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21/Aug/2019

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.

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

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.

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

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.

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.

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

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.

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

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.

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

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.

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 have 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

21/Aug/2019

Spinal fusion is surgery to permanently connect two or more vertebrae in the spine, eliminating motion between them.

Spinal fusion involves techniques designed to mimic the normal healing process of broken bones. During spinal fusion, a bone or a bone-like material is placed within the space between two spinal vertebrae. Metal plates, screws, and rods may be used to hold the vertebrae together, so they can heal into one solid unit.

Why Spinal Fusion is done

Spinal fusion permanently connects two or more vertebrae in the spine to improve stability, correct a deformity or reduce pain. Spinal fusion may be recommended to treat:

  • Deformities of the spine. Spinal fusion can help correct spinal deformities, such as a sideways curvature of the spine (scoliosis).
  • Spinal weakness or instability. The spine may become unstable if there’s abnormal or excessive motion between two vertebrae. This is a common side effect of severe arthritis in the spine. Spinal fusion can be used to restore spinal stability in such cases.
  • Herniated disc. Spinal fusion may be used to stabilize the spine after removal of a damaged (herniated) disc.

Best candidates for spinal fusion surgery

Spinal fusion surgery prevents movement between vertebrae that are rubbing against each other and causing pain. After the procedure, the two vertebrae are fused together, eliminating any movement between them. The pain should then completely disappear, permanently. Surgical procedures are usually performed only as a last resort for treating back pain, spinal fusion can lead to a long-term pain resolution for the right candidate.

Spinal fusion is considered one of the best procedures to treat people with:

  • Lumbar Spondylolisthesis: Spondylolisthesis is a condition in which one of the bones in the vertebra (vertebra) slips forward and out of place. This may occur anywhere along the spine but is most common in the lower back (lumbar spine). In some people, this causes no symptoms at all. Others may have back and leg pain that ranges from mild to severe.
  • Lumbar degenerative disc disease: This condition weakens one or more of the vertebral discs. The discs normally act as a cushion between the vertebrae. Degenerative disc disease can develop as a natural part of the aging process, but it may also result from injury to the back and become a source of chronic pain. One of the first symptoms is experiencing pain, numbness or tingling in the legs. Strong pain tends to come and go. Bending, twisting and sitting may make the pain worse. Lying down often relieves pressure on the spine.
  • Scoliosis: This condition causes a normally straight spine to curve. Scoliosis can limit the ability to move normally. If it’s severe enough, it can cause pain. A misshapen rib cage can restrict normal lung growth and the ability to breathe.
  • Unstable or weak spine
  • Spine fractures
  • Deformities

Whether spinal fusion is right for a patient or not depends on a number of factors. Ideally, the procedure works best when there are only two vertebrae involved in the movement that requires the graft. With a one-level fusion, any limitations in movement may not even be noticed.

Spinal fusion on two levels may feel slightly restrictive, depending on the location of the afflicted vertebrae. Once beyond two levels, though, a marked reduction in movement will definitely be noticed. Typically, a spinal fusion of three or more levels is reserved for those with the most severe spinal handicaps, such as extensive scoliosis or life-threatening deformities.

Important additional factors to be considered before spine fusion surgery

In addition to the spinal fusion approach used, there are a number of other factors to be considered before spine fusion surgery which include:

  • PLIF and TLIF surgery :

The posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) surgeries allow for placement of bone or a cage in the disc space, increasing the fusion rate and hopefully a better clinical outcome. There is a more neurologic risk because of the need to retract the nerve roots, however, major nerve injury is unusual. It has the advantage of placing a structural graft or device in the major weight-bearing part of the spine while avoiding a separate incision.

  • Bone graft :

Traditionally, bone graft has been harvested from the patient’s own iliac crest (pelvis) to stimulate the fusion site. Cadaver bone often is useful in anterior fusions, but it works poorly in posterior applications. Recent advances have allowed spine surgeons to decrease the need for bone graft harvest by using substitutes, e.g., collagen sponges, demineralized bone matrix, platelet-derived growth factors and, most promising, bone morphogenic protein (BMP).

