MEDICATIONS

Medications play an effective role in the treatment of back or neck pain. Your doctor may prescribe several medications to help reduce pain and associated symptoms that are caused by unhealthy spinal conditions or deformities.

When treating a chronic lower back pain, the healthcare professional will prescribe a medication regimen, taking into consideration the precise needs of the patient including severity, period of pain and medical history of the individual. The main aim of prescribing medications is to reduce the pain and increase the comfort level of the patient and to reduce the danger of misuse or abuse of the medications.

Over-the-counter pain relievers:

Over-the-counter pain relievers are medications available without a doctor's prescription. They include acetaminophen, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and topical pain relievers.

  • Acetaminophen (Tylenol) and NSAIDs help to reduce fever and alleviate pain caused by general muscle aches and stiffness. Moreover, NSAIDs can also reduce inflammation. NSAIDs help relieve pain by reducing the level of prostaglandins (hormone-like substances) that cause pain.

  • Topical pain relievers (Asper creme, Ben-Gay, and Capsaicin) include creams, lotions and sprays that are applied to the skin of painful muscles or joints to ease pain.

Opioid pain medications:

Because of possible toxicity to the body, physical dependence, and the loss of efficacy due to developmental tolerance and psychological dependence or addiction, opioid medical care or narcotic administration is widely rejected in the treatment of chronic back pain.

Opioids are typically prescribed for patients with chronic nonmalignant pain, including low back pain who experience high levels of comfort while not developing toxicity to the body or having any indication of psychological dependence or addiction. Opioid therapy should be considered as the last treatment option in cases of unrelieved pain despite alternative medications (such as use of non-opioid drugs). Patients should be informed regarding the side effects of opioids and suggested to follow-up with their doctor regularly. Monthly appointments should be scheduled to assess the dose of the drug until the patient experiences partial or complete relief from pain.

Corticosteroids: Corticosteroids are used to reduce swelling caused due to inflammation. When used to control pain, corticosteroids can be prescribed in the form of pills or injections.

Muscle relaxers: Muscle relaxers are drugs that are commonly used to treat acute muscle problems. Sometimes, they can help treat painful muscle spasms.  These medications help in reducing muscle tone and tension in skeletal muscles. Some muscle relaxers have direct effect on the skeletal muscle fibers, while others work at the level of the spinal cord.

 

 

NUTRITION AND YOUR SPINE

Nutrients are the chemical components present in food which provide energy for carrying normal physiological functions and aid in metabolic processes of the body.

Nutrition refers to the entire cycle of chemical changes occurring within the body depending on what we eat or don’t eat. Nutrition determines the strength of the teeth, bones, and the connective tissues. A healthy diet during childhood paves the way for a healthy adulthood. A well-balanced diet is essential for the repair and maintenance of bones, cartilage, ligament, tendons, and muscles. Vitamin B, C, D, K, and minerals such as calcium, magnesium, copper, zinc, boron and manganese are essential for healthy bones and connective tissues.

Nutrition plays a vital role in maintaining a healthy spine. Good nutrition helps in managing pain and disability in the patient suffering from different types of spinal disorders.  Damage to the spine can occur due to daily wear and tear or due to injuries from work, sports or accidents. Poor nutrition and inadequate hydration can increase the incidence of such injuries. A major part of the connective tissue involved in joining and holding the joints together is made up of protein and water. Degenerative disc diseases (DJD) can damage the connective tissues as well. Adequate dietary protein, along with vitamins A, B6, C, E and minerals such as zinc and copper are essential for maintaining strong and healthy connective tissue. Minerals such as calcium, phosphorus, magnesium, and boron are essential for healthy bones. Healthy nutrition is required for repair and maintenance of bones. Lack of nutrition can lead to bone disease such as osteoporosis. Calcium helps in improving bone density. Other factors such as vitamin D, collagen, magnesium, and L-lysine are also essential for maintaining healthy bones. Calcium metabolism can be hampered due to various conditions, some of which include:

  • Chronic mental or emotional stress causes inflammation of the digestive tract

  • Inadequate acidity of the digestive tract hampers calcium absorption

  • Deficiency of certain nutrients such as vitamin D and L-lysine

  • Excessive urinary excretion of calcium due to intake of caffeine-containing drinks such as coffee and colas

Inflammation results in the loss of the normal cellular framework that keeps bone and connective tissues together. The inflammatory conditions such as osteoarthritis can damage the joints. Inflammation also results in pain which arises due to some chemical changes in the surrounding tissues.

Abdominal obesity can induce strain on the muscles and ligaments supporting the spine causing back pain.

A good circulatory system is essential for the repair of surgical incisions, injured bone, or connective tissue such as cartilage and ligaments. The blood vessels carry all the nutrients to the bone and connective tissues. A diet rich in fat and low in protein and fiber can constrict blood vessels reducing blood flow to the injured areas needing repair. Herbs, fruits and vegetables are rich in anti-inflammatory and antioxidant components like flavonoids which can strengthen the healing process.

Various nutritional supplements are also available which may be recommended based on the specific musculoskeletal condition of the patient. Along with good nutrition, regular exercise is also important for a healthy spine.

 

 

PIRIFORMIS MUSCLE INJECTIONS

The piriformis muscle is present in the buttocks, connecting the sacrum to the outer surface of the hip. This muscle enables us to walk and run. The sciatic nerve is a thick, long nerve passing through or below the piriformis muscle. A spasm of the piriformis muscle can compress the sciatic nerve resulting in severe pain (sciatica).  The pain is usually felt over the buttocks but may radiate to the back of the thigh and down the leg as well.

