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Low Back Pain :

Over 80% of the population will suffer from lower back pain during their lives. Although low back pain can be quite debilitating and painful, in about 90 percent of all cases, pain improves without surgery. However, 50 percent of all patients who suffer from an episode of low back pain will have a recurrent episode within one year.

Lumbar Spine :

The lumbar spine (lower back) consists of five vertebrae in the lower part of the spine between the ribs and the pelvis. The bones (vertebrae) that form the spine in the back are cushioned by small discs. These discs are round and flat, with a tough, outer layer (annulus) that surrounds a jellylike material called the nucleus. Located between each of the vertebra in the spinal column, discs act as shock absorbents for the spinal bones. Thick ligaments attached to the vertebrae hold the pulpy disc material in place. Of the 31 pairs of spinal nerves and roots, five lumbar (L1-L5) and five sacral (S1-S5) nerve pairs connect beginning in the area of the lower back.

Common Causes of Low Back Pain :

1). Herniated disc:

The bones (vertebrae) that form the spine in the back are cushioned by small discs. Located between each of the vertebra in the spinal column, these discs act as shock absorbents for the spinal bones preventing the bony vertebrae from grinding against one another. With age, these cushioning discs gradually wear away and shrink, a condition known as degenerative disc disease. The rubbery discs that lie between the vertebrae in the spine consist of a soft center (nucleus) surrounded by a tougher exterior (annulus). A herniated disc occurs when a portion of the nucleus pushes through a crack in the annulus. A herniated disc (also called a bulged, slipped or ruptured) disc.

A herniated disc in the lower back can put pressure on the nerve that extends down the spinal column. This commonly causes pain to radiate to the buttocks and all the way down the leg. This condition is called sciatica.

2). Osteoarthritis:

It is the most common type of arthritis and affects middle-aged or older people most frequently. It can cause a breakdown of cartilage in joints and occur in almost any joint in the body. It most commonly affects the hips, knees, hands, lower back and neck. Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. It serves as a kind of “shock absorber,” helping to reduce friction in the joints. When osteoarthritis affects the spine, it is known as spondylosis.

3). Spondylosis :

 It is a degenerative disorder that can cause loss of normal spinal structure and function. Although aging is the primary cause, the location and rate of degeneration varies per person. Spondylosis can affect the cervical, thoracic and/or lumbar regions of the spine, with involvement of the inter-vertebral discs and facet joints. This can lead to disc degeneration, bone spurs, pinched nerves and an enlargement or overgrowth of bone that narrows the central and nerve root canals, causing impaired function and pain.

When spondylosis affects the lumbar spine, several vertebrae usually are involved. Because the lumbar spine carries most of the body’s weight, activity or periods of inactivity can both trigger symptoms. Specific movements, sitting for prolonged periods of time and lifting and bending all may increase pain. When spondylosis worsens, a patient may develop spinal stenosis.

4). Lumbar Spinal Stenosis:

It is narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs. If the narrowing is substantial, it causes compression of the spinal cord or spinal nerves, which causes the painful symptoms of lumbar spinal stenosis, including low back pain, buttock pain, and leg pain and numbness that is made worse with walking and relieved by resting. While it may affect younger patients, due to developmental causes, it is more often a degenerative condition that affects people who are typically age 60 and older.

5). Degenerative spondylolisthesis:

Slippage of one vertebra over another is caused by osteoarthritis of the facet joints. Most commonly, it involves the L4 slipping over the L5 vertebra.

6). Degenerative scoliosis:

It occurs most frequently in the lower back and more commonly affects people aged 65 and older. Back pain associated with degenerative scoliosis usually begins gradually and is linked with activity. The curvature of the spine in this form of scoliosis is often relatively minor. Surgery may be indicated when nonsurgical measures fail to improve pain associated with the condition.

Vertebral fractures. Usually caused by osteoporosis (brittle bones)

Diagnosing Low Back Pain:

Diagnosis is made based on history, symptoms, a physical examination and the results of diagnostic studies, if required. Some patients may be treated conservatively and then undergo imaging studies if medication and physical therapy are ineffective. Tests used to help confirm the causes of back pain include:

  • X-rays
  • Magnetic Resonance Imaging (MRI)
  • Computerized axial tomography (CAT) scan or CT scan
  • Bone scan
  • Bone density test
  • Nerve Conduction Studies (NCS)

Lower Back Pain Treatment Options

1). Non Surgical (Conservative):-

It include physical therapy, back exercises, weight reduction, steroid injections (epidural steroids), non steroidal anti-inflammatory medications, rehabilitation and limited activity. It aims at relieving the inflammation in the back and irritation of nerve roots. Usually four to six weeks of conservative therapy is advised before considering surgery.

Anti-inflammatory medications to reduce swelling and pain and analgesics to relieve pain. Most pain can be treated with nonprescription medications, but if pain is severe or persistent, a doctor may recommend prescription medications.

Epidural injections may be prescribed to help reduce swelling. This treatment is not recommended repeatedly and usually provides only temporary pain relief.

Physical therapy and/or prescribed exercises may help stabilize the spine, build endurance and increase flexibility. Therapy may help with the resumption of normal lifestyle and activities. Yoga may be effective for some people in helping to manage symptoms.

Maintaining a proper weight is crucial to effective management of osteoarthritis. Being overweight is a risk factor for osteoarthritis. Practice good posture when sitting or standing. When lifting something, lift with the knees, not with the back.

Smoking — the bad habit that increases the risk of dozens of diseases — can also lead to backaches. Get help to kick the habit of smoking.

