Conditions and Treatments
Herniated Nucleus Pulposus or Disc Herniation
This happens in the cervical, thoracic, and lumbar spines. Simply, the inside of the disc, or the nucleus pulposa squeezes out through the containing annulus which looks like a radial tire. It squeezes out into or on the nerve root or spinal cord similar to when you squeeze a jelly donut the inside of the donut, the jelly goes out onto the plate. This can cause the immediate onset of severe pain in your arms, your legs, or your chest.
There are some times that the disc herniation is so large that it presses the spinal cord and you can suffer a total or partial paralysis. Generally, the type of herniated nucleus pulposus that causes loss of bowel and bladder control, weakness in the upper or lower extremities, needs to be surgically removed on an emergency or semi-emergent basis. The natural history of herniated discs that is well documented throughout many studies in the literature is that they have a tendency to get better with time. The main result of surgery is that if you have a weakness or a neurologic deficit that is the best way to manage the weakness from the pressure of the disc on the nerves.
However, if it is simply nerve pain, often this can be treated conservatively with steroids, nonsteroidal anti-inflammatory drugs, physical therapy, or injections of cortisone onto the nerve root. The goal is to treat the inflammation that the disc herniation causes and given enough time, the body will generally reabsorb the disc or make the disc melt away, but this does take months and months. The balance of the disc herniation in the cervical or lumbar spine is made by the patient and the surgeon. The patient generally enjoys a very fast pain relief if the disc is removed in either the cervical or lumbar spine; however, that is balanced again with the risk of surgical intervention. These have to be clearly discussed between the surgeon and the patient with their wishes to make a decision.
Stenosis means from the Greek, to choke. Simply, during the degenerative phase of the cervical and lumbar spine the discs collapse, the joints enlarge and the result is there is not enough room for your spinal cord or cervical or lumbar nerves. This produces a variety of conditions ranging from being without symptoms to being paralyzed. Most people, however, with stenosis in the lumbar spine simply have leg pain, sometimes leg weakness and, if it is severe enough, limit the ability to walk any distance, especially in older patients.
The cervical stenosis is of two types; one impinges the spinal cord that can cause the changes in the spinal cord itself and weakness in the lower extremities, clumsiness in the hands, and changing in coordination, strength, or inability to control balance. The more moderate type is what is known as foraminal stenosis, which simply pinches the nerves that run down your arm to your hand and cause pain, burning, numbness, tingling, and weakness in the later stages.
The lumbar stenosis can be severe enough to cause paralysis in the lower extremities and the limit the patient’s ability to walk any distance. Generally, it is considered, if walking distance is down to one to two blocks this is an indication that treatment needs to be instituted. It can also cause a condition known as cauda equina syndrome. This is the loss of ability to control your bowel or bladder and weakness in your lower extremities. This is a very rare event but is something that needs to be treated rather promptly with surgical decompression and steroids.
Degenerative Disc Disease
Degenerative disc disease occurs virtually in everybody. It generally starts in the patients 20s to 30s and progresses as long as patients are living. This is a normal progression of aging and is in a large part determined by the genetic structure of the individual patient. There are environmental conditions which can hasten the aging or degenerative process of the discs, such as cigarette smoking, traumatic events, heavy industrial labor, or infection. The most common form of disc degeneration that virtually every human over 30 has is known as arthritis of the spine. This is also associated with the two joints on the back side of the spine called the facet joints. As they age they also become enlarged arthritic and become a source of pain in themselves and a reason for spinal stenosis which is correlated with disc degeneration and facet degeneration causing “pinched nerves” or pain your legs or your arms.
Neck Pain and Back Pain
There is simply only two reasons that the spine becomes painful; either facet arthritis or injury or inflammation or disc degeneration with inflammation, collapse, or instability. Instability means that the disc does not have enough structural competencies to withstand the weight that is placed on it and can cause slippage or painful discs. During your workup and treatment, it is important to know the location or pain generator that is causing either your neck pain, arm pain, back pain, or leg pain. Disc degeneration is something that is interval to all aging spine problems and can present with deformities, such as scoliosis or a crooked spine, or kyphosis which is a spine that is bent forward.