A piriformis muscle injection is used to alleviate the spasm and pain in these patients. The injection comprises an anesthetic and a steroid to reduce the spasm. In most patients, the pain resolves with 1 or 2 injections, however, 3 injections may be required to achieve complete benefit.

Procedure:

The entire procedure usually takes 15-20 minutes. You will lie on your stomach. A local anesthetic is used to numb the area of injection. Your doctor will insert the needle into the piriformis muscle under fluoroscopic guidance. A small amount of contrast dye is injected to guide the doctor in proper placement of the needle. After confirming the position of the needle, a steroid-anesthetic mix is injected into the piriformis muscle. After injecting the medication, the needle is removed and the injection site is covered with a band-aid.

After the Procedure:

Following the procedure, you may experience nausea, sweating, and/or dizziness. You may also develop weakness or numbness in the leg for a few hours. You may also notice a slight swelling, redness, bruising, and tenderness at the injection site, which may subside within a short period. Once the physician has confirmed that you are stable, you will be discharged to go home. Additional instructions and a follow-up appointment will be given to you at the time of your discharge. 

 

 

SACROILIAC JOINT INJECTIONS

Sacroiliac joints (SI joint) are joints in the lower back region, located where the sacrum and ilium bones conjoin.  Even though these joints are small and have limited motion, they have an important role of connecting your spine to the pelvic bone and thus the lower part of your body. They perform important functions by absorbing the injurious shock forces of the upper portion of the body. Any inflammation or irritation in SI joints may cause pain in the lower back, abdomen, groin, buttocks or legs.

Sacroiliac joint injections can be used both for diagnostic as well as therapeutic purposes. As a diagnostic tool, it helps your doctor locate the origin of pain. To diagnose SI joint pain, an anesthetic injection is given to the joint under X-ray guidance. An acute relief in low back pain following the injection indicates an abnormality in SI joint. For therapeutic uses, SI joint injections will contain a steroid medication along with an anesthetic agent to provide relief from pain for a longer duration. When steroid medication is injected into the painful & inflamed joint, the inflammation reduces and thus relieves the pain.

You will have an intravenous catheter placed in your arm before the procedure begins. The catheter is to provide medications if necessary during the procedure. You will be lying on your stomach and the area where the needle is to be inserted near the SI joint is numbed with a local anesthetic injection. Then your doctor will advance the needle under the fluoroscopic guidance. Once the needle is in the right position the medication is injected. Complications are very rare, but do occur sometimes. Possible complications after SI joint injections include allergic reaction, infection, and increased pain.

 

 

FACET INJECTION

The facet joints are the tiny joints situated at the upper and lower part of each vertebra connecting one vertebra to the other. Each of the vertebrae has four facet joints which include a pair that connect to the vertebra above (superior facets) and another pair that connects to the vertebra below (inferior facets). They guide motion and provide stability. Pain may arise in these joints because of an injury to the back, spinal arthritis, or because of increased stress on the backbone. A minimally invasive treatment called facet injection offers symptomatic relief of the back pain caused by inflammation of the facet joints but is not a permanent solution for the condition.

The facet injection procedure may be performed primarily as a diagnostic test to check whether the pain is originating from the facet joints. Secondly, it is used to treat inflammation caused by several spine conditions. A facet injection contains a long-acting corticosteroid and an anesthetic agent which is given either directly into the painful facet joint capsule or into the tissues near the joint capsule. The objective of the treatment is to suppress the pain so that normal activities can be resumed and patients can perform physical therapy exercises.

Facet injection is indicated in conditions where all other conservative treatment modalities such anti-inflammatory medications, rest, back braces and physical therapy have become unsuccessful. Facet injection may reduce inflammation in the facet joints caused by conditions such as spinal stenosis, spondylolysis, sciatica, herniated disc, and arthritis. This treatment is not appropriate for patients with an infection, bleeding disorder or during pregnancy. Patients on aspirin or blood thinners will be advised to stop taking them several days prior to the procedure.

Facet injection is performed as an outpatient procedure where you can return home on the same day but make sure you have someone along to drive you home. Usually the procedure lasts for around 15-30 minutes followed by a short recovery period.

You will be lying face down on a table and be conscious throughout the procedure. Sedatives may be given to make you comfortable and a local anesthetic is administered to numb the area of injection. Then, your doctor will insert a hollow needle through the skin and muscles into the sensory nerves situated at the facet joints under the guidance of a fluoroscope. Once the position of the needle is confirmed, the medication is injected into your facet joint capsule following which the needle is withdrawn.

Facet injections are considered as the most appropriate nonsurgical means of treatment with minimal risks. The possible risks and complications associated with needle insertion may include bleeding, infection, allergic reaction or damage to the nerves. Some of the adverse effects of the corticosteroid medication include weight gain, water retention, flushing and mood swings which usually resolve in 3 days.

 

 

EPIDURAL SPINAL INJECTIONS

Epidural spinal injection is a non-surgical treatment option utilized for relieving back pain. Spine degenerative conditions such as herniated disc, spinal stenosis and many others may induce back pain due to the compression of the associated spinal nerves. This pain or numbness may extend to the other parts of the body such as hips, buttocks, and legs. Doctors start with non-surgical methods to treat back pain and epidural spinal injection is one of these preferences. In cases where the patient finds no relief from non-surgical methods then finally surgery is recommended.

Epidural spinal injections contain a strong anti-inflammatory agent called corticosteroid and an anesthetic for pain relief. It is not the same as epidural anesthesia given before child birth to decrease labor pain. Epidural injections are administered into the epidural space of the spine.  The epidural space is the space between the outermost covering of the spinal cord (dura mater) and the wall of the spinal canal. It is approximately 5 mm wide and is filled with spinal nerve roots, fat and small blood vessels.