2). Surgical:-

When conservative treatment for low back pain does not provide relief, surgery may be needed. One may be a candidate for surgery if:

  • Back and leg pain limits normal activity or impairs quality of life
  • Progressive neurological deficits develop, such as leg weakness and/or numbness
  • Loss of normal bowel and bladder functions
  • Difficulty standing or walking
  • Medication and physical therapy are ineffective
  • The patient is in reasonably good health

Following are some of the procedures for treating low back pain:

  • A discectomy relieves pressure from a nerve root pressed on by a bulging disc or bone spur. In this procedure, a small piece of the lamina, a bony part of the spinal canal is removed.
  • A foraminotomy is a surgical procedure that opens up the foreman, the bony hole in the spinal canal where the nerve root exits.
  • Radiofrequency lesioning or ablation is a way to use radio waves to interrupt the way the nerves communicate with each other. A special needle is inserted into the nerves and heats it, which destroys the nerves.
  • Spinal fusion makes the spine stronger and cuts down on painful motion. The procedure removes discs between two or more of the vertebrae and then fuses the vertebrae next to each other with bone grafts or special metal screws.
  • A spinal laminectomy, also known as spinal decompression, removes the lamina to make the size of the spinal canal bigger. This relieves pressure on the spinal cord and nerves.

How To Prevent Low Back Pain:

There are many ways to prevent low back pain. Practicing prevention techniques may also help lessen the severity of the symptoms of a lower back injury. Prevention involves exercising the muscles in the abdomen and back, losing weight in case overweight, lifting items properly (bending at the knees and lifting with the legs), and maintaining proper posture.

Sleep on a firm surface and sit on supportive chairs that are at the correct height. Avoid high-heeled shoes. Quit smoking – nicotine causes degeneration of spinal discs and also reduces blood flow.


A herniated disc refers to a problem with one of the rubbery cushions (discs) between the individual bones (vertebrae) that stack up to make the spine.

The discs are protective shock-absorbing pads between the bones of the spine (vertebrae). The cushion-like discs between the vertebrae of the spine are also referred to as inter-vertebral discs. A herniated disc can irritate nearby nerves and result in pain, numbness or weakness in an arm or leg. On the other hand, many people experience no symptoms from a herniated disc. Most people who have a herniated disc don’t need surgery to correct the problem.

Symptoms :

Symptoms vary greatly depending on the position of the herniated disc and the size of the herniation. Most herniated discs occur in the lower back (lumbar spine), although they can also occur in the neck (cervical spine). The most common signs and symptoms of a herniated disc are:

1). Lumbar spine (lower back): Sciatica frequently results from a herniated disc in the lower back. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling and numbness that radiates from the buttock into the leg and sometimes into the foot. Usually one side (left or right) is affected. This pain often is described as sharp and electric shock-like. It may be more severe with standing, walking or sitting. Along with leg pain, one may experience low back pain.

2). Cervical spine (neck): Symptoms may include dull or sharp pain in the neck or between the shoulder blades, pain that radiates down the arm to the hand or fingers or numbness or tingling in the shoulder or arm. The pain may increase with certain positions or movements of the neck.

Causes :

A single excessive strain or injury may cause a herniated disc. However, disc material degenerates naturally as one ages, and the ligaments that hold it in place begin to weaken. As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture.

Certain individuals may be more vulnerable to disc problems and, as a result, may suffer herniated discs in several places along the spine. Research has shown that a predisposition for herniated discs may exist in families, with several members affected.

Risk Factors :

Factors that increase your risk of a herniated disc may include:

  • Excess body weight causes extra stress on the discs in the lower back.
  • People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also may increase the risk of a herniated disc.
  • Some people inherit a predisposition to developing a herniated disc.

Treatment :

Fortunately, the majority of herniated discs do not require surgery. However, a very small percentage of people with herniated, degenerated discs may experience symptomatic or severe and incapacitating low back pain, which significantly affects daily life.

The initial treatment for a herniated disc is usually conservative and nonsurgical. (A doctor may prescribe bed rest or advise the patient to maintain a low, painless activity level for a few days to several weeks. This helps the spinal nerve inflammation to decrease. Bed rest is not recommended)

A herniated disc frequently is treated with non steroidal anti-inflammatory medication if the pain is only mild to moderate. An epidural steroid injection may be performed utilizing a spinal needle under X-ray guidance to direct the medication to the exact level of the disc herniation.

Physical therapy may be recommended. Therapy may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation and stretching exercises. Pain medication and muscle relaxants also may be beneficial in conjunction with physical therapy.

Surgery :

Surgery may be recommended if conservative treatment options, such as physical therapy and medications, do not reduce or end the pain altogether.

The benefits of surgery always should be weighed carefully against its risks. Although a large percentage of patients with herniated discs report significant pain relief after surgery, there is no guarantee that surgery will help every individual.

A patient may be considered a candidate for spinal surgery if:

  • Back and leg pain limits normal activity or impairs quality of life
  • Progressive neurological deficits develop, such as leg weakness and/or numbness
  • Loss of normal bowel and bladder functions
  • Difficulty standing or walking
  • Medication and physical therapy are ineffective
  • The patient is in reasonably good health

Lumbar Spine Surgery :

Lumbar laminotomy is a procedure often utilized to relieve leg pain and sciatica caused by a herniated disc. It is performed through an incision down the center of the back over the area of the herniated disc. During this procedure, a portion of the lamina may be removed. Once the incision is made through the skin, the muscles are moved to the side so that the surgeon can see the back of the vertebrae. A small opening is made between the two vertebrae to gain access to the herniated disc. After the disc is removed through a discectomy, the spine may need to be stabilized. Spinal fusion often is performed in conjunction with a laminotomy. In more involved cases, a laminectomy may be performed.