The bone morphogenic protein currently in use (Infuse) has FDA approval for anterior application only. Further research is ongoing to document the utility of these products, which allow for diminished patient trauma that can occur from harvesting bone graft from the patient’s own hip.

  • Minimally invasive surgery (MIS) :

Much work is in development to try to decrease the trauma patients incur by placing pedicle screws through smaller incisions. This is thought to result in less muscle trauma and allow for more rapid recovery after spine surgery.

Caution needs to be exercised, however, as even though a technique is less traumatic, if the spine fusion rate is much lower, then there is really not an advantage. Also, it has yet to be demonstrated that minimally invasive spine fusion systems actually cause better outcomes than some other surgical techniques used in the traditional open approach.

Spine Fusion Risks and Complications

Spinal fusion is generally a safe procedure. But as with any surgery, spinal fusion carries the potential risk of complications.

Potential risks and complications include:

  • Infection
  • Poor wound healing
  • Bleeding
  • Blood clots
  • Injury to blood vessels or nerves in and around the spine
  • Pain at the site from which the bone graft is taken
  • Possible re-operation
  • Lack of a solid fusion

The most common risk of any of the modern spine fusion surgery techniques is the failure to relieve lower back pain symptoms following the surgery. In the best of all situations, this risk occurs in a minimum of 20% of spine fusion surgeries. The likelihood of this result becomes even more frequent with fusions of three or more levels. This outcome is commonly referred to as “failed back surgery syndrome”.

There is also a risk that the vertebrae may not fuse together following the surgery, called pseudoarthrosis. With modern techniques happens in approximately 5% to 10% of spine fusion surgeries.

It is well documented in the medical literature that people who smoke have a lower rate of successful spine fusion.

If pedicle screws are used, there is a risk that the screws may break or become loose and may require further surgery to remove or revise the screws and rods.

Anterior grafts and cages can migrate or subside, which may require repeat spine surgery. If the anterior devices were placed anteriorly (from the front), rather than through a PLIF or TLIF (approaches through the back), it is safest to do this revision spine fusion surgery with a posterior approach (from the back).

All spine fusion surgeries have the potential for complications. Thankfully, most of the complications occur infrequently. The complications that can occur include those that would be associated with any type of surgery, such as infection, bleeding, and anesthetic complications.

Another potential complication of spine fusion surgery in the low back includes any type of nerve damage. Although major loss of the strength and sensation to the legs or loss of bowel or bladder control can occur, it is rare. In a small percentage of men who have an anterior fusion, an infrequent complication results in difficulties with ejaculation following spine fusion surgery. There is a small plexus of nerves in front of the L5-S1 disc space that helps control ejaculation. If these nerves are affected (which can happen 1% of the time) then a valve will not close that forces the ejaculate outward. The ejaculate then follows the path of least resistance, which is up into the bladder. The most significant side effect of this complication is that it is very difficult to complete conception. The potency is not affected, and the sensation of sex is still largely the same. In about half of cases, this complication resolves over the course of about 6 to 12 months.

The success rate of spine fusion surgery

Spinal fusion operation is a salvage procedure. For patients with disabling back pain and leg pain, significant benefits can be obtained with successful spinal fusion.

Studies indicate that the patient’s pain is improved 60% to 70% after spinal fusion surgery and approximately 80% of patients undergoing spinal fusion surgery are satisfied with the surgical result.

An accurate diagnosis is needed with clear objectives for the procedure. The rest of the responsibility for success rests with the candidate. Spinal fusion works best on people who do not smoke, are not obese and live a relatively healthy lifestyle.

As with any surgery, a positive attitude goes a long way. Additionally, it is important to be motivated to pursue the physical therapy that’s going to be required following the spinal fusion surgery. Spinal fusions almost always lead to pain-free living with little or no residual complications.