  • Indications:

An epidural spinal injection may be employed both for diagnostic and therapeutic reasons, including:

  • Medications to determine the specific nerve root involved in the spinal problem (diagnostic purpose)

  • Medication for inducing short or long-term relief from pain and inflammation (therapeutic purpose)

It is to be noted that epidural spinal injection is not a curative intervention, rather it’s a treatment tool to reduce the discomfort of the patient so that rehabilitation programs such as physical therapy may be well executed.

  • Procedure:

Pain management in different conditions such as spinal stenosis, disc herniation and arthritis can be done through epidural injection. Different types of physicians such as physiatrists, anesthesiologists, radiologists, neurologists, and surgeons may recommend epidural injections for pain relief.

Usually epidural spinal injection is done on an outpatient basis. The procedure involves the following steps: 

  • Patient is taken to the pre-op area where trained nursing staff makes prepares the patient for the procedure by taking vitals and reviewing medications. Blood sugar and coagulation status may also be checked if needed.

  • Patient is taken to the procedure room and will lie face down on a table.

  • The injection site is then cleansed and injection of a local numbing agent is given in the area so that you don’t feel pain during the procedure.

  • A thin hollow needle is then inserted into the epidural space, guided by fluoroscopic X-ray to place the needle in the correct position. This system gives real time X-ray images of the position of the needle in the spine on a monitor for the surgeon to view.

  • A contrast material is then injected through the properly placed hollow needle to confirm that the drug flows to the affected nerve when injected.

  • When the doctor is satisfied with the position of the needle, the anesthetic drug and corticosteroid are injected through the same needle inserted in the spine.

  • Finally, the needle is removed and the injection site is covered with a dry, sterile bandage.

Patients may feel some pressure during the injection but mostly the procedure is painless. The procedure takes about 15-30 minutes to complete. After injection, the patient should not drive or go back to work and should rest and avoid any vigorous activities. Your surgeon may give specific post-care instructions. Please follow the instructions to recover faster.

  • Recovery Time:

Patients may feel numbness in the arms or legs just after procedure along with other side effects related to the anesthetic component that usually settles down within 1-8 hours. Patients may continue to feel some back pain, as epidural spinal injections take about 24-72 hours before showing their pain-relieving action. In some cases, if the desired effect is not obtained, then reinjection may be recommended. The standard guidelines for steroid injections state a maximum of 3 injections per year. In case no relief is obtained from spinal injection, then surgery is considered as the final option. 

  • Risks and Complications:

With any procedure, some risk factors will always be there. Likewise, epidural spinal injections have complications such as bleeding or infection at the injection site, pain during or after injection, post-injection headache, nerve injury, bladder dysfunction, fluid retention, respiratory arrest, epidural hematoma, and spinal cord infarction.  Discuss with your doctor if you have any concerns prior to the procedure.

 

 

SCOLIOSIS TREATMENT

Scoliosis is the abnormal curvature of spine giving the spine a “S” or “C” shape. Scoliosis can occur at any age and is more common in girls than boys.  Larger curves cause discomfort while the smaller curves do not cause any problems. In most cases, the exact cause remains unknown.

Scoliosis is categorized into four major types based on the age of onset, cause and spinal curvature. They include:

  • Structural Scoliosis

  • Non-structural Scoliosis

  • Idiopathic Scoliosis

    • Infantile scoliosis

    • Juvenile scoliosis

    • Adolescent scoliosis

Other types include neuromuscular, congenital and degenerative scoliosis.

Based on type of scoliosis, age of the patient, and severity of curvature the surgeons recommend either non-surgical or surgical treatment. Non-surgical treatment includes periodical observation at 4 to 6 months’ intervals. If the curve is mild and patient has balanced patterns of malformation, it requires no treatment. Doctor will observe these changes by X-rays taken during the period of rapid growth. Braces or casts are used to control the compensatory curves that are adjacent to the congenital abnormality of vertebra to prevent them from worsening.

Surgical options include:

  • Spinal fusion - It involves removal of the abnormal vertebra and replacement of vertebrae with bone grafts. Two or more vertebrae are fused together with the help of bone grafts and internal fixators such as metal rods, wires, hooks, or screws are used to form one single bone. These internal fixators help to stabilize the fusion and partially help to straighten the spine. After the surgery, patients must wear a cast or splint to help the healing process.

  • Hemivertebra removal – In this procedure, the hemi vertebrae or abnormally shaped vertebrae are removed and the vertebrae present above and below the hemi vertebrae are fused together with the help of metal screws. This procedure helps to straighten the spine and allows the adjacent portion of the spine to grow normally. After the surgery, patients must wear a cast or splint to prevent mobilization and bring about fusion of vertebra.

  • Growth rod insertion – Spinal fusion surgery will not be effective in a growing child and may cause impairment of the chest and growth of the lungs. Therefore, before going for surgery, doctors recommend a procedure involving insertion of growth rods. One or two rods will be attached to the spine above and below the curve allowing the spine to grow while correcting the curvature. These rods will be left in place until the child is completely grown after which spinal fusion surgery will be performed.

  • Reconstructive osteotomy and instrumentation – This procedure is done if spine deformity in children causes breathing problems, pain and risk to the spinal cord or impairment of the torso shape. In such cases osteotomy is done to remove part of the vertebral column and then followed by insertion of internal fixators such as metal rods, hooks, screws and wires to restore the balance of the spine.

  • Physical therapy – Doctors advice physical therapy after the surgery to help the spine grow normally. Physiotherapists evaluate the posture, muscle strength, and flexibility and then design an exercise program suitable for the patient that helps to control pain and improve the disability.