In artificial disc surgery, an incision is made through the abdomen, and the affected disc is removed and replaced. Only a small percentage of patients are candidates for artificial disc surgery. The patient must have disc degeneration in only one disc, between L4 and L5, or L5 and S1 (the first sacral vertebra). The patient must have undergone at least six months of treatment, such as physical therapy, pain medication or wearing a back brace, without showing improvement. The patient must be in overall good health with no signs of infection, osteoporosis or arthritis. If there is degeneration affecting more than one disc or significant leg pain, the patient is not a candidate for this surgery.

Cervical Spine Surgery :

The medical decision to perform the operation from the front of the neck (anterior) or the back of the neck (posterior) is influenced by the exact location of the herniated disc, as well as the experience and preference of the surgeon. A portion of the lamina may be removed through a laminotomy, followed by a discectomy. After the disc is removed, the spine often needs to be stabilized. This is accomplished using a cervical plate and screws (instrumentation), and, often, spinal fusion.

Post-surgery specific instructions and usually pain medication will be prescribed. Some patients may benefit from supervised rehabilitation or physical therapy after surgery. Discomfort is expected during a gradually return to normal activity, but pain is a warning signal that the patient might need to slow down. Are you want to know more about Cervical Spine Surgery in India?


Majority of people with pain from cervical disc disease will get better on their own over time with simple, conservative treatments. Surgery, however, may help if other treatments fail or if symptoms worsen.

Cervical disc disease is caused by an abnormality in one or more discs, the cushions that lie between the neck bones (vertebrae). When a disc is damaged due to arthritis or an unknown cause, it can lead to neck pain from inflammation or muscle spasm. In severe cases, pain and numbness can occur in the arms from pressure on the cervical nerve roots.

Cervical spine surgery is generally performed on an elective basis to treat either:

  • Nerve/spinal cord impingement (decompression surgery)
  • Spinal instability (fusion surgery).

The two procedures are often combined, as a decompression may de-stabilize the spine and create the need for a fusion to add stability. Spinal instrumentation (such as a small plate) can also be used to help add stability to the spinal construct.

Surgery for cervical disc disease typically involves removing the disc that is pinching the nerve or pressing on the spinal cord. This surgery is called a discectomy. Depending on where the disc is located, it can be removed through a small incision either in the front (anterior discectomy) or back (posterior discectomy) of the neck while under anesthesia.

Microdiscectomy is another similar technique which involves removing the disc through a smaller incision using a microscope or other magnifying device.

When the disc is removed, a procedure is usually performed to close the space that’s left and restore the spine to its original length. Patients have two options:

  • Artificial cervical disc replacement
  • Cervical fusion

Artificial disc can improve neck and arm pain as safely and effectively as cervical fusion while allowing for range of motion that is as good or better than with cervical fusion. People who get the artificial disc are often able to return to work more quickly as well. It’s also not known how the artificial discs will last over time. People who get an artificial disc can always opt for cervical fusion later. But if a patient has cervical fusion first, it’s not possible to later put an artificial disc in the same spot.


It is quite common for patients who underwent surgery to have bouts of constipation—an inability to pass stool, or difficulty passing stool because it’s dry or hardened—than the average person which causes discomfort or pain. There are several aspects of back surgery which may lead to constipation. They include anesthesia, changes in diet, stress and the use of some pain-relieving medicines.

When it comes to defining constipation, there’s no hard-and-fast rule for bowel movement frequency.  Stool tends to become harder and harder as the length of time between bowel movements increases. This is because more water is absorbed back into the bloodstream, causing the stool to dry out in the colon.

Spine injury and constipation :

Spinal cord injuries may cause tightness (spasticity) or looseness (flaccidity) in the muscles of the rectum, sphincters, and pelvic floor. The degree of tightness or looseness may be related to the severity or completeness and level of the injury. If the injury is above level T11/T12, then the muscles of the sphincters and pelvic floor may be tight, which leads to constipation. If the injury is level T11/T12 or lower, then these muscles may be loose, which leads to stool incontinence. People with incomplete spinal cord injuries tend to have more muscle strength and sensation and therefore have fewer bowel problems than people with complete injuries.

A spinal cord injury can lead to bowel problems which can cause pain in the abdomen. Bowel problems can also contribute to depression or anxiety. Symptoms associated with constipation are:

  • Pain and bloating in the abdomen
  • Nausea and vomiting
  • Hard stools and the inability of bowel movement.

Common causes of constipation after spine surgery :

Spine surgery patients are prone to constipation for multiple reasons, the primary reason being the prescription drugs given for pain relief.

1). Pain medication:

Opioids are a powerful type of pain medication and are frequently given after surgery to control the pain. Unfortunately, all opioids have a well-known side effect of causing constipation. One way in which opioids promote constipation is that they decrease the movement of food through the intestinal tract, which gives the body more time to remove water. This can lead to a drier than typical stool. It’s also believed that opioids may actually increase the amount of water that is absorbed from the GI tract. Finally, opioids may decrease the urge to have a bowel movement, which again allows more time for the body to remove water.

2). Food and drink after surgery:

As a part of the preparation for surgery, patients are usually advised not to eat or drink. After surgery, patients may be advised to eat or drink minimally and perhaps not eat at all for a day or two. The combination of too little fluid and no food intake can work against your body’s normal routine of elimination. Too little fluid in the body means less fluid in your stools, resulting in hard, dry bowel movements. Food works to stimulate the digestive system and keep things moving along. With no food being eaten, the “food in, food out” mechanism doesn’t work as well.