21/Aug/2019

Occipital neuralgia is a condition in which the nerves that run from the top of the spinal cord up through the scalp, called the occipital nerves, are inflamed or injured. It is a common cause of headache. It involves the occipital nerves – two pairs of nerves that originate near the second and third vertebrae of the neck. The pain typically starts at the base of the skull by the nape of the neck and may spread to the area behind the eyes and to the back, front and side of the head.

It is often confused with a migraine or other types of headache because the symptoms can be similar. But treatments for those conditions are very different, so it’s important to get the right diagnosis.

How occipital neuralgia is different from other Headaches :

Headaches due to occipital neuralgia are frequently quite painful, starting with sharp, stabbing pain, but most people with this condition respond well to treatment and most recover.

It is different from other types of headaches in two ways:

  • The cause of the condition
  • The specific places where individuals feel pain

Other headaches have more general causes, which can range from sinus infections to high blood pressure to medications and many other potential triggers. But occipital neuralgia only develops when the occipital nerves are irritated or injured. These nerves are found at the second and third vertebrae of the neck.

Occipital neuralgia pain will only develop in areas touched by the greater, lesser, and third occipital nerves. With one on each side of the head, the occipital nerves run from the spine to the scalp, and sensitivity can develop anywhere along this route.

Symptoms of occipital neuralgia :

Occipital neuralgia can cause intense pain that feels like a sharp, jabbing, electric shock in the back of the head and neck. Other symptoms include:

  • Aching, burning, and throbbing pain that typically starts at the base of the head and goes to the scalp
  • Pain on one or both sides of the head
  • Pain behind the eye
  • Sensitivity to light
  • Tender scalp
  • Pain when moving the neck

Causes of occipital neuralgia :

Occipital neuralgia happens when there’s pressure or irritation to your occipital nerves, maybe because of an injury, tight muscles that entrap the nerves, or inflammation. Chronic neck tension is another common cause.

Although many of the following may be causes of occipital neuralgia, many cases can be attributed to chronic neck tension or unknown origins.

  • Osteoarthritis of the upper cervical spine
  • Trauma to the greater and/or lesser occipital nerves
  • Compression of the greater and/or lesser occipital nerves or C2 and/or C3 nerve roots from degenerative cervical spine changes
  • Cervical disc disease
  • Tumors affecting the C2 and C3 nerve roots
  • Gout
  • Diabetes
  • Blood vessel inflammation
  • Infection

Diagnosis :

It can be difficult to distinguish occipital neuralgia from other types of headaches — thus, diagnosis may be challenging. A thorough evaluation will include a medical history, physical examination, and diagnostic tests. A doctor can document symptoms and determine the extent to which these symptoms affect a patient’s daily living. If there are abnormal findings on a neurological exam, the following tests may be ordered:

Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology; can show direct evidence of spinal cord impingement from bone, disc or hematoma.

Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays; can show the shape and size of the spinal canal, its contents and the structures around it.

Treatment of occipital neuralgia :

Nonsurgical treatment

A variety of different treatment options are available for occipital neuralgia. The goal of treatment is to alleviate the pain. To relieve the pain, the following are some home treatment:

  • Apply heat to the neck
  • Rest in a quiet room
  • Massage tight and painful neck muscles
  • Take over-the-counter anti-inflammatory drugs

If those are of no help, medications may be prescribed including:

  • Muscle relaxants
  • Antiseizure drugs
  • Antidepressants
  • Nerve blocks and steroid shots. It may take two to three shots over several weeks to get control of the pain. It’s not uncommon for the problem to return at some point and to need another series of injections

Surgical treatment :

Surgical intervention may be considered when the pain is chronic and severe and does not respond to conservative treatment. The benefits of surgery should always be weighed carefully against its risks. Surgery may include:

Microvascular decompression: it involves microsurgical exposure of the affected nerves, identification of blood vessels that might be compressing the nerves and gentle displacement of these away from the point of compression. Decompression may reduce sensitivity and allow the nerves to recover and return to a normal, pain-free condition. The nerves treated may include the C2 nerve root, ganglion, and postganglionic nerve.