 

 

SPINAL CORD STIMULATOR

Back and leg pain often have causes which either improve on their own or which the surgeon can correct. Sometimes there is no easily correctable cause of the pain.

Among other things, scar tissue around the nerves or chronic inflammation of the nerves such as arachnoiditis may cause leg and back pain. When the neurosurgeon feels that open surgery to decompress the nerves is unlikely to help the pain, an operation to implant a spinal cord stimulator may be very beneficial for the patient.

For reasons not completely understood, the stimulator sends electrical impulses to the areas of the spinal cord causing the pain and interferes with the transmission of pain signals to the brain. It blocks the brain's ability to sense pain in the stimulated areas, thus relieving pain without the side effects that medications can cause. The electrical impulses can be targeted to specific locations and, as pain changes or improves, stimulation can be adjusted as necessary.

Before implanting a permanent stimulator, the patient will undergo a trial stimulation period to see if the stimulation helps with their pain. If it does, a permanent stimulator may be implanted. A battery pack will also be implanted to provide charge to the stimulator.

  • Procedure:

There are several ways of implanting the stimulator. The initial implantation of the trial is generally done with the patient awake so that it can be determined in the operating room if the stimulator is covering the appropriate spot of the spinal cord to give the patient pain relief.

Either a paddle lead is placed over the spinal cord through a small open incision and removal of lamina, or a percutaneous insertion of a lead is performed through the skin. The permanent implant will be fixed several days later if the patient achieves good pain relief with the trial stimulator.

  • Post-operative Care:

Patients are generally discharged on the same day or the following day of the procedure. They should keep the wounds very clean and dry.

  • Risks:

Risks for the procedure are low. Potential risks include bleeding, infection, injury to nerves, injured spinal cord, paralysis, and death.

 

 

FORAMINOPLASTY

Neural foramina are small canals at every level of the spine through which nerves leave the spinal cord and go to the limbs and other parts of the body. Narrowing of this canal is called foramina stenosis. Narrowing may be caused by bone spurs, a herniated or bulging disc, arthritis, ligament thickening or enlargement of a joint in the spinal canal. This puts pressure on the nerve roots causing symptoms that include pain, muscle weakness, muscle spasms, cramping, numbness, and tingling. The symptoms may be felt in the neck, back, shoulders, arms, hands, legs, buttocks, or feet depending on the position of the affected foramen.

Usually, conservative treatment is given which includes rest, moderate exercises like swimming, walking and stretching to strengthen the back, medications for relieving pain and inflammation, physical therapy and hot/cold therapy. For severe pain, epidural injection of corticosteroids may be recommended in some cases. Only when conservative treatment provides little or no relief, surgery is recommended.  Surgery aims at removing the overgrown tissue such as scar tissue, bulging disc and bone spurs thereby enlarging the canal and relieving pressure on the nerves. Traditionally, surgery for foraminal stenosis involved open spine surgery. Open spine surgery is performed through a large incision and involves extensive muscle and soft tissue dissection and removal of a portion of spinal bone to access the affected compressed nerve root. In some cases, it leads to spinal instability and requires another procedure called a fusion to stabilize the spine. Fusion involves placement of bone grafts, screws, and rods to permanently fuse the two vertebrae into one solid bone.

Open spine surgery is thus highly invasive and takes a long recovery time of about a year. With the advent of minimally invasive spine surgery techniques, foraminal stenosis surgery can now be performed by a newer procedure called endoscopic foraminoplasty.

Endoscopic foraminoplasty is performed through a small incision on the back near the compressed nerve root. To access the spine, muscles are not cut but are moved aside with telescoping tubes that are inserted into the incision down to the compressed nerve root. Next, an endoscope (a thin flexible telescope) and tiny surgical tools are inserted through the tubes. The portion of disc or bone material causing pressure on the nerve is removed by manual reamers, powered reamers and laser resection to restore foraminal volume. This reduces the pressure on the nerves and relieves the pain. The surgery is usually performed on an outpatient basis.  Recovery is much quicker as compared to the open spine surgery.

Apart from the above listed benefits, endoscopic foraminoplasty also provides additional benefits that include:

  • Small incision and less scarring

  • No or little blood loss

  • Does not cause spinal instability

  • Usually done under local anesthesia, thus the risks of general anesthesia are avoided

  • Can be performed in medically high risk patients and obese patients

  • Can be performed in multiple levels in the same procedure

  • Physical therapy can begin the same day as the surgery

  • Less post-operative pain

  • Less risk of infection

Endoscopic foraminoplasty is a safe and effective surgical option for treatment of foraminal stenosis.

 

 

SPINAL MANIPULATION

Spinal manipulation is a non-surgical "hands-on" technique in which professional chiropractic specialists use leverage and exercises to adjust spinal structures and restore mobility of the back. During pain, the nerve that is interconnected with the muscles, joints, bone becomes weak and loses its ability to function. With this therapy, the nerve will be made to work normally and the blood circulation in these areas also increases.

There are two types of osteopathic manipulation — direct- and indirect- methods. In direct method, the problematic or tight tissue is moved towards the area of tightness. In indirect procedure, the doctor pushes the tight tissues away, in the opposite direction of the muscle resistance.

Osteopathic manipulation is not recommended for people having broken bone, dislocation, bone cancer, infection of the bone, damaged ligament, and for people who have recently undergone surgery and are on medicines such as aspirin and warfarin. Untoward effects of this therapy include increase in pain, headache and fatigue. However, these are of mild severity and may disappear within a day. Severe complications are very rare.

