Spine

Providing comprehensive information about conditions and treatments available for the spine.

Spine Conditions

Degenerative spine pathology

Spine trauma

Tumours involving spinal column and the spinal cord

Complex congenital spinal cord malformations

Syringomyelia

Neck Treatments & Resources

Neck Procedures (Cervical):

There are several ways to treat problems of the spine in the neck region depending on the pathology. Generally, surgery is done for relieving pressure on the nerves or spinal cord and sometimes for reliving neck pain without nerve compression.

The procedures are divided into:
  • Anterior cervical foraminotomy 
  • Anterior cervical discectomy and fusion
  • Anterior cervical corpectomy (removal of the main part of the vertebra or the body) and fusion
  • Odontoid screw fixation
  • Cervical artificial disc implant (Disc arthroplasty)
  • Cervical laminectomy (removal of the back arch of the vertebra)
  • Cervical laminoplasty (keeping the lamina in place while decompressing the spinal cord)
  • Posterior cervical foraminotomy
  • Posterior fusion (or lateral mass fusion)
  • C1/C2 (Harms/ Goal) fixation
  • Craniocervical fusion

Cervical Procedures

Arm Pain
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There are several reasons that surgery on the neck may be recommended for you. The main reasons are:

  • You have pain in your neck or arm that is coming from compression of one or more of the nerves in your neck 
  • Significant weakness due to nerve root compression.
  • You may have compression of your spinal cord that is causing symptoms (weakness, spasticity, numbness, unsteady gait, difficulty with moving arm and legs) and/or spinal cord swelling on your MRI.
  • Instability due to trauma, degenerative changes or tumour. Tumours can spread to the spine involving the bones or around the nerves/cord. Trauma causing fracture of bones or disruption of the discs). Infection which can cause deformity or compression of the nerves or the cord.
  • You may have chronic neck pain due to chronic inflammation/instability (pain under normal physiological conditions) arising from the facet joints or the disc.
  • You have pain that is persisting and has not responded to non-surgical treatment (physio, medication, cortisone injections) and allowing time to improve.

There are many reasons that you may have pain or neurological symptoms (numbness, pins and needles, or weakness) in your arm. Acute pain can be myofascial in origin meaning from the muscles or soft tissues supporting the spine. Neck pain can also be from the neck joint (facets) or disc degeneration.

Your arm or shoulder region including shoulder blade and chest wall can be painful due to cervical nerve root compression. 

    1. Compression of the nerves as they go through the holes between the vertebra (bone of the spine) by bony spurs (see image) or disc herniation (see image)
    2. Compression of the spinal cord by herniated disc or thickening of the soft tissues behind the spinal cord (ligaments inside the spinal column)
    3. Neck pain could be caused by degeneration (wear and tear) of the facet joints (joints in the back of the spine) or spinal disc (cushions between the vertebra)

  • X-rays with neck flexion and extension is often done to see your spinal alignment and if there is any gross instability/abnormal movement.
  • CT scan is often done by your GP or sometimes by your specialist as this imaging technique shows the bones very well and this could be important in making decisions and planning the surgery
  • MRI is often done as it shows the neuronal and soft tissues well, showing changes in spinal cord or more details of the site of compression of nerves and spinal cord
  • Bone scan/SPECT scan, is a nuclear medicine test that is sometimes ordered as this shows areas of active inflammation which could help in identifying the possible site or source of painful stimulus.
  • Diagnostic blocks. The diagnostic nerve blocks can be used to identify which nerve is particularly causing your symptoms. This could also provide temporary relief.
  • REPEAT of imaging may be needed if your films are more than 12 months old or your symptoms change. This needs to be discussed with your neurosurgeon.
What are the alternative treatment options for my neck or arm pain?

The best proven methods is known as “McKenzie Method” or “Mechanical diagnosis and treatment” (MDT). NOT ALL physiotherapist are familiar with this and only few are experienced with it. In this method you are assessed to find out if there is a directional relief of your pain and then given exercises that essentially repeatedly allows the neck to be in that particular direction and/or relief position is sustained repeatedly. This is found to improve the pain. Gentle massage therapy, sometime traction is also used for acute pain but these are usually do not have sustained benefit. Exercises such as swimming can be beneficial but discuss this with your physio or neurosurgeon.

Often patients use anti-inflammatories (Nurofen, Mobic, Naprosyn, etc) or paracetamol or in combination. Your GP may recommend stronger pain medication like Panadine forte, Endone or Targin, and in cases of severe nerve pain (also known as neuropathic pain) Gabapentin (Neurontin) or Pre-gabalin (Lyrica) are used.

These are commonly known as cortisone blocks. Patients are often confused about these as they are given for variety of problems and in different location. For nerve pain these can be given near the nerve and for joint pain (facet pain) these are given near the joint or the small nerves that supply the joints (“medical branch blocks”). Steroid blocks are given often for relief of pain but sometimes these can help to identify the nerve root that is involved as sometimes it is difficult to know which nerve is particularly compressed just by clinical history and examination, and MRI scan does not show specific location of the problem. The duration of these blocks varies and they are usually effective at best in about 60% of cases. Discussion with your surgeon is essential before trial of these injections. Radiofrequency ablation: where the causes of neck pain is localized to the facet joints and this responds well to the steroid block, radiofrequency ablation is a good option for long term relief of this pain. In this technique small sensory nerves that carry pain signal from the joints are heated with ultrasound frequency machine and made dysfunctional. The effect may last 12 months or more. Your surgeon will decide if this is appropriate for your condition.

