Spine Diseases

Spinal Diseases

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Overview

The spine is made up of 33 bones called vertebrae and divided into four regions: cervical (neck), thoracic (mid back), lumbar (lower back), and sacrum. Spondylolisthesis refers to the improper positioning of a vertebra and occurs in two ways: anterolisthesis, in which the vertebral body is positioned forward in relation to the vertebra it sits above, and retrolisthesis, in which the vertebral body is positioned backward from the vertebra it is positioned above. Spondylolisthesis can be either dynamic, fixed, or glacial. Fixed spondylolisthesis indicates misalignment of one vertebral body on top of another, but that this structure does not move during motion of the spine, such as bending forward. Dynamic spondylolisthesis refers to a misaligned vertebral segment that moves when the spine moves, during flexion and extension (bending forward and bending backward). Dynamic Spondylothesis may mask misalignment because the vertebrae may seem aligned in either the flexion or the extension positions. Glacial spondylolisthesis refers to an increasing misalignment over time. Spondylolisthesis is given a grade based on its severity; the grade is determined by the distance that the vertebral body is misaligned.

There are multiple types of spondylolisthesis including isthmic, degenerative, and iatrogenic. Isthmic spondylolisthesis means that there is a defect or fracture in the area of the vertebrae that makes up the facet joints, called the pars interarticularis. This usually occurs during childhood due to stress on the spine as the part interarticularis has a poor blood supply and therefore does not heal well. The symptoms don’t manifest till adulthood so it is commonly undiagnosed until that time. Degenerative spondylolisthesis refers to degeneration of the disc, joints, and ligaments of the spinal column due to aging and wear and tear. As these parts of the spine weaken, their ability to hold the spine in alignment diminishes and may result in the slip of a vertebra. The term iatrogenic refers to any medical treatment that directly results in a complication. Iatrogenic spondylolisthesis commonly occurs as a complication or result of spine surgery.

Types

Spondylolisthesis is a malalignment of the vertebrae in which one vertebra slips forwards or backwards over the vertebra below it. There are six different types of spondylolisthesis: traumatic, iatrogenic, congenital, degenerative, pathologic, and isthmic. This type of structural abnormality of the spine can be found in all regions (i.e. cervical, thoracic, and lumbar), but most frequently occurs in the lumbar spine.

Congenital/Dysplastic

Congenital spondylolisthesis, also known as dysplastic spondylolisthesis, is an abnormality present at birth. The slip in this type of spondylolisthesis is a defect in the facet joints which connect spinal vertebrae. This occurs in the lower joints at L5 (inferior joint), the upper joints at S1 (superior joints), or at both joints and cause a gradual slip of the L5 vertebrae over time. This type of spondylolisthesis is rare compared to the other types.

Isthmic

Isthmic spondylolisthesis is the most common type of spondylolisthesis and is divided into three separate subtypes, but all have a defect at the same location in the spine. In isthmic spondylolisthesis there is a defect, typically a fracture, of the pars interarticularis, the bone that connects the upper and lower facet joints. This fracture prevents the affected vertebra from staying in line with the other vertebrae, allowing it to slide forward. The L5-S1 level is most frequently affected by isthmic spondylolisthesis.

Degenerative

Degenerative spondylolisthesis is a slip from arthritis within the spine. Degenerative changes or arthritis is common in aging individuals. Once the joints in the spine begin to wear, they have difficulty keeping the spine in line and a vertebra slips forward. This occurs most frequently in the lumbar spine, but can happen in the cervical spine as well.

Traumatic

Traumatic spondylolisthesis is a slip due to an event that places a large amount of force on the spine. This high force results in damage to the neural arch, which is the ring of bone that surrounds the spinal cord. The fracture of the neural arch causes a sliding forward of the vertebrae. Both the cervical and lumbar spine may be affected, but this is an uncommon type of spondylolisthesis.

Pathologic

Pathologic spondylolisthesis is a slip from weakness within the bones, such as tumors, types of cancers, and bone disease. This weakening causes destruction of the posterior (backside) portion of the vertebrae, such as the neural arch, which surrounds the spinal cord. Just like the traumatic type, pathologic spondylolisthesis is a rare type. 

Iatrogenic

Iatrogenic spondylolisthesis is a slip caused directly from a prior spine surgery that involved decompression of the spine without stabilization. During decompression procedure a small amount of bone is removed to release pressure on the spinal cord and/or the nerves that branch off. The removal of too much bone during this procedure can cause the vertebral body to slip. In general, this is avoided using a stabilization surgery when a large portion of bone needs to be removed.

Causes

Spondylolisthesis is typed by the cause. There are six different major causes for a vertebral slip; depending on the cause, the slip will occur in different regions of the spine.

Congenital/Dysplastic

Congenital spondylolisthesis, also known as dysplastic spondylolisthesis, is an abnormality present at birth. The slip in this type of spondylolisthesis is a defect in the facet joints which connect spinal vertebrae. This occurs in the lower joints at L5 (inferior joint), the upper joints at S1 (superior joints), or at both joints and cause a gradual slip of the L5 vertebrae over time. This type of spondylolisthesis is rare compared to the other types.

Isthmic

Isthmic spondylolisthesis is the most common type of spondylolisthesis and is divided into three separate subtypes, but all have a defect at the same location in the spine. In isthmic spondylolisthesis there is a defect, typically a fracture, of the pars interarticularis, the bone that connects the upper and lower facet joints. This fracture prevents the affected vertebra from staying in line with the other vertebrae, allowing it to slide forward. The L5-S1 level is most frequently affected by isthmic spondylolisthesis.

Degenerative

Degenerative spondylolisthesis is a slip from arthritis within the spine. Degenerative changes or arthritis is common in aging individuals. Once the joints in the spine begin to wear, they have difficulty keeping the spine in line and a vertebra slips forward. This occurs most frequently in the lumbar spine, but can happen in the cervical spine as well.

Traumatic

Traumatic spondylolisthesis is a slip due to an event that places a large amount of force on the spine. This high force results in damage to the neural arch, which is the ring of bone that surrounds the spinal cord. The fracture of the neural arch causes a sliding forward of the vertebrae. Both the cervical and lumbar spine may be affected, but this is an uncommon type of spondylolisthesis.

Pathologic

Pathologic spondylolisthesis is a slip from weakness within the bones, such as tumors, types of cancers, and bone disease. This weakening causes destruction of the posterior (backside) portion of the vertebrae, such as the neural arch, which surrounds the spinal cord. Just like the traumatic type, pathologic spondylolisthesis is a rare type.  

Iatrogenic

Iatrogenic spondylolisthesis is a slip caused directly from a prior spine surgery that involved decompression of the spine without stabilization. During decompression procedure a small amount of bone is removed to release pressure on the spinal cord and/or the nerves that branch off. The removal of too much bone during this procedure can cause the vertebral body to slip. In general, this is avoided using a stabilization surgery when a large portion of bone needs to be removed.

Symptoms

The symptoms of spondylolisthesis can range from non-existent to debilitating. The condition may be found incidentally, meaning that the physician was performing a general checkup or looking for something different when the malalignment of the spine was discovered. The symptoms are related to the motion created by the vertebral slip and are often similar regardless of cause. Although spondylolisthesis may occur at any level in the spine, the lumbar region tends to be affected more often than the cervical or thoracic spine except in for cases of traumatic spondylolisthesis which is found in the cervical spine most often.

Congenital/Dysplastic

Symptoms of congenital spondylolisthesis is often not found till later in life, typically till around the time of a growth spurt in adolescence. Low back pain that worsens with activity is the most common complaint, particularly pain that increases with activities that involve extension of the lumbar spine and decreases with rest. Since this type of spondylolisthesis affects the L5-S1 level, radicular symptoms appear in both legs, radiating along the length of the L5 nerve:  into the buttocks and down the back of the thigh. With more severe slips the pain may radiate farther down the leg into the foot, especially on the side with the big toe. Certain neurologic symptoms may be present as well, such as changes in reflexes or weakness, particularly with pulling toes up toward the face or moving toes up when walking. If impingement is severe at this level, this may lead to the foot “slapping” the ground when walking. The symptoms may be progress rapidly compared with other types of spondylolisthesis.

Isthmic

The symptoms of isthmic spondylolisthesis may be diagnosed during adolescence, around the time of a large growth spurt, or may not be identified until adulthood. Low back pain that worsens with activity is the most common complaint, particularly pain that increases with activities that involve extension of the lumbar spine and decreases with rest. Since this type of spondylolisthesis affects the L5-S1 level, radicular symptoms appear in both legs, radiating along the length of the L5 nerve:  into the buttocks and down the back of the thigh. With more severe slips the pain may radiate farther down the leg into the foot, especially on the side with the big toe. Certain neurologic symptoms may be present as well, such as changes in reflexes or weakness, particularly with pulling toes up toward the face or moving toes up when walking. If impingement is severe at this level, this may lead to the foot “slapping” the ground when walking. Other symptoms include tightness in the hamstring muscles, the group on the back of the thigh. There may also be changes in gait, such as taking smaller steps or walking with a waddle.  

Degenerative

Symptoms of degenerative spondylolisthesis tend to start gradually and progress over time. Lower back pain that radiates into the buttocks and the back of the thigh is the most common symptom. Neurogenic claudication, pain with standing and walking, is also a typical symptom. The claudication is generally relieved with rest and may be relieved further with flexion of the lumbar spine (bending forward). Many patients with degenerative spondylolisthesis have other lumbar comorbidities such as spinal stenosis which may cause other symptoms to occur simultaneously with the symptoms of the spondylolisthesis.

Traumatic

Application of a large force may lead to traumatic spondylolisthesis; this usually presents after an acute injury, such as a fall or motor vehicle accident. This type of spondylolisthesis is typically accompanied by severe pain associated in the neck or the back since traumatic spondylolisthesis most often affects the cervical spine. Often the amount of pain and injury from trauma limit the range of motion within the spine. Based on which vertebrae are affected, there will be pain or weakness that radiates into both sides of the body at the areas corresponding to the nerves at that vertebrae. If this occurs in the lumbar spine, this may cause compression on the cauda equina, the nerve roots at the end of spinal cord. Acute compression of these nerve roots can cause dysfunction of the bladder, bowel, numbness in the genital region, and pain.

Pathologic

Pathologic spondylolisthesis is cause by an underlying medical condition that causes weakness within the bones. The symptoms are usually gradual and include localized neck pain or low back pain. The pain may include radicular symptoms, such as pain that radiates into the arms or legs, and usually occurs on both sides of the body.

Iatrogenic

Iatrogenic spondylolisthesis may not create any symptoms, but can also cause low back or neck pain, despite having a prior decompression. The symptoms may radiate into the arms and legs depending on how far the vertebra slides.

Diagnosis

Patient history and physical examination are typically the first step in diagnosing spondylolisthesis. Types of symptoms, duration of symptoms, factors that improve/exacerbate symptoms, treatments that have been already tried, and past relevant medical problems/surgeries are all collected during the history. The physician completes a physical exam to check for specific symptoms by inspecting the back, assessing gait, and testing the upper and lower extremities for motor strength, reflexes, and range of motion.

Both history and physical exam contribute to a diagnosis of spondylolisthesis, but imaging is necessary to finalize the diagnosis. X-rays are typically obtained first to look at the overall alignment of the spine; for cases of spondylolisthesis, one vertebra will have slid either forward (anterolisthesis) or backward (retrolisthesis) from the other vertebrae. It is important that the x-rays are performed standing, as gravity can change the alignment of the spine and spondylolisthesis may not be visible if the spine is in a relaxed, laying down position. Oblique views of the spine (left and right side) are also obtained to better visualize the pars interarticularis, the bone that connects the upper and lower facet joints. The oblique views may show a break or fracture in the pars interarticularis, leading to a diagnosis of isthmic spondylolisthesis. In addition, specialized x-rays are taken with the spine in both flexion and extension, bending to touch the toes and leaning back respectively. These views determine if the vertebra moves with motion in the spine, which is called a dynamic spondylolisthesis. A fixed spondylolisthesis refers to a slip that stays the same whether the spine is in a flexed or extended position.