 

 

REVISION SPINAL SURGERY

Revision spine surgery is surgery performed in certain patients to correct the problems of earlier spine surgery. Revision surgery is indicated in patients with chronic pain even after surgery. Other factors indicated for revision spine surgery include:

  • Scar tissue formation around the incision

  • Unsuccessful surgery

  • Surgery at wrong site

  • Surgery in non-eligible candidates

  • Improper diagnosis

  • Post-surgical complications

Failed back syndrome or failed back surgery is a condition used to describe persistent back pain following back surgeries.

The goal of revision spine surgery is to reduce pain and resume normal activities. The revision spine surgery is performed in certain conditions such as re-herniation of a disc, infection, pseudoarthrosis, hardware failure, non-surgery related spine degeneration, flat back syndrome, instability, or adjacent segment degeneration.

Revision spine surgery can be performed using minimally invasive technique where surgery is done by making small incisions. This method causes less damage to muscles and conjunctive tissue surrounding the spine. Laser scalpel will be used to repair the damaged tissues which involve cutting away broken, malformed, or damaged tissue.

Procedures intended to repair previous interventions include laminotomy, foraminotomy, facet thermal ablation, spinal fusion, and microdiscectomy. Rehabilitation after revision surgery includes exercises to harden the weakened muscles in the affected areas.

Anterior and posterior approach – This approach is used in certain types of deformities. The first approach to spinal column is made from the front. The incision is made on the patient’s side, over the chest wall or lower down along the abdomen. Disc material between the vertebrae is removed. This procedure requires removal of a rib, which is later used for bone grafting.

After the anterior procedure, the wound is closed and the patient is positioned for the posterior approach. The incision is made down the middle of the back. Hooks are attached to the back of the spine on the lamina, and screws are placed in the middle of the spine. After the placement of hooks and screws, a rod is bent and contoured into a more normal alignment for the spine and the correction is performed. After the final tightening, the incision is closed and dressed.

 

 

MINIMALLY INVASIVE SPINE SURGERY (MISS)

MISS is the latest advanced technology available to perform spinal surgeries through small, less than one inch long, incisions. It involves the use of special surgical instruments, devices and advanced imaging techniques to visualize and perform the surgery through such small incisions. MISS is aimed at minimizing damage to the muscles and surrounding structures. MISS possesses numerous benefits over the traditional spine surgery that includes:

  • Small surgery scars

  • Reduced risk of infections

  • Less blood loss during the surgery

  • Less post-operative pain

  • Quicker recovery

  • Shorter hospital stay

  • Quicker return to work and normal activities

  • Procedure:

Minimally invasive spine surgery is done through small incisions. Segmental tubular retractors and dilators are then inserted through these small incisions to retract muscles and provide access to the spine by creating a working channel for the surgery. This minimizes the damage to the muscles and soft tissues and decreases the blood loss during the surgery. An endoscope is inserted through one of the incisions to provide images of the operation field on the monitor in the operation room. The surgery is done with special surgical instruments passed through the working channel. Sometimes surgical microscopes may also be used to magnify the visual field. The tissues fall back in place, as the various instruments are withdrawn. The incision is then closed and dressed.

  • Risk and Complications:

The risks and complications of the surgery may include infection, bleeding, nerve injury, or spinal cord injury. Complications due to general anesthesia may also occur.

 

 

SPINE OSTEOTOMY

Spine osteotomy is a surgical procedure in which a section of the spinal bone is cut and removed to allow for correction of spinal alignment. Spine osteotomy is usually needed for correction of severe, rigid and fixed spinal deformity when nonsurgical treatments do not relieve symptoms such as numbness, weakness, or pain due to nerve compression or when deformity is getting worse over time. A mild or flexible deformity is usually corrected through positioning and instrumentation.

Severe spinal deformity may occur in conditions such as Scheuermann's kyphosis, iatrogenic flat back, post-traumatic, neuromuscular, congenital, degenerative disorders and ankylosing spondylitis. Severe deformity causes symptoms that may include a subjective sense of imbalance, leaning forward (stooping), early fatigue, intractable pain and difficulty of horizontal gaze. A spine osteotomy procedure significantly improves these symptoms. A spine osteotomy reduces pain and restores balance so that the patient can stand erect without the need to flex his/her hips or knees. It also improves the gross appearance (cosmesis) of the patient and even makes a horizontal gaze possible. Functional improvement of the visceral organs may also occur.

Spine osteotomies can be broadly divided into three main types. The type of osteotomy used depends on both the location of the spinal deformity and on the amount of correction that is required. A spinal fusion with instrumentation may also be performed along with spine osteotomy to stabilize the spine and prevent further curvature. The three main types of osteotomy are:

Smith-Petersen Osteotomy (SPO): SPO is recommended in patients in whom a relatively small amount of correction (approximately 10-20° for each level) is required. In this procedure, a section of bone is removed from the back of the spine causing the spine to lean more toward the back. The posterior ligament and facet joints are also removed from this area. Anterior bone graft is not used in this procedure as motion through the anterior portion of the spine or the discs is required for correction. SPO may be performed at one or multiple locations along the spine to restore lordosis.

Pedicle Subtraction Osteotomy (PSO): PSO is recommended generally in patients in whom a correction of approximately 30° is required mainly at the lumbar level. PSO involves all three posterior, middle, and anterior columns of the spine. It involves the removal of posterior element and facet joints like a SPO and removal of a portion of the vertebral body along with the pedicles. PSO allows for more correction of the lordosis than SPO.

Vertebral Column Resection Osteotomy (VCR): VCR involves the complete removal of a single or multiple vertebral bodies. It allows for maximum correction that can be achieved with any spinal osteotomy. As VCR introduces a large defect in the spine, spinal fusion is also performed over these levels for reconstruction. Spinal fusion may involve the use of a structural autograft, structural allograft or metal cage. Initially, VCR was performed through a combined anterior and posterior approach but now it can also be performed through only a posterior approach.