Occipital nerve stimulation: It involves using a nerve-stimulator to deliver electrical impulses via insulated lead wires tunneled under the skin near the occipital nerves at the base of the head. The electrical impulses can help block pain messages to the brain. The benefit of this procedure is that it is minimally invasive, and the nerves and other surrounding structures are not permanently damaged.

For most patients, conservative therapy or occipital nerve blocks are quite effective in relieving their pain. For others, more invasive therapies can be quite successful. As with many other conditions, the response to treatments can vary widely. This type of headache does not lead to other neurological conditions or nerve problems, even if left untreated.


Spondylosis_opt.png
16/Aug/2019

Cervical spondylosis is a common, age-related condition that affects the joints and discs in your cervical spine, which is in your neck. It is also known as cervical osteoarthritis or neck arthritis.

It develops from the wear and tear of cartilage and bones. While it’s largely the result of age, it can be caused by other factors as well. Cervical spondylosis is very common and worsens with age. More than 85 percent of people older than age 60 are affected by cervical spondylosis.

Some people who have it never experience symptoms. For others, it can cause chronic, severe pain and stiffness. However, many people who have it are able to conduct normal daily activities.

Symptoms of Cervical Spondylosis :

Most people with cervical spondylosis don’t have significant symptoms. If symptoms do occur, they can range from mild to severe and may develop gradually or occur suddenly.

One common symptom is pain around the shoulder blade. Some complaint of pain along the arm and in the fingers. The pain might increase when:

  • Standing
  • Sitting
  • Sneezing
  • Coughing
  • Tilting the neck backward

Another common symptom is muscle weakness. Muscle weakness makes it hard to lift the arms or grasp objects firmly.

Other common signs include :

  • A stiff neck that becomes worse
  • headaches that mostly occur in the back of the head
  • tingling or numbness that mainly affects the shoulders and arms, although it can also occur in the legs

Symptoms that occur less frequently often include a loss of balance and a loss of bladder or bowel control. These symptoms warrant immediate medical attention.

Cervical Spondylosis Causes :

The bones and protective cartilage in the neck are prone to wear and tear that can lead to cervical spondylosis. Possible causes of the condition include:

  • Dehydrated discs:- Discs act as cushions between the vertebrae of the spine. By the age of 40, most people’s spinal discs begin drying out and shrinking, which allows more bone-on-bone contact between the vertebrae.
  • Herniated discs:- Age also affects the exterior of your spinal discs. Cracks often appear, leading to bulging (herniated) discs — which sometimes can press on the spinal cord and nerve roots.
  • Bone spurs:- Disc degeneration often results in the spine producing extra amounts of bone in a misguided effort to strengthen the spine. These bone spurs can sometimes pinch the spinal cord and nerve roots.
  • Stiff ligaments:- Ligaments are cords of tissue that connect bone to bone. Spinal ligaments can stiffen with age, making the neck less flexible.

Risk Factors :

The greatest risk factor for cervical spondylosis is agingCervical spondylosis often develops as a result of changes in the neck joints with age. Disc herniation, dehydration and bone spurs are all results of aging.

Factors other than aging can increase your risk of cervical spondylosis. These include:

  • Jobs that involve repetitive neck motions, awkward positioning or a lot of overhead work put extra stress on the neck.
  • Previous neck injuries appear to increase the risk of cervical spondylosis.
  • Some individuals in certain families will experience more of these changes over time, while others will not.
  • Smoking has been linked to increased neck pain.

