Understand Spine and spinal disorders. What are the common causes of spinal disorders?

The Spine

Spine is the central axis of our body that runs from the head to the pelvis and it is made up of a chain of bones (vertebrae) connected to each other by discs and joints. This strong structure acts as an anchor to the trunk and limbs and provides stability to our upright posture while allowing normal movements at the same time.

Apart from providing structural support to out trunk, the spine acts as a strong protective covering for the main nerve (Spinal cord) that carries the signals (stimuli) to and from the brain to the rest of our body. The nerve roots are like cables arising from the spinal cord that exit the spine, one at each level, and run into the arms, around the trunk and the legs, on both sides, supplying all the structures of the body, carrying signals – to and from the brain.

So the functions of the Spine are:

  • Structural support to the trunk and limbs
  • Allows normal range of movements
  • Houses and protects the Spinal cord and nerve roots.

As humans evolved to walk on two legs, the orientation of the spine changed from horizontal to vertical position and that makes the human spine unique, with its own unique problems.

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What are the common spinal problems?

The structures in the spine can be affected by various disorders and lead to the various symptoms related to spine. The common symptoms include back or neck pain, pain radiating down the arms or legs, numbness or weakness in the limbs, limitation of ability to walk and result in inability to do other daily routine activities of life. Less commonly, there can be paralysis of the limbs, severe numbness and loss of bowel and bladder control in situations where there is a significant compression of neural structures in the spine.

The spine can get affected by disorders at all ages from the time of development of fetus in the womb to the old age. The most common disorder affecting the spine is the age related wear and tear changes, known as “degeneration” or “spondylosis“. These wear and tear changes start in the discs of the spine and gradually affect the joints and the bones and can lead to various symptoms like back or neck pain, sciatica, weakness of limb muscles, numbness and deformity in the spine.

 

The spine can get affected by formation defects during development in the womb leading to spinal deformity. Such deformity in the spine may manifest as an abnormal swelling at birth or as a progressive hump back as the child grows. “Scoliosis” or “kyphosis” are the usual terms used to describe these deformities. Scoliosis may also develop in the growing children, that may go unnoticed till it becomes significantly large. “Spondylolisthesis” is a disorder that affects the lower spine and starts in the growing children, where there is a forward slipping of one vertebra over the other, causing back pain and deformity as well as radiating pain into the legs due to compression of the nerve roots at that level.

Traumatic injury to the spine can cause fractures or dislocation in the spine and injure the neural structures in the spine that can lead to devastating consequences like paraplegia (paralysis of both lower limbs) or quadriplegia (paralysis of all four limbs) including loss of bladder and bowel control. Minor injuries can lead to chronic pain, neurological symptoms and disability.

The spine can get affected by bacterial infections at any age, most commonly tuberculosis in India. Other bacterial infections are often encountered though not as common as tuberculosis. Infection destroys the bones and discs in the spine and can make it unstable leading to pain and nerve compression. It may also result in spinal deformity.

Spine is a common location for tumours/cancers that spread from other organs like lungs, breast, gut, liver, thyroid, prostrate gland etc. especially in the older age group. Less commonly, tumours can primarily arise in the spine itself, at any age. Spinal tumours cause pain and disability and neurological symptoms due to compression on the nerves. It is imperative that these are detected at the earliest, to prevent serious consequences and to be able to deal with them in a better way.

Osteoporosis is a disease that occurs in old age, especially in ladies after the menopause. The bones become more porous and weak and can crumble easily leading to fractures. The spine is the most common site for osteoporosis related fractures and deformity, leading to significant disability and limitation of quality of life. Osteoporosis can progress silently, without any symptoms until it results in a fracture. It can be detected early by simple screening tests like DEXA scan.

Posture related spinal problems are very common nowadays due the modern lifestyle. Sitting in bad posture on desk jobs or overuse of mobile phones with a forward bent neck puts undue strain on the spinal muscles and leads to significant pain and disability. Lack of exercise and reduced sleeping hours makes the situation worse.