Dietary choices along with intake level also may have changed after surgery. Even the food provided in the hospital may be a significant change from the normal diet and can cause constipation.

Inactivity: Getting up and walking or being active is one of the triggers for a bowel movement. So suddenly spending most of the time in bed resting after surgery does not assist the bowels in moving stool along.

Preventing constipation after spine surgery

It is ideal to prevent constipation after surgery, rather than develop it and have to treat it. Following are some tips to optimize bowel health and avoid as much discomfort as possible.

1). Medications:

Reduce the use of narcotic medicines and use only what is needed for controlling pain. Narcotic medicines slow bowel movement and cause constipation. Use non-narcotic pain relieving medicines to prevent constipation. Use fiber laxatives, stool softeners or combination products after back surgery to prevent constipation.

2). Increase fluid intake:

Drinking more fluids, avoiding caffeinated beverages and focusing on beverages (water and juice) can help keep well-hydrated and decrease the risk of constipation. Fluids will also help the body to recover after developing constipation. Apple cider juice and prune juice are effective natural laxatives.

3). Eat more fiber:

Increase fiber intake by eating fruits and vegetables, preferably as close to their natural state as possible. A whole orange will do a better job of providing fiber for diet than orange juice with the pulp removed. Avoid foods known to cause constipation. It is best to avoid cheese, meat and processed food. Instead of large meals, have frequent, small meals throughout the day.

4). Physical activity:

Physical activity, such as walking, has also been shown to decrease the risk of constipation. Follow the doctor’s instructions regarding the limits on exercise.

Medicines for constipation :

Non-prescription medicines can be taken for preventing or treating constipation after back surgery. Here is a list of some effective medicines that relieve constipation:

  • Bulk fiber laxatives, which add bulk to stool and encourage water to stay in the colon. These medicines need up to three days to show effect.
  • Stool softeners or emollient laxatives help in softening stool by making fluids mix with them.
  • Stimulant laxatives take action by stimulation of bowel contractions for moving stool out. They are effective and start working very quickly.
  • Suppositories also perform the dual function of stool softening and acting as laxatives. The colon gets contracted, and stool is pushed out and as the stool gets softer, it can pass easily.
  • Enemas perform the function of bowel movement stimulation. Liquids are injected into the rectum, up into the colon. This stimulates the colon, and stool is passed.

Importance of maintaining bowel function :

Worsening and untreated bowel function can lead to many additional health problems:

  • Partial paralysis of the stomach
  • Chronic heartburn
  • Gas pain
  • Stomach or intestinal ulcers
  • Hemorrhoids
  • Abdominal discomfort, pain or distension
  • Nausea
  • Bloating or fullness
  • Change in weight (related to a poor diet or a decrease in appetite)
  • Autonomic dysreflexia – This is a serious condition where a dangerous elevation in blood pressure is associated with a drop in heart rate in people with spinal cord injury at levels T6 and above. It may cause heavy sweating, flushing, headaches, and blurry vision. If left untreated, it may lead to stroke, bleeding in the eyes, swelling of the heart or lungs, and other severe health problems.
  • Worsening pain and/or spasticity
  • Decreased sense of well being

These health problems can reduce your quality of life. Constipation should not be ignored, especially after a stressful experience like surgery. But you may be able to avoid these problems by taking proper precaution and remedies.


Metastatic Spinal Tumor :

A spine tumor is an abnormal growth of tissue found in and/or around the spinal column and/or spinal cord. Spinal metastasis is common in patients with cancer. The spine is the third most common site for cancer cells to metastasize, following the lung and the liver.

Symptoms of Metastatic Spinal Tumor

Early diagnosis of the metastatic spinal disease is important because the functional outcome depends on the neurologic condition at the time of presentation. Back pain, the most common presenting symptom in patients with metastatic tumor to the bone or epidural space, often precedes the development of other neurologic symptoms by weeks or months. However, most back pain is not caused by tumors and not all tumors are symptomatic.

Neurological symptoms, such as weakness, tingling or numbness in the arms or legs may also develop due to a spinal tumor, but these symptoms tend to occur several weeks or months following the onset of back pain.

Patients may experience one or any combination of the following symptoms, and some people with metastatic spinal tumors do not have any symptoms at all. It is important to document symptoms, as they can be used to help diagnose metastatic spinal tumors.

Metastatic Spinal Tumor Pain :

The back pain that is caused by spinal tumors generally tends to be described as severe and not relieved by rest or pain medication. There are a number of types of pain that can be caused by spinal tumor growth.

  • Aching pain in the bones: Tumor growth can result in a number of biological responses, such as local inflammation or stretching of the anatomical structures around the vertebrae. These biological sources of pain are often described by patients as a deep ache that tends to be worse at night, even to the point of causing one to wake up from the pain, and/or pain that is worse first thing in the morning after waking up and improves somewhat after getting up and moving around.
  • Pain that shoots down the arm or leg: This type of nerve pain, also called radicular pain, travels along the path of the nerve – down the leg if the tumor is in the lumbar spine, or down the arm, if the tumor is in the cervical spine. Radicular pain is often described as burning or shooting pain that follows the path of the nerve into the extremities. Radicular pain may be accompanied by neurological symptoms along the affected nerve, such as weakness, tingling or numbness.
  • Pain with movement: If the tumor is growing within the vertebra, the walls of the vertebra can become thin and weaken. If left untreated, the bones can fracture. A vertebral fracture can result in sudden onset pain that tends to be more severe during movement or when placing pressure on the bone, such as when sitting and standing.