Advanced 3D imaging may be used to determine the type of spondylolisthesis, as this is not always evident on x-ray imaging. MRI scans show soft tissues better and are used to determine the amount of compression on the spinal cord and nerve roots, and to evaluate the amount of inflammation in the facet joints, damage to the intervertebral disc, inflammation in the bone, and any underlying bone conditions, such as metastatic cancer or tumors. CT scans show bony elements better and may show the disruption of the neural arch from a traumatic spondylolisthesis, evaluate the defect of the pars interarticularis in isthmic spondylolisthesis, assess the joint formation in congenital spondylolisthesis, or evaluate the extent of arthritic damage in degenerative spondylolisthesis. Together history, physical exam, and imaging are all necessary in order to make a correct diagnosis and design an optimal treatment plan for a spondylolisthesis.

Conservative Treatment

Bracing

Bracing is a mainstay for therapy, especially in isthmic and traumatic spondylolisthesis. Bracing keeps the spine stable and prevents motion. A rigid brace is typically used and is sized to target the specific vertebra with the spondylolisthesis. Bracing is typically needed only during the day and may be removed at night. Several factors may influence how long the brace is needed, but a typical time frame is 6-12 weeks.

Lifestyle Modifications

Certain lifestyle factors may worsen the symptoms from a spondylolisthesis, such as increased weight and repetitive tasks. Added weight may increase symptoms due to the change in the center of gravity, which may worsen the slip. Reducing weight through a low-calorie diet and exercise can reduce pressure on the spine, decreasing the symptoms of a spondylolisthesis.

Repetitive leisure or work-related motions such as excessive bending, lifting, and twisting, along with any activity that may be high impact on the spine, such as running or riding ATVs, can also increase the symptoms of a spondylolisthesis. Some of these repetitive task activities may be due to leisure and others due to demands of a job. For people with full labor or heavy-duty jobs, you may need to change jobs or support your work with proper lifting technique, relaxed breaks, and equipment such as a back brace to avoid worsening symptoms. You may also need to alter or avoid high impact activities, such as running to reduce the symptoms and potential to worsen spondylolisthesis.

Physical Therapy/Exercise

Physical therapy focuses on changing body mechanics to improve posture and walking as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Other techniques that physical therapists may use are manual treatments such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit. A combination of these methods can provide symptom relief.

A home exercise program may be used in conjunction with or instead of a formal physical therapy regimen. A daily low impact exercise regimen is important for strengthening muscles, especially those in the core. Low impact cardiovascular activities such as walking, swimming, elliptical, and biking are also important for increasing blood flow and strengthening muscles without adding stress on the spine. Home exercise can also lead to weight loss which may reduce pressure on the spine and reduce symptoms. Home exercise routines should be paired with stretches and physician supervision to avoid harm.

Medications

There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of spondylolisthesis. Some of these medications include Tylenol (acetaminophen), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, nerve membrane stabilizers, topical medications, and off label medications.

 

Epidural Steroid Injections

Epidural steroid injections reduce pain by injecting steroid, or anti-inflammatory, medication at a specific level/levels in the spine. As the herniation places pressure on a nerve, this causes inflammation of the nerve and surrounding tissue which causes pain. A specialized needle is used to deliver medication to the correct area, past the muscles of the back and as close to the spinal nerves as possible. As steroids are a natural anti-inflammatory, this may reduce the inflammation around the nerve, diminishing pain caused by the disc herniation. Steroid injections have the ability to provide pain relief for up to several months, and provide better pain relief for radiating symptoms, such as leg pain, than treatments designed for back pain alone. Steroid injections are only safe to have completed 3 times in one year and must be at least one month apart between sequential injections. This is due to the muscle and tendon breakdown with exposure to the steroid medication too often or too soon.

Surgical Treatment

Cervical (Neck)

An ACDF is a minimally invasive surgical stabilization procedure. This is performed through a small incision on the front of the neck. The surgeon tunnels between the thin neck muscles until the spinal column is reached. The old disc is removed and bone spurs or disc fragments around the nerve roots are removed to take pressure off the nerves. A special implant with bone graft will then be placed in the disc space with screws to secure placement, which may reduce or fix the slip of the vertebra. Once the procedure is completed, the disc level is fused.

 Lumbar (Lower Back)

 A transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that uses a specialized implant to fix the appropriate disc level. This procedure is performed through a small incision on the midline of the lumbar spine. Once the spine is reached, the backside portion of the vertebrae is removed, the laminae, until the nerve is reached and the compression on the nerve is removed. The disc material is removed from the disc space and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space, that are connected via rods. This implant with screws may reduce the slip and prevents any further motion once fused. Once the procedure is complete the spinal level is fused.

An extreme lateral lumbar interbody fusion, or XLIF, is a minimally invasive surgery that is performed on the lumbar spine. A small incision is made on the left side, between the hip and the ribs. A thin wire, called a guide wire, is placed and sequentially cylindrical tubes, called dilators are placed through the psoas muscle to reach the left side of the spine. Once the spine is reached, the disc is then completely removed. A special implant is sized, filled with bone graft and placed in the empty disc space. The implant is then screwed in place, with screws placed into the upper and lower vertebral body to provide structure. This will fuse and stabilize the level to prevent any further motion. The XLIF can only be performed on certain levels in the lumbar spine, as the space between the hip and lowest rib is limited, even with specialized positioning of the body on the surgical table.

All procedures to address spondylolisthesis are minimally invasive stabilization procedures, they fix the slipped vertebrae in place via a fusion. The spinal cord and spinal nerve roots are decompressed properly and the mal-aligned vertebral body is stabilized to prevent further motion. Multiple factors are taken into consideration in order to plan an appropriate surgical option to treat the symptoms and structural abnormality of a spondylolisthesis.

Overview

The spine is made up of 33 bones called vertebrae and divided into four regions: cervical (neck), thoracic (mid back), lumbar (lower back), and sacral. The vertebrae surround the spinal cord, a thick band of nerve tissue that runs through the spine, providing 360o of protection. Spinal stenosis is a disease marked by narrowing of the spine around the spinal cord or at the foramen, openings in the spinal vertebra through which the spinal cord branches to the hands, legs, torso, and other locations in the body. Narrowing can occur centrally and at the foramen simultaneously. Stenosis most commonly occurs in the cervical and lumbar regions of the spine because these areas experience the most flexibility and movement. The extra motion can place more pressure on the spinal cord or nerve roots over time.

Types

Any narrowing upon the neural elements, including the spinal cord and exiting nerve roots is called spinal stenosis. The narrowing can occur from a variety of things including disc herniations, disc bulges, abnormal alignment, scoliosis, and bone spur formation. The location of the stenosis defines the type of stenosis. There are three main types: central spinal stenosis, lateral recess stenosis, and foraminal stenosis, each of which can happen in any region of the spine (i.e. cervical, thoracic, or lumbar). 

Central Canal Stenosis

Central stenosis is narrowing in the central ring of the spinal vertebrae, the space through which the spinal cord passes. The spinal cord starts in the cervical spine and moves down through the thoracic spine and to a termination point called the conus medullaris, which occurs at about the second level of the lumbar spine. Central canal stenosis is most often found in the cervical and lumbar regions because these regions experience the most motion. 

Foraminal Stenosis

Foraminal stenosis is narrowing at the foramen, the vertebral spaces through which nerves branch off the spinal cord to the left or right and into the body. These provide motor and sensory function in the arms, legs, and torso. Foraminal stenosis is most common in the cervical and lumbar spine because these two regions are involved in movement and the latter also bears the weight of the body. This is the most common form of spinal stenosis.

Lateral Recess Stenosis

Lateral recess stenosis is narrowing around the channels that nerves traverse before they exit through the foramen. The lateral recess is where the nerve is generated just off the spinal cord, before moving through the foramen.  Stenosis of this type affects nerve that branch off the spinal cord and provide motor function to the arms, legs, and torso.

Causes

Stenosis means narrowing; there are multiple changes that can cause a narrowing around neural elements (e.g. the spinal cord or nerve roots). Stenosis is most frequently found in the cervical and lumbar regions due to higher flexibility and range of motion in these regions; the lumbar spine also bears the weight of the body, putting more stress on this region. The stress caused by the motion and weight bearing of the spine puts stress on structures in the spine, such as the intervertebral discs, ligaments, and the facet joints which may lead to spinal stenosis.

Aging

Aging and related arthritis is the primary cause of spinal stenosis. Intervertebral discs contain a lot of water and stress from the aging process causes them to dry out, degenerate, and shrink. As discs shrink in size, the space between vertebral bodies and between the foramen, the space through which nerves exit the spinal cord, narrows. In addition, the ligaments and facet joints on the spinal vertebrae increase in size with arthritis which may place pressure on the spinal nerves. The posterior longitudinal ligament, the largest ligament in the central spinal canal, binds the vertebrae together, but an enlarge and thicken, causing the canal to have less space for nerves.  Arthritis may also cause the formation of bone spurs, or bony growths, at the facet joints. Often, more than one type of arthritic change is contributing to the symptoms of a pinched nerve. 

Disc Herniation

Disc herniation may also lead to spinal stenosis. Intervertebral discs are formed from two elements: an outer fibrous area and an inner jelly-like area. The outer fibrous portion may weaken or develop small tears with aging, trauma, and weight gain, potentially allowing the inner jelly-like substance to herniate or slip through.   Acute trauma is a large amount of force applied to the spine from a single event, for example, from a blunt hit or a motor vehicle accident. Chronic trauma is repeated stress over time, including forces applied by repetitive tasks at work or with recreational activities. Increase in body weight also adds stress on the spine, weakening the discs, and making them more susceptible to a herniation. As the disc herniates, this creates a narrowing around the spinal nerve roots, leading to spinal stenosis. 

Structural Abnormalities

Structural abnormalities of the spine can also lead to spinal stenosis.  The more common structural abnormalities are scoliosis and spondylolisthesis. Scoliosis is an abnormal curvature in the spine which can accelerate the aging process and arthritic changes, leading to spinal stenosis. Spondylolisthesis is an abnormal alignment of spinal vertebrae, when one vertebrae slides forward or backward relative to the vertebrae directly below. As the facet joints of each vertebra in the spine come together, a space called the foramen is created that allows nerves to branch from the spinal cord into the body. If one vertebra is shifted forward relative to the vertebrae below, this causes an abnormal alignment of the facet joints, narrowing the foramen and leading to spinal stenosis.

Symptoms

The symptoms of spinal stenosis range from nonexistent to severe and debilitating. This can depend on the location of the spinal stenosis, amount of compression, and type of spinal stenosis. Spinal stenosis occur most frequently in the cervical and lumbar spine due to their range of motion.

Central Stenosis

Central stenosis is the narrowing of the central canal, which is the area for which the spinal cord passes.  The symptoms of central stenosis are largely the same despite there being several possible causes. Symptoms can vary based upon the spinal region that narrowing occurs in and since spinal stenosis is largely triggered by age related changes, such as arthritis, symptoms tend to have a gradual onset.