Understanding the Spine and common spinal disorders can help you to take better care of your spine and prevent serious spine related disability. There are a lot of misconceptions  regarding the spinal disorders that add to the problem and appropriate education and awareness can prevent significant amount of distress.!

 

 

 

 

 

 

FAQs on spinal problems. Questions mostly asked by the patients in a spine clinic.

Here are a few brief answers to the questions frequently asked by many patients in the Spine clinic, especially in India.

What is the cause for my back/neck pain?

The most common cause of back/neck pain is strain or injury due to bad posture during the daily routine activities like sitting, bending forwards and lifting weights etc. Lack of regular exercise to the back and abdominal muscles, age related wear and tear changes in the discs and bones in the spine, obesity are other contributory factors. Severe wear and tear changes (degenerative changes) in the spine can lead to instability and pain that is worse on certain activities. Mechanical back pain usually gets better with bed rest.

A small percentage of patients have a serious problem like a fracture, infection or tumour in the spine causing the back pain. Any pain that is not relieved by rest or is worse at rest, pain that wakes you up from sleep should be considered serious and that needs a consultation with your doctor.

What should I do when I have significant back/neck pain?

If the back/neck pain is not very severe and is of a short duration, then complete bed rest for two to three days will help reduce the pain significantly. Applying ice packs and light massage with a pain balm/gel is helpful. Consult your doctor if the pain is severe, running down in to the legs/arms, not getting better with rest, night pain, if there is numbness/tingling sensation or weakness in the limbs, is associated with fever, or if the pain started after a significant injury/fall. Thorough clinical evaluation by the doctor will help identify those with possible serious causes of back pain and further investigations are advised accordingly.

Is my back pain due to a kidney stone/problem?

Possible. But not always.

Kidney problems, especially renal or ureteric stones can lead to pain in the mid and lower back, usually limited to one side, often pain radiating down to the groin or lower abdomen. There are certain indicators to differentiate pain coming from kidney or other organs in the abdomen from the pain originating in the spinal structures. In general, spine related pain is mechanical i.e., it is worse in positions where the spine is loaded like while in upright posture, walking or bending or getting up from reclined position and generally gets relieved by resting in reclined position.

Pain from the kidneys can start suddenly in any position, can be waxing and waning and may not change related to a particular posture. It may not get relieved by rest and can be severe even while reclined. These are only general indicators and it is always better to check with your doctor and get the right treatment advise.

I have back/neck pain even though my MRI says my spine is normal !! Why?

A very common cause of back or neck pain is bad posture related stress to the spinal structures that happens during the daily routine activities. Sitting/standing posture, especially at work, has a major role in producing significant pain and disability even though the X rays/MRI of the spine may be normal.

Bad sleeping posture can lead to pain in the neck/back. Sleep is important to allow the spine to recover from the daily stresses it undergoes while we are awake. Reduced sleeping time and lack of proper sleep can lead to accumulated stress in the spine and result in pain. Lack of adequate exercises to keep the spine flexible and muscles strong is another important factor leading to pain.

So, right posture and regular exercises are the two most important treatments to prevent such pain from troubling you.

Other structures close to the spine can also lead to back pain. So if the MRI of spine is normal, further evaluation might be ordered by your doctor depending on the clinical picture.

Is my back pain due to the spinal/epidural injection that was given in my back many years ago for an abdominal or leg surgery?

No. It is a common perception that the spinal / epidural injection that was given in the past for anaesthesia purpose is the cause for back pain. Many patients associate their back pain to that injection as they remember it as painful event and think that the present pain is related to that procedure. Spinal anaesthesia related back pain doesn’t usually last more than 3 to 4 days and almost never beyond one week. So the back pain that continues beyond one week or that starts much later after the spinal anaesthesia is not because of that injection and it needs evaluation by your doctor to find the right cause and treat appropriately.

Is my back pain due to my body weight / pot belly?