Diagnosis :

The following diagnostic tests may be advised to confirm the diagnosis of cervical spondylosis:

  • Neck X-ray:- An X-ray can show abnormalities, such as bone spurs, that indicate cervical spondylosis. Neck X-ray can also rule out rare and more serious causes for neck pain and stiffness, such as tumors, infections or fractures.
  • CT scan:- A CT scan can provide more detailed imaging, particularly of bones.
  • MRI Scan:- MRI can help pinpoint areas where nerves might be pinched.
  • Tracer Dye:- A tracer dye is injected into the spinal canal to provide more detailed X-ray or CT imaging.
  • Nerve function tests:- It is usually advised to determine if nerve signals are traveling properly to the muscles. This test measures the electrical activity in the nerves as they transmit messages to the muscles when the muscles are contracting and at rest.
  • Nerve conduction study:- Electrodes are attached to the skin above the nerve to be studied. A small shock is passed through the nerve to measure the strength and speed of nerve signals.

Treatment of Cervical Spondylosis

#Non-surgical treatment

In most cases, treatment for cervical spondylosis is nonsurgical. Nonsurgical treatment options include:

1). Physical therapy:- Physical therapy is usually the first nonsurgical line of treatment. Specific exercises can help relieve pain, as well as strengthen and stretch weakened or strained muscles. In some cases, physical therapy may include posture therapy or the use of traction to gently stretch the joints and muscles of the neck. Physical therapy programs vary in length but generally last from 6 to 8 weeks. Typically, sessions are scheduled 2 to 3 times per week.

2). Medications:- During the first phase of treatment, several medications may be prescribed to be used together to address both pain and inflammation. Mild pain is often relieved with acetaminophen.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs):- Often prescribed with acetaminophen, NSAIDs such as ibuprofen and naproxen are considered first-line medications for neck pain. They relieve both pain and swelling and may be prescribed for a number of weeks, depending on the specific symptoms. Other types of pain medication can be considered if there are serious contraindications to NSAIDs or if the pain is not well controlled.
  • Muscle relaxants:- Medications such as cyclobenzaprine or carisoprodol can be used to treat painful muscle spasms.

3). Soft cervical collar:- This is a padded ring that wraps around the neck and is held in place with velcro. It may be advised to limit neck motion and allow the muscles in the neck to rest. A soft collar should only be worn for a short period of time since long-term wear may decrease the strength of the muscles in the neck.

4). Ice, heat, and other modalities:- Careful use of ice, heat, massage, and other local therapies may be recommended to help relieve symptoms.

5). Steroid-based injections:- Many patients find short-term pain relief from steroid injections. The most common procedures for neck pain include:

6). Cervical epidural block:- In this procedure, steroid and anesthetic medicine is injected into space next to the covering of the spinal cord (“epidural” space). This procedure is typically used for neck and/or arm pain that may be due to a cervical disk herniation, also known as radiculopathy or a “pinched nerve.”

7). Cervical facet joint block:- In this procedure, steroid and anesthetic medicine is injected into the capsule of the facet joint. The facet joints are located in the back of the neck and provide stability and movement. These joints can develop arthritic changes that may contribute to neck pain.

8). Medial branch block and radiofrequency ablation:- This procedure is used in some cases of chronic neck pain. It can be used to both diagnose and treat a painful joint. During the diagnosis portion of the procedure, the nerve that supplies the facet joint is blocked with a local anesthetic. If the pain is relieved, then the source of your neck pain may have been pinpointed. The next step option may be to block the pain more permanently. This is done by damaging the nerves that supply the joint with a “burning” technique—a procedure called radiofrequency ablation.

# Surgical treatment of Cervical Spondylosis :

Surgery is not commonly recommended for cervical spondylosis and neck pain unless it is determined that:

  • A spinal nerve is being pinched by a herniated disk or bone (cervical radiculopathy), or
  • The spinal cord is being compressed (cervical spondylotic myelopathy).

The surgery might involve:

  • Removing a herniated disk or bone spurs
  • Removing part of a vertebra
  • Fusing a segment of the neck using bone graft and hardware

Patients who have progressive neurologic symptoms, such as arm weakness, numbness, or falling, are more likely to be helped by surgery.