 

 

SPINAL DEFORMITY SURGERY

The Spine or backbone provides stability to the upper part of our body. It helps to hold the body upright. It consists of several irregularly shaped bones, called vertebrae appearing in a straight line.  The spine has two gentle curves, when looked from the side and appears to be straight when viewed from the front. When these curves are exaggerated, pronounced problems can occur such as back pain, breathing difficulties and fatigue and the condition will be considered as deformity. Spine deformity can be defined as abnormality in the shape, curvature and flexibility of the spine.

The different types of spinal deformities include scoliosis, lordosis and Kyphosis. Scoliosis is a condition where the spine or back bone is curved sideways instead of appearing in a straight line. It curves like an “S” or “C” shape. Lordosis is a condition characterized by abnormal excessive curvature of the spine, sometimes called swayback. Kyphosis is a condition where an abnormal curvature of the spine occurs in the thoracic (chest) region resulting in round back appearance.

There are different surgical approaches to repair these deformities and the choice of the approach to the spine is based on the type of deformity, location of the curvature, ease of access to the area of the curve and the preference of the surgeon.

Anterior approach – In this procedure, the surgeon will approach the spinal column from the front of the spine rather than through the back. The incision is made on the patient’s side, over the chest wall or lower down along the abdomen, depending on the part of the spine that requires correction. The lung is deflated and a rib is removed to reach the spine. After the exposure of the spinal column, the disc material between the vertebrae involved in the curve is removed. Screws are placed at each vertebral level involved in the curve, and these screws are attached to a single or double rod at each level. After instrumentation, a fusion is performed, the bony surface between the vertebral bodies is roughened and bone graft is placed. A combination of compression along the rod and rotation of the rod will correct the spine deformity. The incision is closed and dressed.

Posterior approach- It is the most traditional approach and the approach is made through the patient’s back while the patient lies on his or her stomach. The incision is made down the middle of the back. Hooks are attached to the back of the spine on the lamina, and screws are placed in the middle of the spine. After the placement of hooks and screws, a rod that is bent and contoured into a more normal alignment for the spine is attached and the correction is performed. After the final tightening, the incision is closed and dressed.

Anterior and posterior approach – This approach is used in cases where the curve is stiff and severe. The first approach to spinal column is made from the front. The incision is made on the patient’s side, over the chest wall or lower down along the abdomen. Disc material between the vertebrae is removed. This procedure requires removal of a rib, which is later used for bone grafting.

After the anterior procedure, the wound is closed and the patient is positioned for the posterior approach. The incision is made down the middle of the back. Hooks are attached to the back of the spine on the lamina, and screws are placed in the middle of the spine. After the placement of hooks and screws, a rod that is bent and contoured into a more normal alignment for the spine is attached and the correction is performed. After the final tightening, the incision is closed and dressed.

Video-assisted thoracoscopic surgery (VATS) –This is a minimally invasive technique performed using a small video camera. The patient lies on his or her side; four incisions of 1 inch are made on the side of the chest wall. A thoracoscope, a thin instrument with a tiny camera and light at its end, is inserted through one of the incisions. The thoracoscope transfers images of the inside of the chest onto a video monitor, guiding the surgeon to perform the procedure. Retractor, suction and other surgical instruments are inserted through other incisions. Steps involved in the anterior approach are performed which involves intervertebral disc removal, bone grafting and instrumentation. Lung is deflated to gain access to the spine. The incisions are closed with an absorbable suture and the deflated lung is reinflated.

 

 

ROBOTIC SPINE SURGERY

Robotic Assisted Spine Surgery is a minimally invasive spine surgery where the surgeon is assisted by a robotic system (Da Vinci surgical system) to perform the surgery. Robotic systems are becoming increasingly popular in the medical fraternity owing to the unique advantages including the precision, safety and many other advantages. The da Vinci® robotic surgical system is one of the popular and widely employed robotic systems in the specialty of medicine and is used to perform various surgical procedures.

Conventional spine surgery uses a large incision and patients may experience complications such as pain, damage to the surrounding organs and nerves and long recovery period. In contrast, the da Vinci® robotic system is the most effective and least invasive technique which ensures faster recovery with minimal pain and minimal risks as compared with conventional spine surgery. Robotic spine surgery is indicated in patients suffering from chronic, debilitating back pain or restricted range of motion caused by spinal deformities and degenerative conditions.

The da Vinci® surgical system consists of a surgeon's console, a patient-side cart with four interactive robotic arms, a high-performance vision system (3D camera) and miniaturized EndoWrist surgical instruments.

Unlike the traditional surgery, this procedure is performed through small incisions. The surgeon sits on a console and controls the movement of the robotic arms holding the special surgical instruments. The movements of the surgeon’s hands are translated, by the robotic system, into precise movements of the miniaturized instrument that are held by the robotic arms.  Moreover, this approach also provides the surgeon with 3D, magnified view of the operating area.  The enhanced vision and superior control of the micro-instruments improves the precision of the surgery.

Being a minimally invasive approach, robot spine surgery offers the following benefits:

  • Smaller incisions leading to reduced scarring and minimal blood loss

  • Less post-operative pain

  • Shorter hospital stay and recovery period

  • Quicker return to daily normal activities

  • Lower incidence of complications

The da Vinci® Robot System is considered safe and effective, but may not be appropriate for everyone. Always discuss with your doctor about all treatment options suitable for you, as well as the benefits and risks.

 

 

POSSIBLE COMPLICATIONS OF SPINAL SURGERIES

Possible complications may occur before surgery, during surgery and after surgery.