Cervical central stenosis is the narrowing or compression of the spinal cord in the neck.  Symptoms can be gradual and go unnoticed for a period of time. Common symptoms include neck pain or stiffness, decreased range of motion with a cracking sound as the neck moves, or Lhermitte’s sign, an electrical sensation that shoots down the back and the when the chin moves toward the chest.  Other symptoms of central cervical stenosis include myelopathic symptoms, which are neurologic deficits that occur due to compression of the spinal cord. These can manifest as a combination of difficulty with fine motor tasks (such as writing, counting money, and buttoning a shirt), difficulty with walking, and changes in bladder habits. Numbness may occur in the hands, which can decrease the strength of the grip. It is typical for symptoms to not be traced back to cervical spine disease because of the gradual onset.  Spinal stenosis and spinal cord compression can have devastating consequences.  For example, myelomalacia, bruises on the spinal cord; stingers, a form of temporary paralysis; or in severe cases, total paralysis.  

Thoracic and lumbar central stenosis are compression of the spinal cord in the mid, lower back, or as with the case of  the termination of the spinal cord into the cauda equina, cauda equina syndrome.   Compression of the spinal cord in the thoracic spine can cause myelopathic symptoms, which include unsteady walking and inability to urinate or incontinence. Often there may be localized back pain that accompanies central thoracic stenosis. Similar myelopathic symptoms can occur in the lumbar spine as well and with severe compression, this may lead to permanent damage.  For example, the nerves in the cauda equina are responsible for function in the legs and organs within the pelvis, such as the bladder. Compression on the cauda equina, creates symptoms of numbness in the pelvic region or within the sexual organs, weakness in the legs, and loss of bladder or bowel function. This serious medical condition, known as cauda equine syndrome, may lead to permanent loss of bladder control or sexual function without proper treatment.

Foraminal & Lateral Recess Stenosis

Lateral foraminal and lateral recess stenosis cause narrowing at different locations in the spine, but both affect the nerve roots that exit branch from the spinal cord. The symptoms that occur are directly related to the location of the stenosis. This can occur in any area of the spine, but most commonly occurs in the cervical and lumbar regions.

Cervical stenosis may occur at any of the eight nerve roots that branch from the spinal cord and symptoms may manifest bilaterally (both left and right) or unilaterally (either left or right). Symptoms commonly consist of localized pain, stiffness, and decreased range of motion in the neck. Typically, foraminal and lateral recess stenosis can cause radiating symptoms, such as weakness, shooting, or stabbing pain, burning, numbness, and/or tingling in the shoulders, arms, and hands.  The specific location will depend on the location that the compressed nerve root corresponds to.

Thoracic stenosis commonly causes localized mid back pain. Radiating symptoms from thoracic stenosis may occur at any of the twelve nerve roots that branch from the spinal cord in the midback. The level that the spinal stenosis occurs will determine where the symptoms occur because the nerves from the thoracic spine run directly above each rib and supply both sensation to the torso and motor strength to the intercostal and abdominal muscles. Compression of these nerves causes a sharp, shooting, stabbing, or electrical pain that radiates around a single rib, typically on one side of the body. In addition, this may cause decreased sensation with numbness or tingling.

Lumbar stenosis frequently causes symptoms of pain, stiffness, and decreased range of motion in the lower back. Pain is usually relieved by leaning forward into the “flexed position” of the lumbar spine. A common symptom of lumbar stenosis is neurogenic claudication, which means that the pain radiates into the legs while walking, but improves with rest, typically by sitting down. Sharp, stabbing, shooting, burning, or electrical pain in the buttocks, hips, legs, or feet is also common; the specific location will depend on the location that the compressed nerve root corresponds to.

Diagnosis

Patient history and physical examination are typically the first step in diagnosing spinal stenosis. Types of symptoms, duration of symptoms, factors that improve/exacerbate symptoms, treatments that have been already tried, and past relevant medical problems/surgeries are all collected during the history. The physician completes a physical exam to check for specific symptoms by inspecting the back, assessing gait, and testing the upper and lower extremities for motor strength, reflexes, and range of motion.

Both history and physical exam contribute to the diagnosis of spinal stenosis, but imaging is necessary to finalize the diagnosis. X-rays are typically obtained first to look at the overall alignment of the spine and to check for spinal abnormalities such as scoliosis (curve in the spine), that may affect viable treatment options. These 2D results are supplemented with advanced imaging tests such as MRI or CT scans because these show a 3D view of the spine. MRI scans which show soft tissues, such as nerves and discs, are generally preferred over CT scans which show bony elements. Advanced imaging can show exactly which nerve or nerves are affected by spinal stenosis. Together history, physical exam, and imaging are all necessary in order to make a correct diagnosis and design an optimal treatment plan for a disc herniation.  

Thoracic Spinal Stenosis

Physical exams checking for thoracic spinal stenosis will be much less involved than those looking for cervical and lumbar spinal stenosis. The exam typically begins with examining the back for an abnormal curve, uneven muscles, or skin changes such as bruising. After inspection, the doctor will perform palpations over the muscles and center of the back. The legs would be tested for motor strength to ensure that both legs are at full strength and functioning normally. Lastly the physician may check for changes in sensation from one side of the body to the other.

Lumbar Spinal Stenosis

Physical exam abnormalities for the lumbar spine tend to occur exclusively in the lower body. As with evaluating the cervical and thoracic spine, it is important to start by looking at the back for changes in the skin, decreases in muscle size, or unevenness from one side of the back to the other. The next step would be palpation of the muscles and center of the back. Lumbar spine range of motion is tested with flexion, such as touching toes, and extension, leaning back at the waist to look for decreased motion due to pain. Motor strength testing would be performed on the lower extremities because weakness in certain muscle groups could imply spinal stenosis at the lumbar level where the relevant nerve branches from the spinal cord. For example, spinal stenosis at L3-4 or L4-5 levels may cause weakness with knee extension or straightening the leg. Changes in sensation may also be tested throughout the leg to check for areas with decreased sensation throughout or relative to the opposite leg. Increases or decreases in the patellar and Achilles reflexes are commonly used to test for spinal stenosis and can potentially identify the affected spinal level because they are connected to the L3/L4 and S1 nerve roots respectively. Other exam results that imply lumbar spinal stenosis are abnormal walking patterns, including inability to walk on the heels and the toes.

Conservative Treatment

Lifestyle Modification

Certain lifestyle factors may increase the incidence of spinal stenosis, such as smoking and increased weight. Smoking decreases blood flow throughout the body which is needed to repair damaged tissues. Cessation may restore blood flow, allowing the tissues to access proper nutrition. Added weight may increase the risk for acceleration of the aging process and causing spinal stenosis because of the extra stress is placed on the spinal structures, such as the disc and facet joints. Reducing weight through a low-calorie diet and exercise can reduce pressure on the spine, decreasing the symptoms of spinal stenosis.

Repetitive leisure or work-related motions such as excessive bending, lifting, and twisting, along with any activity that may be high impact on the spine, such as running or riding ATVs, can also lead to spinal stenosis. Some of these repetitive task activities may be due to leisure and others due to demands of a job. For people with full labor or heavy-duty jobs, you may need to change jobs or support your work with proper lifting technique, relaxed breaks, and equipment such as a back brace to avoid worsening symptoms. You may also need to alter or avoid high impact activities, such as running to reduce the symptoms of spinal stenosis. 

Alternative Therapy

Alternative therapies include massages, chiropractic care, and acupuncture. These may also be referred to as manual therapies since they address the spine with hands on technique. Massage relieves tension in muscles surrounding the spine and in arm and leg muscles experiencing radiating symptoms. These muscles may be under tension due abnormalities with walking and changes in posture due to pain from disc herniation. Chiropractic care may use specific techniques, such as adjusting the spine or application of traction on the spine. Acupuncture may also provide pain relief as muscles are stimulated electrically.

Physical Therapy/Exercise

Physical therapy focuses on changing body mechanics to improve posture and walking as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Other techniques that physical therapists may use are manual treatments such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit. A combination of these methods can provide symptom relief.

A home exercise program may be used in conjunction with or instead of a formal physical therapy regimen. A daily low impact exercise regimen is important for strengthening muscles, especially those in the core. Low impact cardiovascular activities such as walking, swimming, elliptical, and biking are also important for increasing blood flow and strengthening muscles without adding stress on the spine. Home exercise can also lead to weight loss which may reduce pressure on the spine and reduce symptoms. Home exercise routines should be paired with stretches and physician supervision to avoid harm.

Medications

There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of spinal stenosis. Some of these medications include Tylenol (acetaminophen), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, nerve membrane stabilizers, topical medications, and off label medications.

Epidural Steroid Injections

Epidural steroid injections reduce pain by injecting steroid, or anti-inflammatory, medication at a specific level/levels in the spine. As the herniation places pressure on a nerve, this causes inflammation of the nerve and surrounding tissue which causes pain. A specialized needle is used to deliver medication to the correct area, past the muscles of the back and as close to the spinal nerves as possible. As steroids are a natural anti-inflammatory, this may reduce the inflammation around the nerve, diminishing pain caused by the disc herniation. Steroid injections have the ability to provide pain relief for up to several months, and provide better pain relief for radiating symptoms, such as leg pain, than treatments designed for back pain alone. Steroid injections are only safe to have completed 3 times in one year and must be at least one month apart between sequential injections. This is due to the muscle and tendon breakdown with exposure to the steroid medication too often or too soon.

Surgical Treatment

Cervical Stenosis Treatment

A foraminotomy is a minimally invasive surgical decompression procedure that is performed in the cervical spine to alleviate the compression on a cervical spinal nerve from spinal stenosis. This may be due to bone spur formation or a disc herniation. This procedure is performed through a small midline incision on the back of the neck. A small amount of bone from the back of the vertebrae is removed, called the laminae, so opening for the spinal nerve, the foramen, is reached. The compression is alleviated either by removing disc material or bone spurs that are the source of spinal stenosis. Once the nerve is decompressed, the incision is closed and the procedure is completed.

An ACDF is a minimally invasive surgical stabilization procedure. This is performed through a small incision on the front of the neck. The surgeon tunnels between the thin neck muscles until the spinal column is reached. The old disc is removed and once removed, any contents can be removed around the nerve roots to relieve the spinal stenosis. A special implant with bone graft will then be placed in the disc space with screws to secure placement. Once the procedure is completed, the disc level is fused. 

A cervical disc replacement is a minimally invasive surgical stabilization procedure that is performed similarly to the ACDF, however the implant is slightly different, as it preserves some motion of the cervical spine instead of creating a fusion in the ACDF. Spinal stenosis is alleviated through the removal of the disc material or bone spurs.

Thoracic and Lumbar Stenosis Treatment

A microdiscectomy is a minimally invasive surgical decompression procedure that is typically performed on both the thoracic and lumbar spine to address disc herniations, which cause spinal stenosis.  A small incision is made in the midline of the back until the backside of the vertebrae, laminae, is reached. At this point, a small amount of the laminae is removed until the spinal nerve is well visualized. The compression on the nerve is removed and once completed, the incision is closed.

Endoscopic discectomy is a minimally invasive surgical decompression procedure that uses specialized instrumentation to remove a disc herniation, which is a source of spinal stenosis. A small incision is made on the midline of the back and the use of specialized imaging, called a fluoroscope is used. After the incision is made a thin wire, called the guide wire, is placed until it hits bone. A series of small cylindrical tubes are then placed over the guide wire to dilate the tissue and a retractor is placed over the cylinders and the cylinders are removed. A light source is place down the retractor and instruments are placed down through the retractor to remove the disc fragments pushing on the nerve. The retractor is then repositioned, so that the compression can be removed around the nerve on the opposite side of the body. The instruments are removed and the surgery is completed.

A transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that uses a specialized implant to fix the appropriate disc level. This procedure is performed through a small incision on the midline of the lumbar spine.  Once the spine is reached, the backside portion of the vertebrae is removed, the laminae, until the nerve is reached and the compression on the nerve is removed. The disc material or bone spurs are removed from the disc space and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space, that are connected via rods. Once the procedure is complete the spinal level is fused.  