This is a term that means the spine has slipped. Generally, this is in the lumbar spine, but it can be in the cervical spine. In the lumbar spine, there are two types of spondylolisthesis. In the older age group, it is degenerative spondylolisthesis because the disc has become “incompetent or unstable”. This allows a forward slippage of one vertebral body on the other and generally causes secondary pain and nerve pinching or stenosis. This generally needs to be operatively managed but can be managed with injections, exercise, and the appropriate medications.
The other type, which is less common, is isthmic lytic spondylolisthesis. This can occur in early adolescence and be quite symptomatic. It can also occur later in life, as the disc of the spondylolisthesis degenerates. The isthmic lytic spondylolisthesis refers to an actual fracture in the backside of the spine, which allows the spine to slip forward and in doing so causes stenosis or pinched nerve. This is most common at the L5-S1 level but does occur at L3-4 and L4-5, uncommonly. Generally, when the patient has become significantly symptomatic and fails conservative management, an anterior, or through the front, fusion with a realignment of the spine, and a posterior fusion with rods and screws are necessary to control the patient’s symptoms.
This means pain from a nerve root. This can be a herniated disc or a hard disc or bone spur from stenosis in the cervical, thoracic, or lumbar spine. The early signs of radiculopathy are sensations that shoot down the arms and legs. In the very later stages of this, muscle weakness in the arm, hand, or leg and foot, or even loss of bowel or bladder control can be a result of this.
The treatment is generally initially conservative with steroids, nonsteroidal anti-inflammatory drugs, and a class of medications called neuroleptic drugs. This is a Neurontin or gabapentin, or Lyrica. These are very specific in the treatment of neuropathic pain or radiculopathy. They will slow the firing of the nerve down and in some patients also has a severe side effect of sleepiness, as it slows the firing in your brain. The next level of treatment is injections into the nerve itself by a neurologist. The last level of treatment if the conservative managements do not work would be surgical decompression to free up the nerve or scrape the bone away from the nerve. This condition can become chronic from nerve scarring and generally, this requires medication as well as potentially neuromodulation or spinal cord stimulator, which will be discussed in another section.
This is literally the twisting of the spine. This can be in younger children, idiopathic scoliosis or congenital scoliosis, in which children are born with deformities; paralytic scoliosis or from a paralyzed spine that does not have the muscles to balance; or in the older population a degenerative scoliosis which is caused from collapsing of the disc that is more to one side than the other, causing the offset and, therefore, a bend in the spine. This is very common in patients in their 60’s, 70’s, and 80’s, and is a source of a great deal of pain and if scoliosis progresses surgically with rods and screws in the lumbar spine as well as the thoracic spine, especially in the adolescent type of scoliosis. However, in the much more common aging type of scoliosis in the elderly population, a new minimally invasive approach to reducing the deformity has been highly successful. I was directly involved in developing not only the rod/screw technology in the 1990s that we use commonly, but in the minimally invasive technology that we have currently been using and the new minimally invasive technology provides us with the ability to manage problems in the elderly that we could not do before, and produce increased quality of life.
Kyphosis means, bending the spine forward. This happens most commonly in the elderly females that have degenerative disc disease and subtle collapsing of each vertebral body and they get a large hump in their back and lose the ability to stand up straight. Another type of kyphosis is lumbar kyphosis in the elderly that also makes the patient lose their ability to stand up straight, and that is one of the reasons that the elderly population leans forward when they walk. With new technology, the lumbar degenerative disease can be reversed through the minimally invasive technology which I have contributed to the development of the approach technology, i.e., the retractors as well as the implants themselves and in viewing the website you will find the link to Centinel Spine as wall as Thompson Retractors.
This is a type of kyphosis that was described above in the lumbar spine because of the collapse of the discs and collapse of the vertebral bodies. This is called lumbar kyphosis. The normal contour of the lumbar spine is lordosis or a C-curve that points to the front. Once the C-curve is lost, it pitches the torso over the hips and you lose the ability to stand up straight. This is very common in the elderly and with the new minimally invasive technology this can be successfully reduced or reversed.