There are many aspects to this. Some include avoiding lifting, especially above shoulder level, some house hold chores (vacuuming, mopping, carrying heavy pots/pans) or those that cause repeated neck flexion or sustained extension of the neck. Driving for prolonged time 30-60 min. Sitting in front of a screen for more than 30 min at a time.  Dr. Mckenzie’s books on treatment of neck and back pain are excellent source for patients with neck or back pain. https://www.mckenzieinstituteaustralia.org/

Recovery from surgery varies depending on the type of procedure and individual variation. This is discussed in detailed based on individual circumstances.

Depending on your problem you may expect:

  • Relief of spinal cord compression, surgery is to stop you from getting gradually worse and develop paralysis. If you already have symptoms of spinal cord compression like numbness, tingling and spasticity, these may still be present after surgery. Although many patients do show gradual improvement, some may have these symptoms permanently.
  • Removal of nerve compression and relief of pain and pins and needles.
  • Stabilize the neck, in order to protect the nerves or the cord from possible damage
  • Improvement of pain in order to reduce medication use and be more active
  • In general, the most reliable symptom to improve first is pain in the arm.
  • Weakness also gradually can improve but may take up to 12 months and may not come back fully.
  • Neck pain may take some time (weeks to months) to get better, and on occasions may persist. If surgery is done specifically for neck pain due to joint or disc disease the chances are better, and this is discussed with you in detail.
  • Pins and needles and numbness are less reliable in terms of improvement. This is due to the fact that the nerve fibres that carry these signals are more vulnerable to permanent injury. You should allow up to 12 months for these to improve. If there are fluctuation of these symptoms after surgery you should discuss this with your surgeon.
  • With fusion surgery there is restriction of movement.This is mostly unnoticeable with one or two levels of fusion.

Improvement of specific symptoms depends on many factors and your neurosurgeon will discuss these with you in detail.

It should be remembered in cases of arm pain without weakness where there is no spinal cord compression, the symptoms can continue with recurrent episodes of exacerbation on and off, without any severe consequences.

However, if the symptoms become chronic (lasting more than 3 months) the following can occur:

  • Pain may persist and become permanent
  • Numbness and pins and needles can become permanent
  • Muscle wasting and weakness may occur
  • Clumsiness and poor hand function/coordination may develop or worsen

With cord compression, progressive sensory abnormality and spasticity may occur which will lead to problems with balance and mobility and if left long enough lead to paralysis. Bowel and bladder disturbance can occur as well.

Spine Conditions & Resources

Non-Operative Treatment Options 

Prior to recommending a patient for surgery, Dr Kohan will explore all non-operative treatment options that are available. This may include an intensive physiotherapy program or pain management regime. 

Operative Treatment Options:

Surgery for spine is primarily considered to remove pressure from nerves and spinal cord, as well as opimising spinal alignment and/or provide stability. Most importantly your surgeon needs to be knowledgeable and experienced in various ways to address your specific condition to achieve those objectives. The surgical techniques available must be tailored to your condition and after pros and cons considered, then the appropriate technique to be undertaken.

Spinal Procedures (Lumbar):

  • Lumbar microdiscectomy
  • Lumbar laminectomy or decompression
  • Lumbar foraminotomy
  • Lumbar fusion:
    • Posterior fusion surgery
    • Anterior fusion surgery
    • Lateral fusion surgery
    • Percutaneous fusion surgery

Lumbar Spine or Lower Back Problems

Lumbar spine is the most common segment of the spine to be affected by degenerative (wear and tear) processes. 

It is very important to understand that there are many different conditions that affect lumbar spine and specific treatments or surgeries are required to treat each different condition. Therefore, it is incorrect to think that just because another person was treated with particular surgery and did well or poorly, it is appropriate or required for you or necessarily you are going to respond the same way!

Spinal surgery is complex and must be tailored to your condition. As a general rule, lumbar spinal problems are due to:
  • Degeneration
  • Trauma
  • Infection
  • Tumours of spine

Lower back pain is divided into:
  • Acute or
  • Chronic

Acute back pain is often due to soft tissue injury (myofascial), or sometimes due to disc injury.

In all acute back pain conditions lasting more than 6 weeks further investigation is indicated to exclude fracture, infection or tumours.

Lumbar spine conditions are treated when causing:
  • Pain in the leg (sciatica) due to compression of the nerves
  • Back pain (in specific situations)

The most common indications that you may need surgery are:

  • Nerve compression causing sciatica due to:
    • herniated disc (slipped disc)
    • osteophytes (bony spurs)
    • Deformity
    • Fracture
    • Tumour
    • Infection

  • Pain in the legs when walking (neurogenic claudication)
    • Due to spinal canal stenosis

  • Lumbar pain
    • Due to disc degeneration
    • Facet joint pain
    • Spinal instability: meaning there is pain
    • Spinal deformity
      • Slipped vertebra (spondylolisthesis)
      • Scoliotic deformity

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