All procedures used to alleviate the symptoms and structural problems from spinal stenosis are minimally invasive decompressive and stabilization procedures. The spinal nerve roots are decompressed properly any mal-aligned vertebral body is stabilized to prevent further motion. Multiple factors are taken into consideration to plan an appropriate surgical option to treat the structural problems associated with spinal stenosis.

Overview

Scoliosis is marked by an abnormal sideways curvature in the spine. Unlike natural curves in our spine that run in the parallel direction of our nose, perpendicular curvature causes unevenness in other perpendicular skeletal structures such as the pelvis and shoulders. The unevenness can cause the shoulder or hip to sit higher on one side of the body. Scoliosis can affect any of the four spinal regions: cervical (neck), thoracic (mid back), lumbar (lower back), and sacrum. It may affect more than one area at a time though it most commonly affects the lumbar and thoracic regions.  Curvature can occur to the right (dextroscoliosis) or to the left (levoscoliosis) and occurs as an ‘S’ or ‘C’ shaped curvature. The severity of scoliosis can range from mild to severe and is determined by a specialized measurement known as the Cobb angle. Most scoliosis patients experience mild scoliosis though more severe cases of scoliosis can lead to other spinal conditions such as herniated discs and spinal stenosis. There are four main types of scoliosis based on different causes, risk factors, and age groups: congenital, idiopathic, neuromuscular, and degenerative. Females and adolescents are more prone to scoliosis.

Types

Scoliosis comes in idiopathic, congenital, neuromuscular, and degenerative forms and can affect different age groups from newborns to adults. These types of scoliosis are found in either cervical (neck), thoracic (mid back), or lumbar (low back) spinal regions and can affect more than one region at a time, which is especially common with thoracolumbar scoliosis. 

Idiopathic Scoliosis

Idiopathic scoliosis, meaning that the cause is unknown, is by far the most common type of scoliosis. There is some thought that it may have a genetic or familial part. This type of scoliosis is further broken down into infantile (onset before age 3), juvenile (onset between ages of 3 and 10), adolescent (onset after age 10), and adult (onset after age 18). Idiopathic scoliosis is more frequently found in females and severe curves can continue to progress through adulthood. The curve can worsen with a large growth spurt and in these cases usually slows or stops, once growth has ceased.

Congenital Scoliosis

Congenital scoliosis is present at birth though there has been no genetic or hereditary component found. The abnormal formation of the spine is formed in the womb; the spine forms early in development and is usually completed by the sixth week of pregnancy. Congenital scoliosis branches further into two major types: a hemivertebrae and unilateral bar. Both can affect one or multiple vertebrae.

 Hemivertebrae are vertebrae that are not completely formed and are the most common type of congenital malformation. Since spinal vertebra are stacked on each other, the hemivertebrae acts as a ‘wedge’ which causes a curvature of the spine. 

Unilateral bar, also called block vertebrae, is a failure of the vertebral bodies to separate into single, distinct vertebra during formation which results in a spinal fusion. Inadequate separation of the vertebral bodies can cause only one side to grow, leading to an abnormal curvature.

Both congenital abnormalities can occur together and lead to a more serious condition. Congenital scoliosis is typically detected during a new born exam after birth but can often go unnoticed until adolescence, since the spine may not curve at birth even though the malformation is present.

Neuromuscular Scoliosis

Neuromuscular scoliosis is a result of congenital (i.e. present at birth) neurological or muscular conditions, such as cerebral palsy, muscular dystrophy, and spina bifida: the curvature develops, as the muscles of the body are too weak to support the spine. This type of scoliosis has a larger curve and is more severe in patients who are unable to ambulate, or walk and the curve progresses rapidly.

Degenerative Scoliosis

Degenerative scoliosis, also referred to as adult scoliosis, occurs in people greater than age 18. This type of scoliosis occurs as the elements of the spinal column (e.g. intervertebral discs and facet joints) deteriorate from wear due to repetitive movements, weight gain, and arthritis. It can also be seen in people that have osteoporosis, a loss of bone density. This deterioration can cause one side of the spine to weaken, which causes a shift of the vertebral bodies and the formation of a scoliosis curve. The lumbar spine is the most commonly affected site for degenerative scoliosis, as this region of the spine bears the most body weight.

Causes

The cause in majority of scoliosis cases is idiopathic, or unknown. More rare causes include malformation of the spinal column during formation in the womb when a specific vertebra does not fully form or when multiple vertebrae fuse rather than separating. Other causes of scoliosis include neuromuscular disease such as cerebral palsy, spina bifida, and muscular dystrophy. These conditions cause weakness in the back muscles, which allows curvature of the spine. Lastly, degenerative changes can lead to formation of a scoliosis curve. Degenerative causes include arthritis, osteophyte (bone spurs) formation, disc dehydration (drying out of the intervertebral disc), failure of facet joints to form properly in the spinal column, and osteopenia or osteoporosis. These conditions can cause weakening on one side of the spinal column, leading to scoliotic curvature.

Certain modifiable and non-modifiable risk factors can increase the likelihood of developing scoliosis, especially degenerative scoliosis. Non-modifiable risk factors include gender, family history, and age. Scoliosis is more frequently diagnosed in females than in males and adolescent idiopathic scoliosis is most commonly found in children from ages 10-12. Though idiopathic scoliosis has no known cause, there are studies that have supported genetics as playing a role in its development.

Modifiable risk factors include weight as increased body weight places more stress on the spine. Over time, the added stress causes spinal joints to wear out and intervertebral discs dry, leading to degeneration of the disc and thereby degenerative scoliosis. Decreased estrogen has a negative effect on bone density and is directly related to osteopenia and osteoporosis, both of which increase risk for fracture which can cause the spine to curve. Smoking can also lead to scoliosis, as it may accelerate degenerative changes in the spine and can decrease bone density, leading to osteoporosis. In addition, smoking reduces oxygen in the blood stream, which can prevent nutrients from reaching tissues for proper healing. Smoking may also lead to breakdown of the intervertebral discs, a condition known as degenerative disc disease, which can lead to degenerative scoliosis. Lastly, high impact movement and repetitive motions from sporting activities can increase wear and tear on spinal column or lead to a vertebral body fracture which may lead to scoliosis.

Symptoms

Symptoms of scoliosis can range from nonexistent to debilitating symptoms of pain. The severity and underlying cause has a direct effect on the symptoms that a patient may experience. The main symptoms, across all types of scoliosis, are typically asymmetry throughout the body. One hip, rib, or shoulder may sit higher on one side of the body to compensate for the curve. This may be minimal, but is readily visible in those that have a moderate to severe curve. Unevenness, particularly in the hips, can cause abnormalities in walking and those with severe scoliosis in the thoracic (midback region) may have twisted ribs that put pressure on the lungs and heart. This can lead to difficulty breathing or pumping blood.

Idiopathic Scoliosis

Idiopathic scoliosis is typically diagnosed in adolescents and is referred to as adolescent idiopathic scoliosis (AIS). This type of scoliosis is usually found during a screening examination by a pediatrician or when the parent/teacher notices unevenness in hips, ribs, or shoulders, which prompts evaluation by a medical professional. Scoliosis, in and of itself, does not cause any pain. Back pain in children is usually more related to weak core and back muscles strained over increasing participation in exercise, aerobic, and sports activities.

Congenital Scoliosis

Congenital scoliosis may lead to unevenness of the hips, ribs, or shoulders, which may give a leaning appearance. This unevenness is not always apparent at birth even if the defect is present. Scoliosis itself does not cause pain and since the curve is not always present at birth, the diagnosis may happen later in life. Congenital scoliosis occurs due to spinal malformation early in pregnancy and development; these individuals often have other medical conditions related to the heart, kidneys, or digestive system, as proper development in these may have been disrupted as well.

Neuromuscular Scoliosis

Neuromuscular scoliosis is only present in those that have been diagnosed with certain conditions, such as Muscular Dystrophy, Cerebral Palsy, Spina Bifida. These lead to weakness in the musculature of the back, allowing the curvature of scoliosis to form. The symptoms rarely cause pain, but can lead to a more rapidly progressive scoliosis. The main symptoms these patients experience are difficulty controlling the trunk of their body and difficulty sitting; majority are confined to wheelchairs or other assistive devices because their disease weakens muscles in other areas of the body as well. The severity of the scoliosis may also lead to thoracic insufficiency syndrome, which can limit lung growth and cause difficulty breathing. When the lung capacity is decreased due to the scoliosis curve, the ability for respirations to occur is limited, leading to shortness of breath which necessitate more rapid breathing and thereby fatigue from breathing.

Degenerative Scoliosis

Individuals with degenerative scoliosis commonly suffer from mild to severe pain which typically starts as a lower back ache and gradually increases. The pain is commonly caused by degenerative changes, such as spinal stenosis, disc degeneration, and disc herniations from wear and tear on the spine. Disc degeneration causes the spine to curve and puts pressure on the foramen, vertebral spaces through which nerves branch from the spinal cord. Degenerative scoliosis most frequently affects the lower back and therefore common symptoms of lumbar disease, such as pain and stiffness or radiating symptoms in the buttocks, hips, legs, and feet, commonly occur. Pain tends to be worse with physical activities and better with rest. With idiopathic adolescent scoliosis, many patient may have no pain, but later in adulthood, with worsening of their curve and added degenerative changes, may experience pain. 

Diagnosis

Children are routinely screened for adolescent idiopathic scoliosis at their yearly physical exam, most commonly with the Adam’s Forward Bend Test, a technique that is easily performed at a doctor’s office or school setting. The patient stands with both feet together and the toes even. With either the shirt lifted or removed, the patient bends forward at the waist as far as they can with palms held together, as if they are going to touch their toes. The examiner then inspects the patient from behind, looking for abnormalities or differences between the left and right side of the body. A patient with scoliosis may have a shoulder, scapula, or ribs that sit higher on one side and there may be a visible curve of the spine. If the Adam Bend Test reveals abnormalities, further evaluation would be prompted.

The best way to diagnosis scoliosis is with x-ray imaging because this can uncover underlying causes including partially formed vertebral bodies, fused vertebral bodies, or lack of skeletal maturity and it can determine the degree or progression of spinal curvature. Special scoliosis x-rays show the entire spine with the shoulders and pelvis which emphasizes unevenness of the hips or shoulders in comparison to the curvature of the spine. X-rays are completed while the patient is weight bearing (standing), as this position allows gravity to act on the spine and gives the most accurate representation. The severity of scoliosis is determined by a specific angle, called the Cobb angle.

X-rays are mostly used for the diagnosis of scoliosis; 3D imaging with CT (Computed Tomography Scan) or MRI (Magnetic Resonance Imaging) scans is often needed to assess the cause. CT scans are mainly used to assess the bony anatomy of the spine; it would be used to look for any partially formed vertebral bodies, or fused vertebrae.  MRI scans are primarily used to look at the soft tissue of the body, such as intervertebral discs and nerves. These scans reveal degenerative changes that could lead to scoliosis, such as facet joint disease or degenerative disc disease, and can also reveal conditions caused by scoliosis, such as disc herniation or spinal stenosis.

Conservative Treatment

Bracing

A rigid brace in considered in patients if there has been a five degree Cobb angle increase in the scoliosis curve after 4-6 months or if the curve is already close to 25 degrees and the patient has a significant amount of growth left. The rigid brace does not improve the curve, but aims to prevent further curving of the spine because the scoliosis curve in patients with a Cobb angle of 40-50 degrees will continue to worsen throughout adulthood.

