Spine
Disorders and their Treatment
Spondylosis:-
The gradual deterioration of the disc between the vertebrae
is referred to as Degenerative Disc Disease (DDD) or Spondylosis. Degenerative
Disc Disease is very common affecting 40-50% of people over the age of 40 and
becomes increasingly common as we age. It is a kind of wear and tear disease
similar to osteoarthritis.
Although it can occur at any spinal level, it is most common
in the lumbar spine (low back). DDD can cause the discs to flatten losing their
normal height. This disc height is important as it separates the disc above
from the one below.
When disc height is lost, the nerve pathways may become
narrowed and cause nerve impingement, inflammation, and pain. As the 'discs'
degenerate, they become thinner.
Sometimes the vertebrae develop small, rough areas which may
irritate the nearby nerves. This causes troublesome symptoms like severe neck
pain and stiffness and pain down the arms and hands. Most patients tend to get
better with medication and exercises.
However occasionally the spondylotic changes can lead to
compression of the spinal cord or the nerve roots and this may result in pain,
numbness and weakness in the upper limbs (radiculopathy).
Cervical spondylosis is chronic degeneration of the bones of
the neck (cervical spine) and the cushions between the vertebrae (inter
vertebral disc). The treatment involves removal of worn out discs or bone spurs
- depending on the underlying problem.
If required the surgeon will fill the gap with a graft of
bone or other implants made of metal combined with bone. Patients have reported
their symptoms as being as mild occasional backaches to chronic low back pain
that is severe enough to limit their activities at work and play.
The pain is typically mechanical in nature. This means the
pain increases as more stress or load is placed on the low back. Bending,
lifting, and twisting are the types of movement that may exacerbate DDD. Management rarely does DDD require surgery.
There are several non-surgical treatments including
anti-inflammatory medication, physical therapy and exercise programs. Surgery
is only considered when the patient's symptoms are debilitating; interfere with
activities of daily living, and non-surgical treatment has failed after a
reasonable period of time, usually at least six months.
Fusion permanently stops the motion of the spine at the level
of the degenerated disc. This helps to relieve pain. Fusion for DDD is best
when limited to one or two discs. Fortunately we have five discs in the lumbar
spine.
The un-fused discs take over to provide adequate function of
the lower back. An artificial disc can also be inserted into the space after
removing the entire degenerated disc. This surgery is done from the front. This
restores disc height, improves spine function, and helps to eliminate debilitating
pain.
Slipped Disc
A prolapsed disc is a condition when the inner, softer part
of the disc bulges out through a weakness in the outer part of the disc. This
bulging disc may then press on nearby nerves which in turn causes discomfort
and pain.
The symptoms include - back pain, ache in the arm or leg and
pinpricks felt in feet, toes and hands. Management As a rule, surgery may be considered
if the symptoms have not settled after about six weeks or so.
At Apollo Hospitals, the spine surgeons may opt for: Keyhole
surgery - Also known as microdiscectomy spine surgery, it is typically
performed when there is a prolapsed disc in the lumbar (lower back) region
which is pressing against a nerve.
Disc replacement - An artificial disc is a device that is
implanted into the spine to imitate the functions of a normal disc (carry load
and allow motion). Artificial discs are usually made of metal or plastic-like
(biopolymer) materials, or a combination of the two.
The disc replacement for prolapsed disc is done in the
cervical (neck) spine.
Spondylolisthesis
Spondylolisthesis is a Greek term meaning slipping of the
spine. It is the abnormal forward movement of one vertebra over the vertebra
below. Most often, this forward slip of the vertebra occurs in the lumbar area
of the spine.
This slippage and herniation of the disc causes pressure on
the nerve roots associated with the affected vertebrae, causing pain and
dysfunction. There are various types of spondylolisthesis.
·
Type
1 - Congenital spondylolisthesis
An individual is born with the
abnormality of the posterior bony arch of the spine, which causes the slippage.
This is usually seen at the L5-S1 level and often associated with abnormality
of the facet joints. Patients usually present with back pain during the adolescent
growth spurt. CT and MRI scans are required to diagnose the dysplasia (abnormal
bone formation).