Adjacent Segment Breakdown
This refers to the discs that are above or below a fusion, either in the cervical, thoracic, or lumbar spine. It is well known that you fuse parts of either the cervical, thoracic, and lumbar spine the level next to it, or the adjacent segment has more stress put on it and the discs will wear out 3% per year faster than the average population. So that translates into in most patients, if you have a fusion in your 30s or 40s, within 10-20 years you will require another surgical intervention at the adjacent segment as it degenerates and then has secondary stenosis with pinching of the nerve. If you have the surgery now, in 10-15 years the technology to fix that may be completely different and unheard of from what is being done today.
Lower Back Pain and the Sacroiliac Joint
Where is the sacroiliac joint? The sacroiliac joint connects the last segment of the spine, the sacrum, to the pelvis. The integrity of the sacroiliac joint depends on strong ligaments that encase and cover the joint. These ligaments compress and stabilize the joint.
Dr. Thalgott has trained in the latest minimally invasive surgical (MIS) techniques, including the use of the iFuse Implant System® from SI-BONE®, Inc., a medical device company pioneering MIS sacroiliac (SI) joint treatment. The iFuse Implant System is intended for sacroiliac joint fusion for some causes of SI joint pain. Multiple published studies on The iFuse Implant System have documented procedure safety and effectiveness.6 There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit www.si-bone.com/risks.
The SI joint is a significant cause of low back pain. Clinical publications have identified the SI joint as a pain generator in 15-30% of chronic low back pain patients.1-4 In addition, the SI joint is a pain generator in up to 43% of patients with continued or new onset low back pain after a lumbar fusion.5.
Sacroiliac Joint (SI Joint) Anatomy
The sacroiliac joint (SI joint) is located in the pelvis; it links the iliac bones (pelvis) to the sacrum (lowest part of the spine above the tailbone). It is an essential component for shock absorption to prevent impact forces from reaching the spine.
Do you have SI Joint Problems?
The SI joint is a significant cause of low back pain.Clinical publications have identified the SI joint as a pain generator in 15-30% of chronic low back pain patients.1-4 In addition, the SI joint is a pain generator in up to 43% of patients with continued or new onset low back pain after a lumbar fusion.5
Like any other joint in the body, the SI joint can be injured and/or become degenerative. When this happens, people can feel pain in their buttock and sometimes in the low back and legs. This is especially true while lifting, running, walking or even sleeping on the involved side.
According to scientific data, it’s common for pain from the SI joint to feel like disc or low back pain. For this reason, SI joint disorders should always be considered in low back pain diagnosis.
Do you experience one or more of the symptoms listed below?
- Low back pain
- Sensation of low extremity: pain, numbness, tingling, weakness
- Pelvis/buttock pain
- Hip/groin pain
- Feeling of leg instability (buckling, giving way)
- Disturbed sleep patterns
- Disturbed sitting patterns (unable to sit for long periods, sitting on one side)
- Pain going from sitting to standing
Making a Diagnosis
A variety of tests performed during the physical examination may help reveal the SI joint as the cause of your symptoms. Sometimes, X-rays, CT-scan or MRI may be helpful in the diagnosis of SI joint-related problems.
The most relied upon method to accurately determine whether the SI joint is the cause of your low back pain symptoms is to inject the SI joint with a local anesthetic. The injection will be delivered under either X-ray or CT guidance to verify accurate placement of the needle in the SI joint. If your symptoms are decreased by at least 50%, it can be concluded that the SI joint is either the source of or a major contributor to your low back pain. If the level of pain does not change after SI joint injection, it is less likely that the SI joint is the cause of your low back pain.
Once the SI joint is confirmed as the cause of your symptoms, treatment can begin. Some patients respond to physical therapy, use of oral medications, or injection therapy. These treatments are often performed repetitively, and frequently symptom improvement using these therapies is temporary. At this point, you and your surgeon may consider other options, including minimally invasive surgery.
SI Joint Fusion with the iFuse Implant System®
The iFuse Implant System is designed to provide stabilization and fusion for certain SI joint disorders. This is accomplished by inserting triangular-shaped titanium implants across the sacroiliac joint to maximize post-surgical stability and weight bearing capacity. The procedure is done through a small incision and takes about an hour.