Overweight is an important factor contributing to back pain, especially in the lower back. Excess weight and a large belly lead to some changes in posture. The pelvis tilts forwards and the lumbar spine is also pulled forward and this posture can lead to back pain due to additional stress on the spinal joints and muscles. Lack of exercises weakens the back and pelvic muscles and contributes to the problem. Back pain due to other problems in the spine can get worse if overweight is associated. Weight reduction and core strengthening exercises in obese people are helpful in reducing the back pain.

I have back pain. Is it due to slipped disc/disc prolapse?

Not necessarily. Although disc is a predominant source of back pain, all back pains are not because of a disc prolapse. The other structures in the spine like the facet joints, ligaments, vertebrae(bones) or the muscles of the back can be the cause of pain in the back. Less commonly, pain related to abdominal organs like kidneys or pelvic organs can be perceived as back pain. Rarely, more serious conditions like infections or tumours in the spine can be the cause of pain. It is essential to see your doctor if there is significant persistent pain. There are certain red flag signs that the physicians look for to decide if further investigation is required.

Does the disc bulge/prolapse seen on my MRI get reversed again naturally?

No. The changes that happen in the disc that lead to the prolapse or bulge are not reversible. They are due to age related wear and tear changes and we all know that ageing doesn’t get reversed !. But usually, the symptoms and signs that are related to a disc prolapse get relieved with appropriate treatment, although the MRI picture may continue to be the same. So the treatment decisions are mostly dependent on patient’s symptoms and signs rather than in MRI picture alone. Only if the prolapsed disc is causing persistent symptoms and significant neurological deficits, a surgical intervention is considered.

Is lumbar disc prolapse a cause of erectile dysfunction/impotency? 

Rarely a large lumbar disc prolapse can result in severe compression of lumbar spinal nerves causing numbness and weakness in both lower limbs and loss of urine and bowel control – a condition called “cauda equina syndrome”. It is only in this condition that a disc prolapse can affect the erectile function. An erectile dysfunction in isolation, without other neurological symptoms and signs, cannot be caused by a disc prolapse.

Does the disc problem affect the ability to become pregnant in future?

No. A disc prolapse/bulge doesn’t affect the ability to get pregnant. But, there is a possibility that the back pain due to a preexisting spinal problem may get worse during pregnancy due to the extra weight that is carried and the relaxation of ligaments of pelvis and spine that occurs as a result of pregnancy related changes.

Does it help to sleep on the floor/hard surface without a bed to cure back pain?

No. It is not advisable to sleep on the floor when there is a back problem. Sleeping on the floor when there is significant back pain can actually make it worse as you need to put an extra strain on the spine while getting up from the floor. Sleeping on the regular cot with a firm mattress is alright. It is advisable not to sleep on a very soft mattress that doesn’t support the spine well and can aggravate the back pain. Do not use a thick pillow or multiple pillows while sleeping as it can cause or aggravate neck/upper back pain. A thin pillow  or a rolled sheet supporting the neck is an ideal kind of head rest.

I exercise only when I get back/neck pain. !

Many patients say this when asked about any exercise they do. It is not advisable to start exercise when there is significant back or neck pain. But it is essential to start exercises after the pain subsides, to prevent the pain from coming back again. Exercises can help strengthen your spinal muscles, increase flexibility and protect you from recurrent episodes of pain. So it is important to keep exercising when there is no pain, to keep the pain from coming back and troubling you. So do not start exercising when there is pain!!.

If you have more questions about spine related problems, please do post here.

Endoscopic lumbar discectomy

 

The SPINE lends structural stability and balance to our body helping us stand upright, while allowing flexibility in various movements. Moreover, it forms a protective canal in which the SPINAL CORD, the most important part of the neural network, flows down from the brain to the rest of our body. The spinal column is an interconnected structure of bony (vertebrae) and cartilage tissues (intervertebral discs) and it is prone to age related wear and tear. Read through to learn more about a HERNIATED DISC, its manifestations and treatment options, with special reference to a minimally invasive surgical technique called Endoscopic discectomy.

What is a herniated disc?