Neurologic Dysfunction :

After pain, the next most common symptom of metastatic spinal tumors is neurological dysfunction, such as tingling, weakness and/or numbness, or impaired muscle control in the arms or legs.

Neurological symptoms can occur if the tumor growth or vertebral fracture compresses neurological structures in and around the spine. In addition to nerve symptoms that accompany radiculopathy (as discussed above), potentially serious neurological symptoms may include:

  • Cauda equine compression: Significant compression of the cauda equina (bundle of nerves at the base of the spine) may result in varying degrees of bowel or bladder problems, lower extremity weakness and/or loss of sensation in the buttocks. This condition requires immediate medical attention and may require prompt surgery.
  • Spinal cord compression: Compression of the spinal cord may result in various degrees of limb weakness and an impaired ability to move limbs.

Other symptoms may include :

  • Loss of ability to control the bladder or bowel.
  • Instability while walking.
  • Diminished sensation, particularly below where the tumor is located.
  • Overactive reflexes, such as twitching and spastic tendencies.
  • The rapid succession of alternating contractions and partial relaxations.

Metastatic Spinal Tumor Treatment :

There are several considerations that must be examined to determine the best treatment. For many metastatic spinal tumor patients, treatment plans focus mainly on preserving and improving the patient’s quality of life. For others, treatment may focus on the removal of the tumor.

Treatment of metastatic spinal tumors must take into consideration the following:

  • Type of cancer
  • Number of tumors in the spine
  • Location of tumor
  • Current cancer treatment
  • Life expectancy
  • Patient’s quality of life
  • Patient’s general condition, including comorbidities such as anemia, diabetes, high blood pressure, etc.

Overall, the patient’s personal preferences and considerations regarding his or her primary cancer are important in deciding how to treat the spinal tumor(s).

The goals of treatment for metastatic spinal tumors are generally :

  • Palliative treatments designed to optimize the patient’s quality of life, and to minimize pain and disability, including:
  • Pain relief
  • Preservation of neurological function
  • Prevention of fracture
  • Correction of spinal instability
  • Improvement of the patient’s general functionality and ability to move/walk
  • Support the patient’s ongoing cancer treatments that are designed to bring cancer into remission or to prolong the patient’s life. Debulk, or shrink, the spine tumor to decrease the tumor burden

In general, earlier diagnosis and treatment of spinal tumor symptoms result in a better outcome. Cancer patients who experience the development of new symptoms of back pain and/or limb neurological symptoms should seek immediate medical care.

Nonsurgical treatment of Metastatic Spinal Tumors :

Nonsurgical options are considered first-line treatment for many metastatic spinal tumor symptoms and tumor management. Nonsurgical options vary from medications to radiation therapy.

  • Medications: Medications, such as nonsteroidal anti-inflammatory drugs, may be used to reduce pain. Narcotics may be used for short term pain management. Hormonal treatments may be used for metastases that are sensitive to hormones, such as breast and prostate cancer.
  • Back braces: Braces may be used for symptom relief when mechanical pain develops as a result of spinal instability. Braces are generally used in combination with other treatments.
  • Radiation therapy: Radiation therapy has proven effective in shrinking tumors and is often the treatment of choice for alleviating pain associated with metastatic spine tumors. High levels of radiation energy directed at the tumor can shrink tumor cells, relieving pressure on nerve roots and/or the spinal cord. Studies have indicated a success rate of 70% in alleviating pain. However, it can take up to 2 weeks to feel pain relief.

There are a variety of methods of radiation delivery. For spinal tumors, external radiation therapy methods are used – a machine outside the body delivers radiation to the tumor. Stereotactic radiosurgery uses imaging to target the tumor so that higher doses of radiation can be given with less risk of damage to healthy tissue.

  • Ablation: Ablation refers to an energy source that is transmitted locally to the tumor through a needle. Ablation is designed to target and destroy unhealthy tissue (the tumor) while sparing healthy tissue. The goal of treatment is to shrink the tumor to relieve pain associated with pressure on the nerve roots and/or spinal cord.
  • Radiofrequency ablation: designed to target and destroy the tumor tissue with heat (radiofrequency energy)
  • Cryoablation: designed to use cold gas to freeze and destroy tumor cells.

Primary cancer treatments do not have to be stopped for ablation procedures, and pain relief is often felt in hours/days.

  • Chemotherapy: Chemotherapy can be divided into antitumor drugs and drugs that prevent or ameliorate the effects of the tumor. Antitumor chemotherapy currently plays a relatively limited role in the treatment of spinal metastases. Chemotherapy may also be used to kill tumors cells that may remain after surgical removal of the tumor.

Surgical treatment of Metastatic Spinal Tumors :

Surgical removal of a spine tumor is indicated for patients who may benefit from the tumor removal, either in terms of removing cancer and/or lessening any severe symptoms associated with the tumor. There are many types of surgery that may be considered as part of treatment for a spinal tumor. In general, there are two categories of surgery:

  • Minimally invasive surgery – surgical approaches that include relatively small incision(s)
  • Open surgery – more extensive surgical procedures that require larger incision(s)

Minimally invasive procedures are more commonly performed, although open (more extensive) surgical procedures may be an option in certain cases.

Minimally invasive treatment for spinal tumors :

Surgery is considered minimally invasive when it involves small incisions (e.g. ½ inch) and minimal tissue disruption. Most minimally invasive procedures have relatively short recovery times.