A rigid plastic brace, called a TLSO brace because it targets thoracic, lumbar, and sacral orthosis, is fitted from the hips to the underarms and surrounds the entire body. Daytime and nighttime use is recommended because the time spent in the brace is correlated with its ability to prevent progression. Length of treatment is typically over two years but is dependent on how much more the patient is expected to grow. Once the growth plates are closed and the patient stops growing taller, the brace is discontinued. Bracing in an adult with degenerative scoliosis cannot reverse the curve or prevent further progression of the curve, as the bones are no longer growing. Bracing in adults is not recommended because it causes core muscles of the abdomen and back to weaken.  The brace prevents motion within the spine and without continued motion, the muscles begin to weaken.

Manual Therapy

Manual therapy for the spine includes both chiropractic treatment and massage. Massage can reduce pain in the muscles surrounding the spine which is useful because the malposition of the spine can create tension and frequent spasms in the muscles. Chiropractic care can aid with stretching, manipulations, and traction to provide pain relief.

Physical Therapy/Exercise

Physical therapy focuses on changing body mechanics to improve posture and walking as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Other techniques that physical therapists may use are manual treatments such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit. A combination of these methods can provide symptom relief.

A home exercise program may be used in conjunction with or instead of a formal physical therapy regimen. A daily low impact exercise regimen is important for strengthening muscles, especially those in the core. Low impact cardiovascular activities such as walking, swimming, elliptical, and biking are also important for increasing blood flow and strengthening muscles without adding stress on the spine. Home exercise can also lead to weight loss which may reduce pressure on the spine and reduce symptoms. Home exercise routines should be paired with stretches and physician supervision to avoid harm.

Medications

There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of scoliosis. Some of these medications include Tylenol (acetaminophen), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, nerve membrane stabilizers, topical medications, and off label medications.

Epidural Steroid Injections

Epidural steroid injections reduce pain by injecting steroid, or anti-inflammatory, medication at a specific level/levels in the spine. As the herniation places pressure on a nerve, this causes inflammation of the nerve and surrounding tissue which causes pain. A specialized needle is used to deliver medication to the correct area, past the muscles of the back and as close to the spinal nerves as possible. As steroids are a natural anti-inflammatory, this may reduce the inflammation around the nerve, diminishing pain caused by the disc herniation. Steroid injections have the ability to provide pain relief for up to several months, and provide better pain relief for radiating symptoms, such as leg pain, than treatments designed for back pain alone. Steroid injections are only safe to have completed 3 times in one year and must be at least one month apart between sequential injections. This is due to the muscle and tendon breakdown with exposure to the steroid medication too often or too soon. 

Surgical Treatment

A transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that uses a specialized implant to fix the appropriate disc level. This procedure is performed through a small incision on the midline of the lumbar spine.  Once the spine is reached, the backside portion of the vertebrae is removed, the laminae, until the nerve is reached and the compression on the nerve is removed. The disc material is removed from the disc space and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space, that are connected via rods. Once the procedure is complete the spinal level is fused.  

An extreme lateral lumbar interbody fusion, or XLIF, is a minimally invasive surgery that is performed on the lumbar spine. A small incision is made on the left side, between the hip and the ribs. A thin wire, called a guide wire, is placed and sequentially cylindrical tubes, called dilators are placed through the psoas muscle to reach the left side of the spine. Once the spine is reached, the disc is then completely removed. A special implant is sized, filled with bone graft and placed in the empty disc space. The implant is then screwed in place, with screws placed into the upper and lower vertebral body to provide structure. This will fuse and stabilize the level to prevent any further motion. The XLIF can only be performed on certain levels in the lumbar spine, as the space between the hip and lowest rib is limited, even with specialized positioning of the body on the surgical table.

All procedures used to alleviate the symptoms and structural problems from scoliosis are minimally invasive decompressive and stabilization procedures. The spinal nerve roots are decompressed properly any mal-aligned vertebral body is stabilized to prevent further motion. Multiple factors are taken into consideration to plan an appropriate surgical option to treat the structural problems associated with scoliosis.

Overview

The spine is made up of 33 bones called vertebrae and divided into four regions: cervical (neck), thoracic (mid back), lumbar (lower back), and sacrum. The spinal cord, a thick band of nerve tissue that runs through the spine, is surrounded by bones called vertebrae which provide 360o protection. The spinal cord ends most frequently at the 1st or 2nd lumbar vertebra, though it can end anywhere from the 12th thoracic vertebra to the 3rd lumbar vertebra, in a structure called the cauda equina. At the cauda equina the spinal cord branches into ten separate nerve roots, five of which exit through openings in the vertebra, called foramen, and combine in the buttock to form the sciatic nerve, the longest and largest nerve in the body. The sciatic nerve supplies sensory and motor function to the legs; compression of the sciatic nerve leads to a set of symptoms known as sciatica.

Types

The sciatic nerve is the largest nerve in the body; it is made up of the nerve roots L4 through S3 meaning that it runs down the back of each leg and branches at each knee. Sciatica is a relatively well-known condition that produces pain symptoms down the back of the legs.

Sciatica comes in acute and chronic forms, defined by the duration of symptoms. Acute cases occur suddenly, often because of disc herniations, and last for six weeks or less. Chronic cases typically start as an acute condition, but progresses and causes pain for over three months. Any spine condition may cause chronic sciatica, including spinal stenosis, spondylolisthesis, and disc degeneration.

Causes

The sciatic nerve is the largest nerve in the body; it travels down the buttock from the spine and into the leg, where it branches into two separate nerves at the knee. Compression of the sciatic nerve, the cause of sciatic pain, can be caused by spinal stenosis, disc herniation, or structural abnormalities such as a spondylolisthesis and disc degeneration.

Spinal Stenosis

Spinal stenosis, narrowing around spinal nerves because of wear and age, is the most common cause of sciatica. Spinal stenosis can cause bone spur formation in the foramen, spaces through which nerves branch from the spinal cord into the body. The facet joints in the spine can also increase in size, narrowing the foramen. If this occurs in the lumbar region, specifically at the L4 and L5 levels, it may cause sciatica since the L4 and L5 nerve roots help to form the sciatic nerve, along with the S1, S2, and S3 nerve root.

Disc Herniation

Each pair of spinal vertebrae has an intervertebral disc in between for shock absorption, which is made of two parts, the outer fibrous area, annulus fibrosis, and an inner jelly-like substance, the nucleus pulposus. As the disc experiences wear and tear from increased weight gain, repetitive bending and twisting, and natural aging processes, the outer portion of the disc develops small tears and these weak areas make it easier for the inner disc portion to push through and compress nerves. The disc also begins to dry over time and it loses its height, causing the amount of space between each pair of vertebrae to decrease and shrink the foramen, the space through which nerve roots exit the spinal cord.

Spondylolisthesis

A spondylolisthesis is a malalignment of the vertebra in which one vertebra slides forwards or backwards over the one below vertebra. There are different causes for a spondylolisthesis, but the most common cause is a fracture of the pars interarticularis, which is the piece of bone that connects the upper and lower facet joints on each vertebra. The fracture usually occurs as a result of hyperextension injuries in the back with activities such as gymnastics. This malalignment occurs at the L5-S1 level most frequently and as the vertebrae slides forward, this narrows the space the nerve roots have to exit the spine, causing compression. 

Symptoms

The multiple causes of sciatica all create similar symptoms, though these will vary by which nerve root is being affected and causing the symptoms. Severe leg pain is the most common symptom and back pain is sometimes present as well. Patients with spinal stenosis, disc degeneration, and spondylolisthesis are more likely to have symptoms of low back pain.

Leg Pain

Leg pain is the most common symptom of sciatica and can range from mild to severe and debilitating. Pain is usually sharp, shooting, with numbness or tingling and radiates in the pattern that the sciatic nerve runs, starting in the buttock and moving down the back of the leg and into the foot. The pain generally worsens while sitting or standing in one area for too long and while changing positions from laying to sitting or sitting to standing though activity and laying down seem to help with improving pain. Pain also worsens while extending the lumbar spine, for example while leaning back at the waist, as more compression is placed on the already compressed nerve.

Leg Weakness

There may also be symptoms of weakness in the leg though specific symptoms will vary with the nerve root being compressed. These symptoms may or may not be present and can be present in combination if multiple nerve roots are affected.

Cauda Equina

Severe forms of sciatica, can lead to cauda equina syndrome, which is in the cauda equina, a series of nerves at the end of the spinal cord that resembles a horse’s tail. Cauda equina syndrome produces a large amount of inflammation around the cauda equina and distinct symptoms which include saddle anesthesia (numbness in the perineal regions, or the region that would make contact while sitting in a saddle), bowel and/or bladder incontinence, weakness in the legs, and unsteadiness while walking. This is a rare condition, but is serious and requires immediate attention to prevent irreversible damage to the nerves.

Diagnosis

Patient history and physical examination are typically the first step in diagnosing sciatica.  Types of symptoms, duration of symptoms, factors that improve/exacerbate symptoms, treatments that have been already tried, and past relevant medical problems/surgeries are all collected during the history. The physician completes a physical exam to check for specific symptoms by inspecting the back, assessing gait, and testing lower extremities for motor strength, reflexes, and range of motion.

Both history and physical exam contribute to the diagnosis of sciatica, but imaging is necessary to finalize the diagnosis. X-rays are typically obtained first to look at the overall alignment of the spine and to check for spinal abnormalities such as scoliosis (curve in the spine), that may affect viable treatment options. These 2D results are supplemented with advanced imaging tests such as MRI or CT scans because these show a 3D view of the spine. MRI scans which show soft tissues, such as nerves and discs, are generally preferred over CT scans which show bony elements. Advanced imaging can show exactly which nerve or nerves are affected.  Together history, physical exam, and imaging are all necessary in order to make a correct diagnosis and design an optimal treatment plan for sciatica.  

Physical exam abnormalities for the lumbar spine tend to occur exclusively in the lower body. It is important to start by looking at the back for changes in the skin, decreases in muscle size, or unevenness from one side of the back to the other. The next step would be palpation of the muscles and center of the back. Lumbar spine range of motion is tested with flexion, such as touching toes, and extension, leaning back at the waist to look for decreased motion due to pain. Motor strength testing would be performed on the lower extremities because weakness in certain muscle groups could imply sciatica at the lumbar level where the relevant nerve branches from the spinal cord. Changes in sensation may also be tested throughout the leg to check for areas with decreased sensation throughout or relative to the opposite leg. Increases or decreases in the patellar and Achilles reflexes are commonly used to test for spinal nerve compression and can potentially identify the affected spinal level because they are connected to the L3/L4 and S1 nerve roots respectively. Other exam results that imply sciatica are abnormal walking patterns, including inability to walk on the heels and the toes.

Conservative Treatment

Lifestyle Modification

Certain lifestyle factors may increase the incidence of sciatica, such as smoking and increased weight. Smoking decreases blood flow throughout the body which is needed to repair damaged tissues. Cessation may restore blood flow, allowing the tissues to access proper nutrition. Added weight may increase the risk for sciatic because of the extra stress placed on the disc. Reducing weight through a low-calorie diet and exercise can reduce pressure on the spine, decreasing the symptoms of sciatica.

Repetitive leisure or work-related motions such as excessive bending, lifting, and twisting, along with any activity that may be high impact on the spine, such as running or riding ATVs, can also lead to sciatica. Some of these repetitive task activities may be due to leisure and others due to demands of a job. For people with full labor or heavy-duty jobs, you may need to change jobs or support your work with proper lifting technique, relaxed breaks, and equipment such as a back brace to avoid worsening symptoms. You may also need to alter or avoid high impact activities, such as running to reduce the symptoms of sciatica.