  • Before Surgery:

The most serious complication of a herniated disc that may occur before surgery is the development of the cauda equine syndromeIt occurs when a large particle of disc material is ruptured into the spinal canal. It occurs in the area where the nerves that control the bowels and bladder travel before they leave the spine. This causes pressure on these nerves resulting in permanent damage. Bowel and bladder controlling ability is lost. If this problem occurs, surgery could be recommended immediately to try to remove the pressure on the nerves.

  • During Surgery:

Complications during surgery occur due to anesthesia given during any type of surgery. Possible complications that can occur during removal of a herniated disc may include injury to the nerves and a dual tear. There is a risk of injuring the spinal cord leading to nerve damage that causes paralysis. Tear in the dura mater covering the spinal cord may occur.

  • After Surgery:

Sometimes complications may take some months to become evident after surgery and may include:

  • Infection

    Any surgical procedure has a risk of developing infection. Infection may occur in the skin incision, inside the disc or in the spinal canal around the nerves. If infection involves the skin incision, antibiotics may be needed, and if infection involves the spinal canal, a secondary operation may be required to drain the infection. Antibiotics may be required to treat the infection after the second operation.

  • Re-herniation

    In 10 to 15 % cases re-herniation occurs during first six weeks after surgery. It can occur at any time and may require a second operation.

  • Persistent Pain

    Occasionally, surgical procedure does not eliminate the pain. Pain may persist due to several reasons. Disc herniation may put pressure against the spinal nerves causing nerve damage thus resulting in pain along the nerve. Scar tissue may form around the nerves a few weeks after the operation, causing pain like the pain before the operation.

  • Degenerative Disc Disease

    Degeneration of the spinal segment can result from injury to the disc. A disc that has undergone operation has been injured. Additional problems may develop in the area where a disc has been removed. If pain from the degenerative process becomes severe, a second operation may be required. Several years may be needed to develop degenerative disc disease.

 

 

POST-OPERATIVE INSTRUCTIONS

Your surgeon may recommend a few specific post-operative instructions following spinal surgery. You should follow the instructions of the surgeon to aid in faster recovery with optimum results.  The duration of hospitalization depends on the treatment rendered. The period of your rest or inactivity depends on a few factors such as the type of surgical procedure and the approach used to access your spine, the size of the incision and presence of any complications. Return to work or normal activity depends on the type of work or activity you plan to perform.

The instructions that you should follow after your surgery are as follows:

  • Take medications as recommended by your doctor

  • Keep your incision area clean and dry to promote wound healing

  • Avoid smoking, driving, lifting heavy things, swimming or using a hot tub

  • Follow the specific restriction of activity, as advised

  • Start physical therapy as instructed by your doctor

  • Schedule your follow up appointment with your doctor as advised.

Please consult your doctor immediately if you experience fever over 101° F or if the incision site shows signs of infection such as pain, redness, swelling, or increased drainage from the incision.

 

 

SPINE REHABILITATION

Effect of Spine Dysfunction

Dysfunction of the spine can be severely debilitating to one’s ability to perform activities at both home and work.  Pain in the lumbar spine (lower back) is the number one reason for missed days of work, followed by pain of the cervical spine (neck) as the second. 

Physical Therapy Intervention

Research has shown that targeted exercises, proper body mechanics, and correct postural concepts taught within physical therapy can help decrease spine dysfunction and significantly reduce the risk of recurrence. 

Rehabilitation team consists of physical therapists, orthopedic doctors, massage therapists and athletic trainers in case of rehabilitation for sports injuries. The rehabilitation team works on various physical activities and flexibility exercises that help to regain the strength and motion of the injured site.

How can beFIT THERAPY Help?

At beFIT THERAPY, each of our Doctors of Physical Therapy is trained and up-to-date in the most current manual therapy techniques and exercise prescriptions specific to spine rehabilitation.  Using treatment regimens customized by the individual and their injury, we can simultaneously treat both the injury itself and the resulting symptoms.

The advantages of the rehabilitation program include:

  • Stretching and bending exercises improve flexibility of the injured site

  • Massage techniques - Massage relieves the tension of the muscles and improves the blood flow to the injury site

  • Restores the functions and movements of the broken or injured joints

  • Corrects biomechanical dysfunction - Running shoes are recommended for people having foot injuries. These shoes have a harder material inside of the sole which prevents the foot from rolling in.

 

 

HEALTHY BACK TIPS

Back and neck pain are the most common health problems experienced by most people, at some point of their lives. People with back pain or neck pain may have trouble in performing daily routine activities.

There are several things that you can do to relieve stress and lessen your back and neck pain. Some of the preventive measures which can help include:

  • Posture: Ensure that you maintain a proper posture while sitting and standing.

If you require sitting for a long time, try to move around every 20 minutes. In addition, anything that supports your back – such as a rolled-up towel can be used to relieve the stress on the back. When standing, keep one foot forward of the other with knees slightly bent, this position relives pressure off your back.

  • Bending: If possible, avoid bending straight from the waist.

  • Lifting: Ensure that you use correct lifting techniques such as squatting to lift a heavy object. Always lift objects with your leg muscles and not with your lower back and keep the objects close to the body.

  • Weight control: If you are overweight or obese, it can strain the back muscles. Hence it is advised that you lose some weight and maintain a healthy diet.

  • Quit smoking: Smoking reduces blood flow to the spinal discs and causes back pain. So, quitting smoking can help you keep your back healthy and strong.

  • Exercise: Exercise everyday as it improves spine stability and prevents extra stress on your back. Do warm up exercises before the start of any physical activity or sports and take short breaks in between the activity.