Vertebroplasty and kyphoplasty are also known as vertebral augmentation are typically reliable procedures designed to provide pain relief for patients who have a vertebral fracture associated with a spinal tumor.

  • Vertebroplasty: This procedure involves inserting a needle through a small incision in the back so that a medical-grade bone cement can be inserted into a fractured vertebra to fill in the empty spaces and act as an internal cast to stabilize the bone. The treatment is designed to reduce pain, prevent further collapse of the vertebra, and restore the patient’s mobility.
  • Kyphoplasty (vertebral augmentation): Kyphoplasty also involves injecting bone cement into a vertebra and involves the additional step of first inserting a balloon into the bone and inflating the balloon to create a cavity. This treatment is designed to stop the pain caused by a spinal fracture and to stabilize the bone via an internal cast.
  • Transarterial Chemoembolization: This procedure involves a small incision in the thigh for access to the femoral artery. A catheter guided by a wire is directed through the vascular system to the tumor with the aid of imaging. Once the tumor is located, a chemotherapeutic agent is injected directly into the tumor to shrink or destroy the tumor to remove pressure on individual nerve roots or the spinal cord.

Open surgery for spinal tumors :

In general, extensive surgical procedures (open surgery) are often avoided in patients with metastatic spinal tumors. Patients with metastatic cancer are susceptible to systemic complications, and studies have not proven that survival is extended reliably with aggressive treatment of spinal metastases.

Open surgical procedures for the treatment of metastatic spine tumors are primarily performed on patients who meet the following criteria:

  • A life expectancy of more than 6 months
  • Only one tumor
  • Neurological deficits (such as weakness, loss of muscle control) and/or significant spinal instability

Patients with slow-growing metastatic spinal tumors, such as those resulting from breast or thyroid primary cancers, and those with only one spinal tumor are potential candidates for removal with a curative goal.

It is likely that stabilization of the vertebra is necessary after the removal of the tumor, which can be done at the same time (as part of the same surgery) as the tumor removal.

  • Spinal stabilization surgery: The goal of treatment is to stabilize the spine and to reduce any deformity that may have developed. Surgeons will choose the best stabilization method based on tumor type, the extent of bone destruction, general patient condition, and anticipated cancer treatments. There are various surgical approaches as well as stabilization methods available. While the goal of surgery is fusion, treatments for cancer, like chemotherapy, may interfere with the bone healing required to create a fusion. Stability in cases where fusion does not occur relies on solid mechanical fixation from implants such as titanium screws, plates, rods and cages
  • Spinal decompression surgery: Operative methods to relieve pressure placed on the spinal cord are classified as follows:
  • Corpectomy – removal of the body of a vertebra and the discs
  • Laminectomy – removal of a small part of the bony arches of the spinal canal called the lamina
  • Costotransversectomy – removal of a part of a rib along with the transverse process of a vertebra

The most suitable method of decompression is selected based on a number of considerations, including the anatomical location of the tumor and general condition of the patient.

In general, surgical treatment is customized to the patient’s overall health condition, the type and stage of cancer, as well as the location, size, and type of spinal tumor(s). Open surgery is relatively rare but can be helpful in certain cases.


Vertebral compression fractures (VCFs) are the most common fracture in patients with osteoporosis. The prevalence of this condition increases as people age. People who have sustained one VCF are at five times the risk of sustaining a second VCF. Occasionally, a VCF can be present with either minor symptoms or no symptoms, but the risk still exists for additional VCFs to occur.

Causes :

VCFs occur when the bony block or vertebral body in the spine collapses, which can lead to severe pain, deformity and loss of height. These fractures more commonly occur in the thoracic spine (the middle portion of the spine), especially in the lower part. While osteoporosis is the most common cause, these fractures may also be caused by trauma or metastatic tumors.

1). Osteoporosis

In people with severe osteoporosis, a VCF may be caused by simple daily activities such as:

  • stepping out of the shower
  • sneezing vigorously
  • lifting a light object

In people with moderate osteoporosis, it usually takes increased force or trauma, such as:

  • falling down
  • attempting to lift a heavy object

2). Trauma

People with healthy spines most commonly suffer a VCF through severe trauma. Injury severe enough to cause a vertebra to break can occur with a fall from a tall height in which the person lands on his or her feet or buttocks. It can also occur in a person involved in a car accident.

3). Pathologic fracture

Pathologic fracture is a fracture occurring in the vertebra due to the pre-existing disease at the fracture site. Most commonly, this type of break is from cancer in the bone, which has often traveled from other sites in the body called metastasis, such as from the prostate, breast, or lungs. Metastatic tumors should be considered as the cause in patients younger than 55 with no history of trauma or only minimal trauma. The bones of the spine are commonplace for many types of cancers to spread. Cancer may cause destruction of part of the vertebra, weakening the bone until it collapses.

The pathologic fracture can also occur with other diseases, such as Paget’s disease of bone and infection of the bone (osteomyelitis).

Symptoms :

The main clinical symptoms of VCFs may include any of the following, alone or in combination:

  • Sudden onset of back pain. It tends to be in the lower back but may occur in the middle or upper back or neck. Some people may also have hip, abdominal, or thigh pain
  • Numbness, tingling, and weakness which could mean compression of the nerves at the fracture site
  • An increase in pain intensity while standing or walking
  • A decrease in pain intensity while lying on the back
  • Limited spinal mobility
  • Eventual height loss
  • Eventual deformity and disability
  • Losing control (incontinence) of urine or stool or inability to urinate (urinary retention) which could mean the fracture may be pushing on the spinal cord itself

Complications :

Complications related to VCF include:

  • Segmental instability
  • Kyphosis
  • Neurological complications

1). Segmental instability

There is a risk of segmental instability when a fracture leads to a vertebral body collapse of more than 50 percent. The spinal segments work together to enable weight-bearing, movement and support of the entire spine. When one segment deteriorates or collapses to the point of instability, it can produce pain and impair daily activities. The instability ultimately results in quicker degeneration of the spine in the affected area.