Alternative Therapy

Alternative therapies include massages, chiropractic care, and acupuncture. These may also be referred to as manual therapies since they address the spine with hands on technique. Massage relieves tension in muscles surrounding the spine and in arm and leg muscles experiencing radiating symptoms. These muscles may be under tension due abnormalities with walking and changes in posture due to pain from sciatica. Chiropractic care may use specific techniques, such as adjusting the spine or application of traction on the spine. Acupuncture may also provide pain relief as muscles are stimulated electrically.

Physical Therapy/Exercise

Physical therapy focuses on changing body mechanics to improve posture and walking as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Other techniques that physical therapists may use are manual treatments such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit. A combination of these methods can provide symptom relief.

A home exercise program may be used in conjunction with or instead of a formal physical therapy regimen. A daily low impact exercise regimen is important for strengthening muscles, especially those in the core. Low impact cardiovascular activities such as walking, swimming, elliptical, and biking are also important for increasing blood flow and strengthening muscles without adding stress on the spine. Home exercise can also lead to weight loss which may reduce pressure on the spine and reduce symptoms. Home exercise routines should be paired with stretches and physician supervision to avoid harm.

Medications

There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of scitaica. Some of these medications include Tylenol (acetaminophen), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, nerve membrane stabilizers, topical medications, and off label medications.

Epidural Steroid Injections

Epidural steroid injections reduce pain by injecting steroid, or anti-inflammatory, medication at a specific level/levels in the spine. As the herniation places pressure on a nerve, this causes inflammation of the nerve and surrounding tissue which causes pain. A specialized needle is used to deliver medication to the correct area, past the muscles of the back and as close to the spinal nerves as possible. As steroids are a natural anti-inflammatory, this may reduce the inflammation around the nerve, diminishing pain caused by the disc herniation. Steroid injections have the ability to provide pain relief for up to several months, and provide better pain relief for radiating symptoms, such as leg pain, than treatments designed for back pain alone. Steroid injections are only safe to have completed 3 times in one year and must be at least one month apart between sequential injections. This is due to the muscle and tendon breakdown with exposure to the steroid medication too often or too soon. 

Surgical Treatment

Decompressive Procedures

A microdiscectomy is a minimally invasive surgical decompression procedure that is typically performed on the lumbar spine to address disc herniations that lead to sciatica. A small incision is made in the midline of the back until the joint of the spine, the facet, is reached. A small portion of the joint is removed to visualize the spinal nerve and disc herniation. The disc herniation is removed and once the nerve is free of compression, the incision is closed.  

Endoscopic discectomy is a minimally invasive surgical decompression procedure that uses specialized instrumentation in order to perform the disc removal. A small incision is made on the midline of the back and a specialized imaging tool, called a fluoroscope is used to determine the correct vertebral level is targeted for the procedure. After the incision is made a thin wire, called the guide wire, is placed until it hits bone. A series of small cylindrical tubes are then placed over the guide wire to open the incision. A specialized retractor and light source is place down these tubes and all the instruments are placed down through the tubes and the disc material is removed to free the nerve root of compression.  This special retractor is then readjusted to target the opposite side of the spine. All the instruments are removed and the surgery is completed.

Stabilization Procedures

A transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that uses a specialized implant to fix the appropriate disc level. This procedure is performed through a small incision on the midline of the lumbar spine.  Once the spine is reached, the backside portion of the vertebrae is removed, the laminae, until the nerve is reached and the compression on the nerve is removed. The disc material is removed from the disc space and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space, that are connected via rods. Once the procedure is complete the spinal level is fused.  

All of these procedures are minimally invasive and are either decompressive or stabilization procedures. Decompressive surgeries remove tissue, such as a disc herniation that is compressing the nerve root, without adding any hardware or fusing the spine. Stabilization procedures remove the old, worn out intervertebral disc and replace this with an implant and bone graft that will fuse the level, in addition to hardware, to lock down this level of the spine. The procedure that is most appropriate to perform will depend on multiple factors including cause of sciatica, amount of bony removal that will be necessary to achieve proper decompression of the nerve, any prior surgeries, and imaging. The history, physical examination, and imaging are all necessary components to planning the proper minimally invasive surgery for sciatica.

Overview

The spine is made up of 33 bones called vertebrae and divided into four regions: cervical (neck), thoracic (mid back), lumbar (lower back), and sacrum. The vertebrae surround the spinal cord, a thick band of nerve tissue that runs through the spine, providing 360o of protection. Each vertebral body has openings called foramen for nerves branching off the spinal cord to exit the spine and run to the hands, legs, torso, and other locations in the body. Pinched nerve is an umbrella term for any spinal condition that compresses nerves exiting the spine and causes symptoms in the region that particular spinal nerve exits to. This can include structural problems like disc herniation, spondylolisthesis, and disc degeneration or the formation of bone spurs, cysts in the spine joints, or tumors. These problems can cause narrowing of the foramen on the vertebral bodies, leading to symptoms below.

Types

A pinched nerve is a form of compression that applies to nerves that exit from the spinal cord through an opening in the vertebrae, called the foramen, moving into the limbs to provide motor and sensory function.  The type of pinched nerve depends on spinal region (i.e. cervical, thoracic, and lumbar) where the pinch occurred. The cervical and lumbar regions provide motion and flexibility for the spine, whereas the thoracic region supports and protects organs along with the ribs. The extra motion in the cervical and lumbar regions make them more prone to pinched nerves.

Cervical Pinched Nerve (Neck)

The cervical spine has seven vertebrae with intervertebral discs between most pairs, which create flexibility and a wide range of motion in the neck. The discs in the cervical spine can wear over time and with increased motion, resulting in a disc herniation or spinal stenosis in the neck, which pinches the nerve.  These changes within the cervical spine may lead to a pinched nerve which can cause problems in the arms.

Thoracic Pinched Nerve (Mid Back)

There are 12 thoracic vertebrae that are all separated by intervertebral discs. Unlike the lumbar and cervical spine, the thoracic spine mainly functions in support and structure; because it is minimally involved in movement, the discs in this region are not as thick as those found in the lumbar and cervical regions. Since there is limited motion, the thoracic spine is not a typical site for causes of a pinched nerve, including disc herniation and spinal stenosis.

Lumbar Pinched Nerve (Lower Back)

The lumbar spine contains five vertebrae, each separated by an intervertebral disc. Like the cervical region, the lumbar region has a higher level of flexibility and a large range of motion. It also bears most of the weight of the body, so it is subject to pinched nerves from the wear of weight bearing, aging, and repetitive motions. Spinal elements such as the discs and joints begin to wear over time which may lead to compression of nerves that branch to the lower extremities, from disc herniations and spinal stenosis.

Causes

A pinched nerve refers to compression of a nerve from a causes, such as disc herniation and spinal stenosis. All three regions of the spine (i.e. cervical, thoracic, and lumbar) are susceptible to pinched nerves, but the cervical and lumbar regions are more prone due to their higher range of motion and the burden of weight bearing in the latter. The motion and weight bearing increase stress on structures in the spine, such as facet joints and shock absorbing discs, which can lead to pinched nerves. 

Aging

Aging and related arthritis is the primary cause of pinched nerves. Intervertebral discs contain a lot of water and stress from the aging process causes them to dry out, degenerate, and shrink. As discs shrink in size, the space between vertebral bodies and the foramen, the space through which nerves exit the spinal cord, narrows.  In addition, the ligaments and facet joints on the spinal vertebrae increase in size with arthritis which may place pressure on spinal nerves.  Arthritis may also cause the formation of bone spurs, or bony growths, at the facet joints. Often, more than one type of arthritic change is contributing to the symptoms of a pinched nerve.

Disc Herniation

Disc herniation may also lead to a pinched nerve. Intervertebral discs are formed from two elements: an outer fibrous area and an inner jelly-like area. The outer fibrous portion may weaken or develop small tears with aging, trauma, and weight gain, potentially allowing the inner jelly-like substance to herniate or slip through.  Acute trauma is a large amount of force applied to the spine from a single event, for example, from a blunt hit or a motor vehicle accident. Chronic trauma is repeated stress over time, including forces applied by repetitive tasks at work or with recreational activities. Increase in body weight also adds stress on the spine, weakening the discs, and making them more susceptible to a herniation. As the disc herniates, this pinches the spinal nerve.

Structural Abnormalities

Structural abnormalities of the spine can also lead to pinched nerves. The more common structural abnormalities are scoliosis and spondylolisthesis. Scoliosis is an abnormal curvature in the spine which can accelerate the aging process and arthritic changes, leading to a pinched nerve. Spondylolisthesis is an abnormal alignment of spinal vertebrae, when one vertebrae slides forward or backward relative to the vertebrae directly below. As the facet joints of each vertebra in the spine come together, a space called the foramen is created that allows nerves to branch from the spinal cord into the body. If one vertebra is shifted forward relative to the vertebrae below, this causes an abnormal alignment of the facet joints, narrowing the foramen and leading to a pinched nerve.

Symptoms

The symptoms of pinched nerves range from nonexistent to severe and debilitating. This can depend on the location of the pinched nerve, amount of compression, and cause of the pinched nerve. Pinched nerves occur most frequently in the cervical and lumbar spine due to their range of motion, but more frequently affects the latter.

Cervical Pinched Nerve (Neck)

Spinal nerves that exit in the cervical region are directly involved in the function of the shoulders, arms, and hands, meaning that pinched nerves in this region will create symptoms in those locations. Typically, symptoms from a pinched nerve will only produce unilateral symptoms, symptoms that occur on one side of the body. Symptoms usually manifest as a sharp shooting or throbbing pain, numbness, tingling, or decreased sensation. Pain is experienced in the body part that the pinched nerve is involved in the function of. For example, weakness in the deltoid muscle while raising your arms from your sides could indicate a pinched nerve at the C4-5 level. Other potentially affected muscles include the bicep, triceps, wrist, and hand muscles.

Thoracic Pinched Nerve (Mid Back)

The spinal nerves from the thoracic spine are involved with the function of the chest and abdomen. The exception is with the first thoracic nerve, which is also responsible for the ring and pinky fingers. A pinched nerve at the thoracic levels may cause pain and/or numbness in the back, chest, abdomen, and/or the ring and pinky finger. The nerves from the thoracic spine run directly above each rib. These nerves supply sensation to the torso and motor strength to the intercostal and abdominal muscles. Symptoms of pinched nerves typically unilateral, or only occurring on one side of the body.

Lumbar Pinched Nerve (Lower Back)

Spinal nerves that branch out of the lumbar spine control function in the lower extremities (buttocks, hips, legs, and feet). Therefore, a herniated disc causing nerve compression in this region will produce symptoms in the lower extremities including a sharp, shooting, burning, or electrical pain and potentially numbness or changes in sensation. For example, weakness while straightening the leg could indicate a pinched nerve at the L3-4 level. Other potentially affected muscles include the quadriceps, tibialis anterior, and flexors of the foot. Symptoms may also include neurogenic claudication, a nerve-related pain that increases with walking and improves with rest. These typically occur unilaterally, only on one side of the body, and the specific location of the symptom will vary based on the nerve being compressed.

Diagnosis

Patient history and physical examination are typically the first step in diagnosing pinched nerves. Types of symptoms, duration of symptoms, factors that improve/exacerbate symptoms, treatments that have been already tried, and past relevant medical problems/surgeries are all collected during the history. The physician completes a physical exam to check for specific symptoms by inspecting the back, assessing gait, and testing the upper and lower extremities for motor strength, reflexes, and range of motion.

Both history and physical exam contribute to the diagnosis of a pinched nerve, but imaging is necessary to finalize the diagnosis. X-rays are typically obtained first to look at the overall alignment of the spine and to check for spinal abnormalities such as scoliosis (curve in the spine), that may affect viable treatment options. These 2D results are supplemented with advanced imaging tests such as MRI or CT scans because these show a 3D view of the spine. MRI scans which show soft tissues, such as nerves and discs, are generally preferred over CT scans which show bony elements. Advanced imaging can show exactly which nerve or nerves are being pinched and what is causing the nerve to be pinched. Together history, physical exam, and imaging are all necessary in order to make a correct diagnosis and design an optimal treatment plan for a pinched nerve.  