First, let’s understand an intervertebral disc. It is essentially a disc shaped, rubber like tough and flexible structure made of outer layers of fibrous cartilage with a softer gel like tissue in the centre. A disc lies between two adjoining vertebral bones of the spine and acts as a shock absorber. This disc undergoes wear and tear changes (degeneration) after a certain age. When the degenerated disc is subjected to any external strain or injury, the substance from the central part of the disc comes out through the tears in the outer fibrous layers. This condition is called a herniated disc. It is also referred to as prolapsed or slipped disc. A disc prolapse can occur in any part of the vertebral column; but, mostly observed in the lumbar (lower back) or in cervical (neck) region.

What happens when an intervertebral disc herniates ?

When the inner disc material protrudes through the disc surface, it may pinch or irritate the nerve roots it comes in contact with. It also elicits a severe inflammatory chemical response in that area. If this happens in the lumbar spine, it induces symptoms such as:

  1. Pain in the back,
  2. Pain running down the leg,
  3. Weakness of the muscles in the leg supplied by the affected nerve root,
  4. Numbness or tingling sensation in the respective part of the leg.
  5. Loss of bladder and bowel control if a large disc prolapse compresses multiple nerve roots.

If you feel recurring radiating pain in any of the body parts, it would be a good call to see a Spine specialist.

What causes disc herniation?

Disc herniation happens as a result of degeneration that is mostly related to the genetic composition of the person. Smoking is another well established factor that causes disc degeneration. Other factors also play a role in the process of wear and tear of the discs. Though the exact reason is hard to pick, disc herniation may be precipitated by strain on the spine during physical work, certain kind of frequent body movements or spinal injury due to any accident. Sometimes adopting improper body posture for physically demanding jobs of time may result in this condition.

What are the treatment options for herniated disc condition?

Most cases of disc herniation can be treated medically with rest, pain relievers, anti-inflammatory medication and physiotherapy. But, if the symptoms persist or the pain is severe or if it is affecting the nerve function causing numbness and weakness, it needs surgical intervention.

Minimally Invasive (Endoscopic) Spine Surgery

Spine surgery is generally adopted as the last resort to treat painful disc prolapse that do not respond to medication for a longer period (usually 3 months). Rarely, a severe nerve compression causing weakness of muscles or severe sciatica may need surgical treatment straight away. Conventional open surgery involves cutting the muscles and removing some portion of bone in the spine, which has its own complications and disadvantages. But, the advent of high definition image guided systems and surgical tools, now-a-days spine surgery for herniated discs can be done with minimal invasion.

Endoscopic Discectomy for herniated disc is a minimally invasive spine surgery carried out through a small on the back. It involves removal of herniated disc material that protrudes and compresses the adjacent nerve roots, through specially designed spine endoscopes that help in clear visualization of the structures. Instead of cutting the muscles in an open surgery, endoscopic surgery involves dilation of the muscles causing much less damage and procedure related pain. It can also be performed under local anesthesia as a day care procedure in suitable patients.

The “carelessness” gene.

We, the people of India seem to be genetically programmed to be callous and careless in almost everything that we do in our lives. It is so ubiquitous and obvious that many of us do not even consider it as abnormal or out of place to be callous!. I see it every day, in almost every thing that we do in our routine lives. I am sure you all will agree that it is most obvious in our behaviour on the roads. It is no wonder that our nation is the world capital of deaths in road accidents, loosing almost one and a half lakh people, mostly young and productive people every year to this menace. The fact that most of these accidents are preventable by being a little careful, but still there is no effort to change the behaviour; despite several attempts by the police and other organisations to educate us, makes me think that there is something wrong in our genetic composition. Lets call it the “carelessness gene” for now 🙂 .

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The disease from any abnormal gene depends on the environmental and behavioural factors also, to be expressed and manifest to the fullest. The education we get from our elders, from the schools and other sources seems to lack the ability to teach us to think about safety in what ever we do during our daily activities. Whatever safety rules we are taught seem to loose their seriousness when we see them being flouted so commonly all around us. This manifests as a serious lack of thought for safety measures in most of the things we do as grown-ups. Sometimes such behaviour is considered heroic and brave. Isn’t it the perfect environment for our carelessness gene to be expressed to the fullest.!