 2). Kyphosis

Kyphosis is a common disorder in older women who have osteoporosis and frequent VCFs. The front of the vertebrae will collapse and “wedge” due to the lack of normal vertebral space. Kyphosis leads to a more rounded thoracic spine. This deformity is sometimes referred to as hunchback or dowager’s hump.

Severe kyphosis may cause extreme and debilitating pain. The hunchback deformity may eventually compress the heart, lungs, and intestines. This, in turn, can lead to fatigue, shortness of breath and loss of appetite.

3). Neurological complications

If the fracture causes part of the vertebral body to place pressure on the spinal cord, the nerves and spinal cord can be affected. The normal space between the spinal cord and the beginning of the spinal canal can be reduced if pieces of the broken vertebral body push into the spinal canal.

The narrowing of the spinal canal due to a VCF can lead to immediate injury to the spinal nerves or can cause problems later from irritation of the nerves. The lack of space can also lower the supply of blood and oxygen to the spinal cord. This can lead to numbness and pain in the nerves that are affected. The nerves may lose some of their mobility when the space around them decreases, which can lead to nerve irritation and inflammation.

Diagnosis :

1). X-rays: People older than 65 years, who have cancer, or who have had significant trauma may have X-rays performed. If younger than 65 years and do not have any medical problems or severe pain, then X-rays may not be necessary.

2). CT scan of the spine: If a fracture is discovered, it may be needed to determine the extent of the fracture.

3). MRI of the spine: A diagnostic test that produces 3-D images of body structures using powerful magnets and computer technology; can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration, and tumors.

4). Dual-energy x-ray absorptiometry (DXA or DEXA) or bone densitometry: This test is the established standard for measuring bone mineral density and can determine if osteoporosis exists. The scanner painlessly and rapidly directs x-ray energy from two different sources towards the bone being examined in an alternating fashion at a set frequency. A DEXA scan can detect small changes in bone mass and is also more flexible since it can be used to examine both the spine and the extremities. A scan of the spine, hip or the entire body requires less than four minutes.

Treatment :

1). Non-surgical treatment for Vertebral Compression Fractures

Traditionally, people with severe pain from VCFs have been treated with bed rest, medications, bracing or invasive spinal surgery, often with limited effectiveness. Pain secondary to acute vertebral fracture appears to be caused in part by vertebral instability (non-union or slow-forming union) at the fracture site. VCF-related pain that is allowed to heal naturally can last as long as three months. However, the pain usually decreases significantly in a matter of days or weeks.

  • Pain medications: Over-the-counter pain medications are often effective in relieving pain. Both acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended. Narcotic pain medications and muscle relaxants are often prescribed but only for short periods of time, due to the risk of addiction.
  • Activity modification: Bed rest may be advised for a short period of time, followed by a limitation on some activities. However, prolonged inactivity should be avoided.
  • Back bracing: A back brace can provide external support to limit the motion of fractured vertebrae, similar to the support a cast provides on a leg fracture. The rigid style of back brace limits spine-related motion greatly, which may help reduce pain. However, braces should be used cautiously and only under a doctor’s supervision. Weakening and loss of muscle can occur with excessive use of braces for lumbar conditions.

2). Surgical Treatment for Vertebral Compression Fractures :

When conservative treatment options have proven ineffective, the following surgical procedures may be used to treat VCFs:

  • Vertebroplasty
  • Kyphoplasty

Vertebroplasty and Kyphoplasty

These procedures for spinal compression fractures involve small, minimally invasive incisions, so they require very little healing time. They also use acrylic bone cement that hardens quickly, stabilizing the spinal bone fragments and therefore stabilizing the spine immediately. Most patients go home the same day or after one night’s hospital stay.

Patients with the following criteria may be considered candidates for vertebroplasty or kyphoplasty:

  • Osteoporotic VCFs in any area of the spine that has been present for more than two weeks, causing moderate to severe pain and unresponsive to conservative therapy
  • Painful metastases and multiple myelomas
  • Painful vertebral hemangiomas (benign, malformed vascular tumors composed of newly formed blood vessels)
  • Vertebral osteonecrosis (a condition resulting from poor blood supply to an area of bone, which causes bone death)
  • Reinforcement of a pathologically weak vertebral body before a surgical stabilization procedure

Vertebroplasty: This procedure is effective for relieving pain from vertebral compression fractures and helping to stabilize the fracture. During this procedure:

  • A needle is inserted into the damaged vertebrae.
  • X-rays help ensure that it’s done with accuracy.
  • The doctor injects a bone cement mixture into the fractured vertebrae.
  • The cement mixture hardens in about 10 minutes.
  • The patient typically goes home the same day or after a one-night hospital stay.

Kyphoplasty: This procedure helps correct the bone deformity and relieves the pain associated with vertebral compression fractures. The procedure involves:

  • A tube is inserted through a half-inch cut in the back into the damaged vertebrae. X-rays help ensure the accuracy of the procedure.
  • A thin catheter tube — with a balloon at the tip — is guided into the vertebra.
  • The balloon is inflated to create a cavity in which liquid bone cement is injected.
  • The balloon is then deflated and removed, and bone cement is injected into the cavity.
  • The cement mixture hardens in about 10 minutes.