Cervical Pinched Nerve (Neck)

Physical exam results that imply a cervical pinched nerve include decreased range of motion in the neck with difficulty moving the chin toward the chest, leaning the head back, or turning left and right as if checking a blind spot while driving. Motor strength testing would be performed on both the upper and lower extremities because weakness in certain muscle groups could imply a pinched nerve at the cervical level where the relevant nerve branches off of the spinal cord. For example, weakness in the deltoid muscle while raising your arms from your sides could indicate a pinched at the C4-5 level. Increases or decreases in the bicep, brachioradialis, or tricep muscle reflexes are commonly used to test for spinal pinched nerve and can potentially identify the affected spinal level because they are connected to the C5, C6, and C7 nerve roots respectively. Other tests include checking for changes in sensation and a heel to toe walk to evaluate balance.

Thoracic Pinched Nerve (Mid Back)

Physical exams checking for a thoracic pinched nerve will be much less involved than those looking for cervical and lumbar pinched nerves. The exam typically begins with examining the back for an abnormal curve, uneven muscles, or skin changes such as bruising. After inspection, the doctor will perform palpations over the muscles and center of the back. The legs would be tested for motor strength to ensure that both legs are at full strength and functioning normally. Lastly the physician may check for changes in sensation from one side of the body to the other.

Lumbar Pinched Nerve (Lower Back)

Physical exam abnormalities for the lumbar spine tend to occur exclusively in the lower body. As with evaluating the cervical and thoracic spine, it is important to start by looking at the back for changes in the skin, decreases in muscle size, or unevenness from one side of the back to the other. The next step would be palpation of the muscles and center of the back. Lumbar spine range of motion is tested with flexion, such as touching toes, and extension, leaning back at the waist to look for decreased motion due to pain. Motor strength testing would be performed on the lower extremities because weakness in certain muscle groups could imply a pinched nerve at the lumbar level where the relevant nerve branches from the spinal cord. For example, a pinched nerve at L3-4 or L4-5 levels may cause weakness with knee extension or straightening the leg. Changes in sensation may also be tested throughout the leg to check for areas with decreased sensation throughout or relative to the opposite leg. Increases or decreases in the patellar and Achilles reflexes are commonly used to test for spinal pinched nerve and can potentially identify the affected spinal level because they are connected to the L3/L4 and S1 nerve roots respectively. Other exam results that imply lumbar pinched nerves are abnormal walking patterns, including inability to walk on the heels and the toes.

Conservative Treatment

 

Lifestyle Modification

Certain lifestyle factors may increase the incidence of a pinched nerve, such as smoking and increased weight. Smoking decreases blood flow throughout the body which is needed to repair damaged tissues, including those around a compressed nerve. Cessation may restore blood flow, allowing the tissues to access proper nutrition. Added weight may increase the risk for disc herniation which may pinch the nerve, or the acceleration of the aging process, leading to pinched nerves. Reducing weight through a low-calorie diet and exercise can reduce pressure on the spine, decreasing the symptoms of a pinched nerve.

Repetitive leisure or work-related motions such as excessive bending, lifting, and twisting, along with any activity that may be high impact on the spine, such as running or riding ATVs, can also lead to pinched nerves. Some of these repetitive task activities may be due to leisure and others due to demands of a job. For people with full labor or heavy-duty jobs, you may need to change jobs or support your work with proper lifting technique, relaxed breaks, and equipment such as a back brace to avoid worsening symptoms. You may also need to alter or avoid high impact activities, such as running to reduce the symptoms of a pinched nerve.

Alternative Therapy

Alternative therapies include massages, chiropractic care, and acupuncture. These may also be referred to as manual therapies since they address the spine with hands on technique. Massage relieves tension in muscles surrounding the spine and in arm and leg muscles experiencing radiating symptoms. These muscles may be under tension due abnormalities with walking and changes in posture due to pain from a pinched nerve. Chiropractic care may use specific techniques, such as adjusting the spine or application of traction on the spine. Acupuncture may also provide pain relief as muscles are stimulated electrically.

Physical Therapy/Exercise

Physical therapy focuses on changing body mechanics to improve posture and walking as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Other techniques that physical therapists may use are manual treatments such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit. A combination of these methods can provide symptom relief.

A home exercise program may be used in conjunction with or instead of a formal physical therapy regimen. A daily low impact exercise regimen is important for strengthening muscles, especially those in the core. Low impact cardiovascular activities such as walking, swimming, elliptical, and biking are also important for increasing blood flow and strengthening muscles without adding stress on the spine. Home exercise can also lead to weight loss which may reduce pressure on the spine and reduce symptoms. Home exercise routines should be paired with stretches and physician supervision to avoid harm.

Medications

There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of a pinched nerve. Some of these medications include Tylenol (acetaminophen), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, nerve membrane stabilizers, topical medications, and off label medications.

 

Epidural Steroid Injections

Epidural steroid injections reduce pain by injecting steroid, or anti-inflammatory, medication at a specific level/levels in the spine. As the herniation places pressure on a nerve, this causes inflammation of the nerve and surrounding tissue which causes pain. A specialized needle is used to deliver medication to the correct area, past the muscles of the back and as close to the spinal nerves as possible. As steroids are a natural anti-inflammatory, this may reduce the inflammation around the nerve, diminishing pain caused by the disc herniation. Steroid injections have the ability to provide pain relief for up to several months, and provide better pain relief for radiating symptoms, such as leg pain, than treatments designed for back pain alone. Steroid injections are only safe to have completed 3 times in one year and must be at least one month apart between sequential injections. This is due to the muscle and tendon breakdown with exposure to the steroid medication too often or too soon.

Surgical Treatment

Cervical

A foraminotomy is a minimally invasive surgical decompression procedure that is performed in the cervical spine to alleviate the compression on a cervical spinal nerve from a pinched nerve. This may be due to bone spur formation or a disc herniation. This procedure is performed through a small midline incision on the back of the neck. A small amount of bone from the back of the vertebrae is removed, called the laminae, so opening for the spinal nerve, the foramen, is reached. The compression is alleviated either by removing disc material or bone spurs that are pinching the nerve. Once the nerve is decompressed, the incision is closed and the procedure is completed.

An ACDF is a minimally invasive surgical stabilization procedure. This is performed through a small incision on the front of the neck. The surgeon tunnels between the thin neck muscles until the spinal column is reached. The old disc is removed and once removed, any contents can be removed around the nerve roots to relieve the pinched nerve. A special implant with bone graft will then be placed in the disc space with screws to secure placement. Once the procedure is completed, the disc level is fused.

A cervical disc replacement is a minimally invasive surgical stabilization procedure that is performed similarly to the ACDF, however the implant is slightly different, as it preserves some motion of the cervical spine instead of creating a fusion in the ACDF. The pinched nerves are alleviated through the removal of the disc material.

Lumbar (and Thoracic)

 A microdiscectomy is a minimally invasive surgical decompression procedure that is typically performed on both the thoracic and lumbar spine to address disc herniations, which cause pinched nerves. A small incision is made in the midline of the back until the backside of the vertebrae, laminae, is reached. At this point, a small amount of the laminae is removed until the pinched spinal nerve is well visualized. The compression on the nerve is removed and once completed, the incision is closed.

Endoscopic discectomy is a minimally invasive surgical decompression procedure that uses specialized instrumentation to remove a disc herniation, which is a source or pinched nerves. A small incision is made on the midline of the back and the use of specialized imaging, called a fluoroscope is used. After the incision is made a thin wire, called the guide wire, is placed until it hits bone. A series of small cylindrical tubes are then placed over the guide wire to dilate the tissue and a retractor is placed over the cylinders and the cylinders are removed. A light source is place down the retractor and instruments are placed down through the retractor to remove the disc fragments pushing on the nerve. The retractor is then repositioned, so that the compression can be removed around the nerve on the opposite side of the body. The instruments are removed and the surgery is completed.

 A transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that uses a specialized implant to fix the appropriate disc level. This procedure is performed through a small incision on the midline of the lumbar spine. Once the spine is reached, the backside portion of the vertebrae is removed, the laminae, until the nerve is reached and the compression on the nerve is removed. The disc material is removed from the disc space and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space, that are connected via rods. Once the procedure is complete the spinal level is fused.  

An extreme lateral lumbar interbody fusion, or XLIF, is a minimally invasive surgery that is performed on the lumbar spine. A small incision is made on the left side, between the hip and the ribs. A thin wire, called a guide wire, is placed and sequentially cylindrical tubes, called dilators are placed through the psoas muscle to reach the left side of the spine. Once the spine is reached, the disc is then completely removed. A special implant is sized, filled with bone graft and placed in the empty disc space. The implant is then screwed in place, with screws placed into the upper and lower vertebral body to provide structure. This will fuse and stabilize the level to prevent any further motion. The XLIF can only be performed on certain levels in the lumbar spine, as the space between the hip and lowest rib is limited, even with specialized positioning of the body on the surgical table.

All procedures used to alleviate the symptoms and structural problems from pinched nerves are minimally invasive decompressive and stabilization procedures. The spinal nerve roots are decompressed properly any mal-aligned vertebral body is stabilized to prevent further motion. Multiple factors are taken into consideration to plan an appropriate surgical option to treat the structural problems associated with a pinched nerve.

Overview

The spine is made of bones called vertebrae and is separated into four regions: cervical (neck), thoracic (mid back), lumbar (lower back), and sacrum. Between each vertebra in the first three regions is a disc used to provide shock absorption and to increase range of motion in the spine. The discs are named by the two vertebral bodies that are located above and below the disc (e.g. the L2-3 disc is between the 2nd and 3rd lumbar vertebral body). Each disc is made of two separate parts: the annulus fibrosis, a thick band of fibers, which surrounds the nucleus pulposus, a jelly-like middle. The disc material in your spine contains a lot of water, but dries out with excessive stress and from natural aging processes. The drying reduces flexibility and creates weakness in the disc, allowing the jelly-like material of the nucleus pulposus to protrude through the annulus fibrosis, becoming a herniated disc. Herniated discs mostly occur in the cervical and lumbar spine due to the higher mobility and flexibility of these regions, though they can occur in any of the regions. A disc herniation may occur towards the spinal cord, a thick band of nerve tissue that starts at the brain and moves through the spine, or off to the side, where nerves exit from the spinal cord and move into the arms, torso, and legs.

Types

The cervical (neck), thoracic (mid back), and lumbar (lower back) regions of the spine contain discs, structures made of a thick band of fiber, surrounding a jelly-like middle. Disc herniations are created when the jelly-like middle of a disc protrudes through the fibrous surroundings. They come in three types depending on the region of the spine where the herniation occurred. The thoracic spine is mainly used for support and protection, whereas the cervical and lumbar spine are used for support and movement, making the latter pair more likely to experience disc related problems including herniations.

Cervical Herniation (Neck)

Discs between the 7 vertebrae of the cervical spine or neck are prone to herniations because of the flexibility and range of motion in that region. With time and increased motion, the fibrous outer portion of the disc, the annulus fibrosis, develops small tears and weak areas allowing the jelly-like inner portion of the disc, the nucleus pulposus, to extrude through. The herniation usually occurs to either the posterior (back) or lateral (side) sides of the body. A posterior herniation is more likely to be central and press on the spinal cord, a thick band of nerves that starts at the brain and moves through the spinal vertebrae. Lateral or side herniations tend to cause compression on spinal nerve roots, nerves exiting the spinal cord and branching into the body.