Lot of two-wheeler riders do not wear helmets despite knowing that they are at risk of serious head injury if they happen to fall. I see many parents wearing the helmets themselves while the kids are riding without their heads protected. Many cars marketed in our country have failed basic safety tests but are allowed to run on the roads. Driving on the wrong side of the road instead of driving a few more meters, jumping the traffic signals instead of waiting a few more seconds, crossing the roads at will and jumping over the dividers instead of walking/waiting a little more to cross safely.. all these are glaring evidence of this special gene in us expressing itself. The serious risk of injury or loss of life is completely ignored!.

I am sure you must have read or seen the news of kids loosing their lives in road accidents, while travelling in school vans or escalators, while playing near water bodies or bore holes and most recently, while going in a lift at the school. All these incidents originate from one factor.. somewhere someone has been careless.. and unnoticed or ignored despite being obviously so!.. till some innocent life is lost.

The fact that it could have been completely prevented makes me wonder why no body thought about it. Probably, the answer is that it is this genetic predisposition in us to be so callous.. the “carelessness” gene at work.

From safe garbage disposal to building norms, from personal hygiene to food safety measures, from health insurance to financial planning, from mosquito control to public healthcare delivery, and in many other aspects, we seem to be ignoring safety, hardly learning from the incidents that continue to happen all around us. This article may sound a bit of over-generalisation but if you look around and observe, I am sure you can see it.

Unless it is acknowledged that the root cause is the general lack of thought for safety, unless measures are taken to educate ourselves and our children on safety in various aspects, this attitude is unlikely to change. I think that there is a need to spend some time in schools and at home, on cultivating the habit of thinking about safety in our children from a young age. May be we should start a “THINK SAFETY” movement to raise the awareness of the necessity to think about safety.. and help in saving someone from injury or death.. what do you say!?.

Ending on a lighter note, it seems that the expression of the carelessness gene can be controlled only by modification of our behavioural and the environmental factors, until the gene is identified and genetically modified..  😉 .

 

ARE YOU WALKING AROUND WITH FRAGILE BONES?

ARE YOU AT HIGH RISK OF DEVELOPING A FRACTURE IN YOUR SPINE OR HIP? Read on to know more about OSTEOPOROSIS.

There is another silently progressing, common disease other than diabetes and hypertension that can cause potentially serious risk to your health in old age. Osteoporosis meaning “porous bones” indicates a condition where your bones become more porous, thinner and weaker due to accelerated loss of bone or reduced bone formation or both. It is most evident in the vertebrae of spine, hip bones and in the wrists.

Thin and porous vertebrae fracture easily. They crumble on their own or due to minor stresses during daily activities like coughing, sneezing, bending forwards. These fractures can be painless and go unnoticed in multiple levels till the spine develops a forward bend and a noticeable loss of height. Or it can cause significant pain and disability, limitation in daily activities and increased dependence on others. A simple slip and fall at home can cause a fracture in the hip bones that can make the patient completely bed ridden. These situations commonly cause depression and general deterioration of health and leads to other risky complications in old age.

Though it is most common women after menopause, it also happens in men above age of 65 years and in those with certain risk factors like liver or kidney disease, thyroid or parathyroid disorders, and certain tumours. Smoking has been proven to cause osteoporosis. Long term steroid intake given for various conditions and medications given for seizure disorders also can cause osteoporosis.

Osteoporosis can be detected easily by a screening test called the DEXA scan. Any one above the age of 50 years should consult an orthopaedic surgeon to know if they are at risk of osteoporosis and whether he/she needs a DEXA scan. If the DEXA scan reveals that you have osteoporosis, you must be evaluated by an orthopaedic surgeon and an endocrinologist to look for other treatable conditions that can cause osteoporosis. There are medications that are prescribed to strengthen the bones and reduce the risk of fractures in future. Diet rich in calcium and vitamin D and supplementary calcium and vitamin D medications are also an essential part of treatment.