Surgery may also be recommended if there is severe pain that has not been relieved by nonsurgical treatment. However, some patients with severe neck pain will not be candidates for surgery. This may be due to the widespread nature of their arthritis, other medical problems, or other causes for their pain, such as fibromyalgia.


16/Aug/2019

Lumbar disc replacement surgery:

A lumbar disc replacement is a type of back or spine surgery. The spine is made up of bones called vertebrae that are stacked on top of each other. Discs between the vertebrae act like cushions to allow the vertebrae to rotate and move without the bones rubbing against each other. The lumbar vertebrae and discs are at the bottom of the spine. Lumbar disc replacement involves replacing a worn or degenerated disc in the lower part of the spine with an artificial disc made of metal or a combination of metal and plastic. The goal of the procedure is to relieve back pain while maintaining more normal motion than is allowed with some other procedures, such as spinal fusion.

Lumbar fusion and artificial disc replacement:

It is estimated that 70% to 80% of people will experience low back pain at some point in their lives, however most will not need surgery to improve their pain. Surgery is considered when low back pain does not improve with conservative treatment.

Lumbar fusion and artificial disc replacement

For patients who have exhausted nonsurgical options and are still in pain, lumbar fusion surgery remains the most common option for treating low back pain. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.

While many patients are helped by lumbar fusion, the results of the surgery can vary. In addition, some patients whose fusion surgeries heal perfectly still end up with no improvement of their back pain. Artificial disc replacement has emerged as an alternative treatment for low back pain with the aim to preserve normal motion unlike spinal fusion which prevents normal motion in the spine.

Indications of lumbar disc replacement surgery:

In general, lumbar disk replacement surgery might be recommended if:

  • the back pain mostly comes from only 1 or 2 disks in the lower spine
  • there is no significant joint disease or compression on the nerves of the spine
  • body size is not excessively overweight
  • there has been no prior major surgery on the lumbar spine
  • there is no deformity of the spine (scoliosis)

Risk associated with lumbar disc replacement:

Like all surgeries, lumbar disc replacement poses some risks. A disc replacement requires greater access to the spine than standard lumber fusion surgery. This also makes it a riskier procedure. Some of the potential risks of this surgery include:

  • Infection of the artificial disk or the area around it
  • Dislocation or dislodging of the artificial disc
  • Implant failure or fracture (break)
  • Implant loosening or wear
  • Narrowing of the spine (stenosis) because of the breakdown of spinal bones
  • Problems due to a poorly positioned implant
  • Stiffness or rigidity of the spine
  • Blood clots in the legs due to decreased activity

Surgical procedure:

Generally artificial disk replacement surgeries take from 2 to 3 hours.

An incision will be made in the abdomen to approach the lower back. With this approach, the organs and blood vessels must be moved to the side. This allows access to the spine without moving the nerves.

The damaged disc will then be removed and the new artificial disc implant will be inserted into the disc space. The organs and blood vessels are put back in place and the incision will be closed.

Recovery:

In most cases, the patient will stay in the hospital for 3 to 4 days following artificial disc replacement. The length of hospital stay will depends upon how well-controlled the pain is and return to function.

Patients are encouraged to stand and walk by the first day after surgery. Because bone healing is not required following artificial disc replacement, the typical patient is encouraged to move through the mid-section. Early motion in the trunk area may lead to quicker rehabilitation and recovery.

Patient is allowed to perform basic exercises, including routine walking and stretching, during the first several weeks after surgery. During this time, it is important to avoid any activities that cause hyperextension of the back.

Cost of surgery:

The cost for lumbar artificial disc replacement is approx. USD 7500 with 4-5 days hospital stay. There are certain factors that determines the cost of treatment which include:

  • Overall health of the patient
  • Diagnosis, type of surgery, extent of the surgery, medications used
  • Technology or approach used
  • Expertise of the specialist
  • Accreditation, brand value of the hospital



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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