 

 

PROPER LIFTING

Lifting heavy weights and improper lifting of weights is one of the foremost causes for neck pain or lower back pain. Practicing proper lifting techniques is essential to avoid strain on the neck and back.

Prior to lifting weights, stretch slowly and stop lifting weights if you experience any sharp pain. While lifting weights never bend at the waist. Put one knee on the ground, and use your arms and legs to lift the object up onto the opposite thigh. Stand up. Take the object close to the body while lifting weight and put effort on your legs to get the object off the ground, rather than your lower back.

You will never hear of thigh muscle strain due to lifting weights; that is because the thigh muscles are longer, stronger and more resistant to strain. The muscles and ligaments in the back however are shorter and prone to muscle spasm. Hence, while lifting weights, put one knee on the floor, use your arm strength to raise the object up to your mid-thigh, and then use the power of your legs to stand up. Another approach is to bend both knees in a squatting position, grasp the object keeping fingers underneath it, keep your back straight, and stand up slowly. In either case, strain your leg muscles to generate the lifting force, not back muscles.

Recreational Dos & Don'ts While Lifting Weights:

Dos:

  • Do place your feet and knees at least shoulder wide apart while lifting

  • Do squat or lean over with the chest and buttocks sticking out

  • Do take weight off one or both arms if possible

  • Do balance your load on either side if possible, so that both sides are equally stressed

  • Do level the pelvis, lower back and neck in uniform alignment while lifting overhead

  • Do stretch and walk around before or after bending or heavy lifting

Don’ts:

  • Don't lift or carry unbalanced and heavy weights

  • Don't lift and bend too quickly

  • Don't lift things overhead with your neck and back bent.

  • Don't tense and arch the neck when lifting

  • Don't lift things when your feet are too close together

  • Don't lift with your knees and hips straight and your lower back rounded

  • Don't lift heavy objects directly following a prolonged period of relaxation

 

 

TREATMENT OPTIONS FOR BACK AND NECK PAIN

Back and neck pain are common symptoms of injury, damage, deformity or unhealthy spinal conditions. Pain may range from a mild ache to a sharp shooting pain that can spread down your arms and legs. There are many conservative and surgical treatment options that can relieve pain by targeting the symptoms or the underlying problem.

  • Non-surgical Treatment:

Some common non-surgical treatment options to relieve back and neck pain include:

  • Hot or cold compresses: Applying heat or ice on the affected region of the back or neck over a towel to relieve pain and inflammation

  • Physical therapy: Staying active and performing core, muscle strengthening and stretching exercises to relieve pain and improve strength, flexibility and endurance.

  • Manipulation, mobilization and massage

  • Relaxation techniques such as deep breathing and meditation

  • Pain relievers: Non-steroidal anti-inflammatory drugs (NSAIDs), opioid medications (like morphine), anticonvulsants, muscle relaxants and antidepressants

  • Nerve block: Corticosteroids and/or anesthetics are usually injected into the epidural space (space between vertebrae and spinal cord) or facet joint (joints betwTREATMENT OPTIONS FOR BACK AND NECK PAIN

    Back and neck pain are common symptoms of injury, damage, deformity or unhealthy spinal conditions. Pain may range from a mild ache to a sharp shooting pain that can spread down your arms and legs. There are many conservative and surgical treatment options that can relieve pain by targeting the symptoms or the underlying problem.

  • Non-surgical Treatment:

Some common non-surgical treatment options to relieve back and neck pain include:

  • Hot or cold compresses: Applying heat or ice on the affected region of the back or neck over a towel to relieve pain and inflammation

  • Physical therapy: Staying active and performing core, muscle strengthening and stretching exercises to relieve pain and improve strength, flexibility and endurance.

  • Manipulation, mobilization and massage

  • Relaxation techniques such as deep breathing and meditation

  • Pain relievers: Non-steroidal anti-inflammatory drugs (NSAIDs), opioid medications (like morphine), anticonvulsants, muscle relaxants and antidepressants

  • Nerve block: Corticosteroids and/or anesthetics are usually injected into the epidural space (space between vertebrae and spinal cord) or facet joint (joints between vertebrae).

  • Maintain good posture

  • Transcutaneous electrical nerve stimulation (TENS): low-voltage electric pulses are targeted to stimulate the nerve that carries pain signals

  • Bracing: Braces support your back or neck and allow it to heal after a sprain, strain or fracture.

  • Surgical Treatment:

There are many surgical procedures indicated for severe cases of back and neck pain that do not improve with conservative treatments. Surgery treats the underlying cause of pain and may include:

  • Discectomy: removal of a diseased intervertebral disc compressing the spinal nerves causing pain

  • Spinal fusion: removal of an intervertebral disc that is causing painful rubbing of the vertebrae followed by fusion of adjacent vertebrae with bone graft

  • Artificial disc replacement: removal of intervertebral disc causing painful rubbing of the vertebra, and replacing the space with an artificial metal disc

  • Spinal decompression: removal of part of the bone that is compressing a neighboring nerve

  • Laminectomy: removal of parts of bone, bone spurs or ligaments

  • Foraminotomy: the space through which nerve roots exit is widened by trimming bone at the sides of vertebrae

  • Corpectomy: removal of the one or more vertebral bodies along with the discs and replacing with bone graft

  • Vertebroplasty and kyphoplasty: injection of bone cement to fuse fragments of compression fractures and stabilize the vertebra.

  • Reduction: use of metal rods, screws and cages to support and stabilize reduced fractureseen vertebrae).

  • Maintain good posture

  • Transcutaneous electrical nerve stimulation (TENS): low-voltage electric pulses are targeted to stimulate the nerve that carries pain signals

  • Bracing: Braces support your back or neck and allow it to heal after a sprain, strain or fracture.