Although the vertebral osteoporotic fractures commonly heal in a few weeks with bed rest and medications, some of them may not heal in time or cause severe pain and disability. These patients might need surgical intervention. Vertebroplasty is a procedure that involves injection of bone cement into the broken vertebra and can give immediate pain relief. Kyphoplasty is a similar procedure that can restore the height of the fractured vertebral body and reduce the forward stoop in the spine. Open surgery might be required sometimes if the collapsed vertebra causes a compression of the spinal cord or nerves in the spine. Osteoporotic hip fractures and wrist fractures often need surgical treatment for fixation.

Prevention of osteoporosis should begin in childhood. Growing bones accumulate calcium and the calcium in bones reaches a peak at around age of 26 to 30 years. After that age, there is a slow decline in the bone calcium, which accelerates in old age especially in women after menopause. So those who reach a lower peak of calcium in bones by the age of 30 are at a higher risk of developing osteoporosis in old age. This means that adequate intake of dietary calcium, vitamin D and adequate exercise from young age is very important to prevent osteoporosis.

Prevention of falls and resultant fractures in those who are osteoporotic is an important aspect of treatment. This needs modification of their living spaces to remove the risks of a slip and fall. Routine exercises and an active lifestyle load the bones and make them stronger and it is a must for all those with osteoporosis and those at risk of developing osteoporosis.

HOW SAFE IS SPINE SURGERY TODAY ?

Spinal disorders have been recognised as early as 1500 BC. Treatment of spinal disorders has evolved through various phases since then to the present day advanced interventions on the Spine.

Although most of the spinal disorders are treatable with conservative measures like medication, physiotherapy, exercises, braces etc., certain conditions need a surgical intervention to achieve best possible results. But any surgical procedure has certain risks associated with it. Spinal column houses the spinal cord and the nerve roots, which are very delicate and sensitive structures, carrying signals from the brain to the rest of the body. These structures are at risk of damage during a surgical procedure on the spine, which can lead to a minor or sometimes a serious disability due to loss of function of the limbs, bladder or bowel control or due to pain.

Spine surgery in particular, had earned a bad reputation among the general population due to the bad results of wrongly done surgeries without a complete understanding of the biomechanics of the spine, lack of adequate surgical implants or instruments, or lack of adequate training in the early decades of the 20th century.

Treatment of spinal disorders has undergone a significant and rapid change in the last few decades with introduction of various equipment and techniques. There has been a tremendous advancement in understanding the biomechanics of the spine as well as in the technological support in the last few decades, which has dramatically changed the way of surgical management of various spinal disorders. At the same time it has also improved the safety of the surgical procedures on spine by many folds. The imaging techniques like MRI and CT scan have made possible an early diagnosis of spinal problems. The imaging techniques used in the operation theatre help visualise the spine while inserting implants into the spine used to stabilize it. Technologies like computer navigation and O-arm image intensifiers provide a three dimensional visualisation of the spine and help protect the neural structures from damage during surgery. Neuro-monitoring systems are used to monitor the neural function during surgical manipulation of the spine, especially while correcting spinal deformities. These systems warn the surgeon of any impending damage to the spinal cord and help make the surgery safer. New spinal implant systems are continuously being developed to make surgical manipulation and stabilization of the spine easier and safer. Minimally invasive techniques, made possible by the special instruments, are designed to preserve the spinal muscles.

Today spine surgery has obtained a special place for itself and both Orthopaedic surgeons and Neurosurgeons dealing with spinal disorders need to have a specialised training and focus on spine surgery to be able to achieve best results consistently. Improved safety and the good results have changed the image of spine surgery today and more and more people with spinal disorders are getting the benefit of having a better quality of life with a pain free spine.

With multiple non-surgical and surgical treatment options available, it is the thorough evaluation in the clinic and the right decision making that makes a big difference in the results of treatment of spinal disorders and hence, it is of utmost importance to take the opinion of a spine specialist.