·
Type
2 - Isthmic spondylolisthesis
Isthmic spondylolisthesis is caused
by a defect in a part of the bone called the pars interarticularis. The pars
bone connects the upper joint of one vertebra to the lower joint. The defect is
usually caused by a stress fracture in individuals with a hereditary
predisposition (some minor abnormality or weakness of the pars at birth). In
certain individuals a defect may exist without any forward slip, referred to as
spondylolysis. This condition can be painful.
·
Type
3 - Degenerative spondylolisthesis
Degenerative spondylolisthesis is a
forward slippage secondary to arthritis of the spine. Spinal stenosis is
usually associated with this process. This is due to a long standing
degenerative disc leading to weak facet joints in the back of the spine. This
is usually seen at L4-L5 level.
Management In degenerative spondylolisthesis,
surgery is indicated if slippage progressively worsens or if back pain does not
respond to nonsurgical treatment and begins to interfere with activities of
daily living.
In the congenital and high dysplastic
group, surgery is done at early stages to prevent neurological complications.
Scoliosis
The spine has normal curves if seen from the sides and is
seen as a straight column from the front. But in certain conditions the spine
shows curvatures from the front and it is called scoliosis.
The abnormal forward bending of the spine is called kyphosis.
Scoliosis is a term taken from a Greek word meaning curvature. During the 19th
Century physicians thought poor posture was the primary cause of scoliosis.
Today scoliosis is known to be either congenital (present at
birth) or developmental and may be hereditary. The disease causes the spine to
curve to the side usually in the shape of an "S" or "C".
The curvature is measured in degrees. 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.
Physical signs may include uneven shoulders, one hip lower than the other, a
rib hump when bent over at the waist and leaning to one side.
Whatever the patient's age, the goal is to stabilize the
spine to prevent additional curvature. Some patients with scoliosis are pain
free and do not seek treatment until the deformity is noticed.
Unfortunately, at that point it may be too late to treat the
disease. The size of the curve is measured in degrees on an X-ray. The
progression of scoliosis is monitored by periodic x-ray studies. When scoliosis
is severe it may cause the spine to rotate, which can cause spinal spacing to
narrow on the opposite side of the body.
While minor deformities may be treated non-operatively, more
severe and progressive ones require surgery. Surgical Management of Scoliosis Surgical treatment of scoliosis is
employed if the curvature at detection is of greater magnitude.
The aim of surgical correction is to achieve a well-balanced
spine in which the patient's head, shoulders and trunk are cantered 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.
Usage of Staple A more recent development in the treatment of Scoliosis 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 concave side thereby correcting the curve as the child grows.
Special spinal implants made from Nitinol - a titanium based
alloy has been studied extensively and is being employed clinically in a few
centers in USA and Europe. 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-yr old girl, from a small town near
Madurai, by the senior spine surgeon Dr. Sajan Hegde and his team.
Spinal
Tumor
A spinal tumor or a growth of any kind - whether cancerous or
not, can impinge on nerves, leading to pain, neurological problems and
sometimes paralysis.
The symptoms include loss of sensation or muscle weakness,
especially in the legs, difficulty in walking, sometimes leading to falls and
loss of bowel or bladder function. Newer techniques and instruments enable
surgeons at Apollo Hospitals, India to reach tumors or treat delicate injuries
even in the most inaccessible areas.
High-powered microscopes are used during surgery and in some
instances even intradural tumors are removed. In select patients, Total Spondylectomy
- removal of the entire vertebra is done as a definitive cure.
Spinal
Injuries
A spinal cord injury occurs when there is damage to the
spinal cord either from trauma, loss of its normal blood supply, or compression
from tumor or infection.
The injuries may be of two types - complete or incomplete. In
complete injuries the body ceases to function below the level of injury. In
incomplete injuries there is some function remaining below the level of injury.
Surgery is performed for spinal cord injury to stabilize the
spine. If the vertebrae are weakened from fracture, tumor or infection, they
may not be capable of supporting the normal weight from the body and protecting
the spinal cord.
A combination of metal screws, rods and plates may be
necessary to help hold the vertebrae together and stabilize them until the
bones heal. After surgery it is critical that patients undergo a thorough
rehabilitation program.