Patients with any of the following criteria should not undergo these procedures:

  • A VCF that is completely healed or is responding effectively to conservative therapy
  • A VCF that has been present for more than one year
  • Greater than 80-90 percent collapse of the vertebral body
  • Spinal curvature, such as scoliosis or kyphosis, that is due to causes other than osteoporosis
  • Spinal stenosis or herniated discs with nerve or spinal cord compression and loss of neurological function not associated with a VCF
  • Untreated coagulopathy (a disease or condition affecting the blood’s ability to coagulate)
  • Osteomyelitis (an inflammation of the bone and bone marrow, usually caused by bacterial infection)
  • Discitis (nonbacterial inflammation of an intervertebral disc or disc space)
  • Significant compromise of the spinal canal caused by impeding bone fragment or tumor


A spinal tumor is an abnormal mass of tissue within or surrounding the spinal cord and/or spinal column. These cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells.

One way to describe a spine tumor is by whether it is primary or metastatic:

  • primary tumor is one that originated in the area in the area in which it is found.
  • metastatic tumor is one that develops as an extension of another cancer (such as lung, breast, colon, or kidney).

Another way to describe a tumor is by whether it is benign vs. malignant:

  • benign spinal tumor usually has definite borders and clean edges and does not infiltrate into healthy tissue. A benign tumor is not cancer, but it may need to be removed if it’s causing symptoms or creating pressure on the spine. Benign spine tumors include meningiomas, schwannomas, osteoid osteomas, and osteoblastomas.
  • malignant tumor is a cancerous growth that spreads and infiltrates into other tissue. Malignant spine tumors include chondrosarcomas, Ewing sarcomas, and osteosarcomas.

Spinal tumors may be referred to by the region of the spine in which they occur. These basic areas are cervical, thoracic, lumbar and sacrum. Additionally, they also are classified by their location in the spine into three major groups: intradural-extramedullary, intramedullary and extradural.

  • Intradural-extramedullary: These are tumors that occur outside the spinal cord but within its protective covering. These tumors are often meningiomas, Schwannomas, or neurofibromas. Like intramedullary tumors, these tumors are often benign, but they can be difficult to remove surgically and may recur after treatment.
  • Intramedullary: These tumors grow in the spinal cord itself, or in the nerves extending from the spinal cord, usually in the upper spine or neck (called the cervical spine). They are often astrocytomas, ependymomas, or hemangioblastomas. Intramedullary tumors are usually benign but can also be difficult to remove due to their location.
  • Extradural: These are the most common type of spinal tumors, forming outside the spinal cord and the dura in the bones and cartilage of the vertebrae. Some extradural tumors, such as osteosarcomas, osteoblastomas, and osteoid osteomas, arise from the vertebrae themselves (primary), but extradural tumors are more often metastatic tumors that spread from cancers of the lung, breast, prostate, and kidney.

Symptoms :

Non-mechanical back pain, especially in the middle or lower back, is the most frequent symptom of both benign and malignant spinal tumors. This back pain is not specifically attributed to injury, stress or physical activity. However, the pain may increase with activity and is often worse at night. Pain may spread beyond the back to the hips, legs, feet or arms and may worsen over time even when treated by conservative, nonsurgical methods that can often help alleviate back pain attributed to mechanical causes. Depending on the location and type of tumor, other signs and symptoms can develop, especially as a malignant tumor grows and compresses on the spinal cord, the nerve roots, blood vessels or bones of the spine. Impingement of the tumor on the spinal cord can be life-threatening in itself.

Additional symptoms can include the following:

  • Loss of sensation or muscle weakness in the legs, arms or chest
  • Difficulty walking, which may cause falls
  • Decreased sensitivity to pain, heat and cold
  • Loss of bowel or bladder function
  • Paralysis that may occur in varying degrees and in different parts of the body, depending on which nerves are compressed
  • Scoliosis or other spinal deformity resulting from a large, but benign tumor

Diagnosis :

A thorough medical examination with emphasis on back pain and neurological deficits is the first step to diagnosing a spinal tumor. Radiological tests are required for an accurate and positive diagnosis which includes – X-ray, CT scan, MRI

After radiological confirmation of the tumor, the only way to determine whether the tumor is benign or malignant is to examine a small tissue sample (extracted through a biopsy procedure) under a microscope. If the tumor is malignant, a biopsy also helps determine the cancer’s type, which subsequently determines treatment options.

Treatment Options:

Treatment options include surgery, radiation, chemotherapy, or a combination of all three depending on the unique circumstances associated with each individual tumor.

Tumors that are asymptomtic or mildly symptomatic and do not appear to be changing or progressing may be observed and monitored with regular MRIs. Some tumors respond well to chemotherapy and others to radiation therapy. However, there are specific types of metastatic tumors that are inherently radioresistant (i.e. gastrointestinal tract and kidney): in those cases, surgery may be the only viable treatment option.

Multiple surgical treatment options are available ranging from surgery to correct spinal deformity or neural compression to interventional techniques where cement is injected into the bone to help strengthen the spine.


About Dr. Arun Saroha

Dr.Arun Saroha is working as Neurosurgeon with a special interest in spine surgery for the last 15 years. He specializes in Neuro-oncology, Paediatric Neurosurgery, Neurotrauma, Stroke & Cerebrovascular surgery including Transnasal surgeries. He has also been performing instrumented/ Non-instrumentation spine surgeries, including minimally invasive spine surgeries. He has performed more than 6,000 Neurosurgeries (Spine and Brain) successfully till date with patients from all over the world.


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