known spine surgeons from the United States, Dr. Randal Betz and Dr. Ogilvie designed this implant. The staples are in the shape of C’ when they are manufactured at room temperature. When the staples are cooled to below freezing point the prongs become straight but clamp down into the bone in a C’ shape when the staple returns to body temperature providing secure fixation. These are called Shape Memory Alloy (SMA) staples. As no fusion is done the child grows normally and even the residual deformity tends to improve with growth.

This novel procedure was performed for the first time in India at Apollo Hospitals, Chennai on a 6-year old girl, from a small town near Madurai by our team of surgeons.