Thoracic Herniation (Mid Back)

The thoracic spine typically does not experience herniations because its primary functions are stabilization, support, and protection of the internal organs (i.e. not movement related). However, they do occur occasionally and can occur centrally, pressing on the spinal cord, or toward the side, pressing on nerve roots. Symptoms are occur based on which direction the disc herniates.

Lumbar Herniation (Lower Back)

The lumbar spine has a large range of motion, like the cervical spine, and also bears the majority of body weight. These conditions make lumbar discs more susceptible to herniations than discs in any other region of the spine. With added wear from weight bearing, aging, and repetitive motions, the fibrous outer portion of the disc, the annulus fibrosis, weakens or develops small tears that allow the inner jelly portion of the disc, the nucleus pulposus, to squeeze through and cause a herniated disc. Lumbar herniations can compress the spinal nerve roots, the spinal cord, or both.

Causes

Discs in the cervical and lumbar regions of the spine are larger and more prone to injury than those in the thoracic region which has less flexibility and range of motion. Based on the individual’s spinal structure and motion, disc herniations are more likely to occur either towards the back, by the spinal cord, or towards the sides, by the nerve roots. Causes include aging, weight, trauma, and genetics.

Aging

As our bodies age, structures that contained a lot of water and moisture, such as the skin and the spinal discs, begin to dry. This dehydration process that occurs naturally with aging causes the discs to degenerate and shrink; it is the most common cause of disease in spinal discs. In addition, wear caused by movement can create tears in the outer annulus portion. The tears in the annulus make it easier for the inner nucleus pulposus to be released, creating a herniated disc.

Weight

Weight is another common cause of disc herniations because the spine, particularly the lumbar region, supports most of your body weight. As weight increases beyond a healthy level, the vertebral bodies struggle under the increased pressure and this is transferred to the discs. The pressure squeezes the discs, which results in the development of annulus tears and nucleus pulposus leaks. Weight and obesity can lead to recurring herniations at the same disc. 

Trauma

Chronic trauma caused by repetitive motions and tasks often related to occupation, leisure, or sports can create wear on the disks. This is particularly common when the discs are subjected to repeated stress from tasks, such as physical labor jobs, that involve bending, lifting, and twisting of the lumbar spine. Wear increases with the amount of repetition and stress.

Acute trauma is any single occurrence event, such as an automobile accident, that places a large amount of stress on the spine. The large excess pressure placed on the spine causes the disc to herniate immediately instead of over time like it does with chronic trauma.

Genetics

Disc herniations are more likely with certain genetics; the likelihood of disc herniation or degeneration increases if other family members struggled with similar issues. The direct causation is still being researched but there is evidence to support a relationship between genetics and predisposition to disc herniations. 

Symptoms

Disc herniations range from causing no symptoms to causing severe and incapacitating symptoms. Symptoms are based on the spinal region, nerve proximity, and size of the herniation. They occur most commonly in the lumbar, cervical, thoracic spinal regions, in that order.

Cervical Herniation (Neck)

Spinal nerves that branch out of the cervical spine control function in the upper extremities (shoulders, arms, and hands). Therefore, a herniated disc in this region that compresses a nerve will produce symptoms in the upper extremity including a sharp shooting or throbbing pain, numbness or tingling, and decreased sensation. These typically occur unilaterally, only on one side of the body, and the specific location of the symptom will vary based on the nerve being compressed. For example, weakness in the deltoid muscle while raising your arms from your sides could indicate a disc herniation at the C4-5 level. Other potentially affected muscles include the bicep, triceps, wrist, and hand muscles.

Thoracic Herniation (Mid Back)

Spinal nerves exiting from the thoracic spine are related to chest and abdominal functions (such as skin sensation, intercostal and abdominal muscles), except for the first thoracic nerve which also is responsible for some of the fingers. Therefore, a herniation at the thoracic level will produce symptoms of pain that radiate around the torso near a specific rib. These typically occur unilaterally, only affecting one side of the body. Common symptoms include sharp, shooting, stabbing, or electrical pain. The specific location of the symptom will vary based on the nerve being compressed. 

Lumbar Herniation (Lower Back)

Spinal nerves that branch out of the lumbar spine control function in the lower extremities (buttocks, hips, legs, and feet). Therefore, a herniated disc causing nerve compression in this region will produce symptoms in the lower extremities including a sharp, shooting, burning, or electrical pain and potentially numbness or changes in sensation. For example, weakness at the knee while straightening the leg could indicate a disc herniation at the L3-4 level. Other potentially affected muscles include the quadriceps, tibialis anterior, and flexors of the foot. Symptoms may also include neurogenic claudication, a nerve-related pain that increases with walking and improves with rest. These typically occur unilaterally, only on one side of the body, and the specific location of the symptom will vary based on the nerve being compressed.

Diagnosis

Patient history and physical examination are typically the first step in diagnosing disc herniations. Types of symptoms, duration of symptoms, factors that improve/exacerbate symptoms, treatments that have been already tried, and past relevant medical problems/surgeries are all collected during the history. The physician completes a physical exam to check for specific symptoms by inspecting the back, assessing gait, and testing the upper and lower extremities for motor strength, reflexes, and range of motion.

Both history and physical exam contribute to the diagnosis of a disc herniation, but imaging is necessary to finalize the diagnosis. X-rays are typically obtained first to look at the overall alignment of the spine and to check for spinal abnormalities such as scoliosis (curve in the spine), that may affect viable treatment options. These 2D results are supplemented with advanced imaging tests such as MRI or CT scans because these show a 3D view of the spine. MRI scans which show soft tissues, such as nerves and discs, are generally preferred over CT scans which show bony elements. Advanced imaging can show exactly which nerve or nerves are affected by a herniated disc and the size of the disc herniation. Together history, physical exam, and imaging are all necessary in order to make a correct diagnosis and design an optimal treatment plan for a disc herniation.  

Cervical Herniation (Neck)

Physical exam results that imply a cervical disc herniation include decreased range of motion in the neck with difficulty moving the chin toward the chest, leaning the head back, or turning left and right as if checking a blind spot while driving. Motor strength testing would be performed on both the upper and lower extremities because weakness in certain muscle groups could imply a disc herniation at the cervical level where the relevant nerve branches off of the spinal cord. For example, weakness in the deltoid muscle while raising your arms from your sides could indicate a disc herniation at the C4-5 level. Increases or decreases in the bicep, brachioradialis, or tricep muscle reflexes are commonly used to test for spinal disc herniation and can potentially identify the affected spinal level because they are connected to the C5, C6, and C7 nerve roots respectively. Other tests include checking for changes in sensation and a heel to toe walk to evaluate balance.

Thoracic Herniation (Mid Back)

Physical exams checking for a thoracic disc herniation will be much less involved than those looking for cervical and lumbar disc herniations. The exam typically begins with examining the back for an abnormal curve, uneven muscles, or skin changes such as bruising. After inspection, the doctor will perform palpations over the muscles and center of the back. The legs would be tested for motor strength to ensure that both legs are at full strength and functioning normally. Lastly the physician may check for changes in sensation from one side of the body to the other.

Lumbar Herniation (Lower Back)

Physical exam abnormalities for the lumbar spine tend to occur exclusively in the lower body. As with evaluating the cervical and thoracic spine, it is important to start by looking at the back for changes in the skin, decreases in muscle size, or unevenness from one side of the back to the other. The next step would be palpation of the muscles and center of the back. Lumbar spine range of motion is tested with flexion, such as touching toes, and extension, leaning back at the waist to look for decreased motion due to pain. Motor strength testing would be performed on the lower extremities because weakness in certain muscle groups could imply a disc herniation at the lumbar level where the relevant nerve branches from the spinal cord. For example, a disc herniation at L3-4 or L4-5 levels may cause weakness with knee extension or straightening the leg. Changes in sensation may also be tested throughout the leg to check for areas with decreased sensation throughout or relative to the opposite leg. Increases or decreases in the patellar and Achilles reflexes are commonly used to test for spinal disc herniation and can potentially identify the affected spinal level because they are connected to the L3/L4 and S1 nerve roots respectively. Other exam results that imply lumbar disc herniations are abnormal walking patterns, including inability to walk on the heels and the toes.

Conservative Treatment

Lifestyle Modification

Certain lifestyle factors may increase the incidence of a herniated disc such as smoking and increased weight. Smoking decreases blood flow throughout the body which is needed to repair damaged tissues, including those around a herniated disc. Cessation may restore blood flow, allowing the tissues to access proper nutrition. Added weight may increase the risk for single-occurrence or recurring disc herniation because extra stress is placed on the disc, making it easier to tear. Reducing weight through a low-calorie diet and exercise can reduce pressure on the spine, decreasing the symptoms of a disc herniation.

Repetitive leisure or work-related motions such as excessive bending, lifting, and twisting, along with any activity that may be high impact on the spine, such as running or riding ATVs, can also lead to disc herniations. Some of these repetitive task activities may be due to leisure and others due to demands of a job. For people with full labor or heavy-duty jobs, you may need to change jobs or support your work with proper lifting technique, relaxed breaks, and equipment such as a back brace to avoid worsening symptoms. You may also need to alter or avoid high impact activities, such as running to reduce the symptoms of a disc herniation.

Alternative Therapy

Alternative therapies include massages, chiropractic care, and acupuncture. These may also be referred to as manual therapies since they address the spine with hands on technique. Massage relieves tension in muscles surrounding the spine and in arm and leg muscles experiencing radiating symptoms. These muscles may be under tension due abnormalities with walking and changes in posture due to pain from disc herniation. Chiropractic care may use specific techniques, such as adjusting the spine or application of traction on the spine. Acupuncture may also provide pain relief as muscles are stimulated electrically.

Physical Therapy/Exercise

Physical therapy focuses on changing body mechanics to improve posture and walking as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Other techniques that physical therapists may use are manual treatments such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit. A combination of these methods can provide symptom relief.

A home exercise program may be used in conjunction with or instead of a formal physical therapy regimen. A daily low impact exercise regimen is important for strengthening muscles, especially those in the core. Low impact cardiovascular activities such as walking, swimming, elliptical, and biking are also important for increasing blood flow and strengthening muscles without adding stress on the spine. Home exercise can also lead to weight loss which may reduce pressure on the spine and reduce symptoms. Home exercise routines should be paired with stretches and physician supervision to avoid harm.

Medications

There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of disc herniation. Some of these medications include Tylenol (acetaminophen), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, nerve membrane stabilizers, topical medications, and off label medications.

 

Epidural Steroid Injections

Epidural steroid injections reduce pain by injecting steroid, or anti-inflammatory, medication at a specific level/levels in the spine. As the herniation places pressure on a nerve, this causes inflammation of the nerve and surrounding tissue which causes pain. A specialized needle is used to deliver medication to the correct area, past the muscles of the back and as close to the spinal nerves as possible. As steroids are a natural anti-inflammatory, this may reduce the inflammation around the nerve, diminishing pain caused by the disc herniation. Steroid injections have the ability to provide pain relief for up to several months, and provide better pain relief for radiating symptoms, such as leg pain, than treatments designed for back pain alone. Steroid injections are only safe to have completed 3 times in one year and must be at least one month apart between sequential injections. This is due to the muscle and tendon breakdown with exposure to the steroid medication too often or too soon.

Surgical Treatment

Cervical Herniation (Neck)

A foraminotomy is a minimally invasive surgical decompression procedure that is typically performed on the cervical spine to alleviate compression on a cervical spinal nerve from a disc herniation. This procedure is performed through a small midline incision on the back of the neck. A small amount of bone from the back of the vertebrae, called the laminae, is removed so that the foramen, an opening for the spinal nerve is reached. The disc material is then clipped away to leave the nerve decompressed. The incision is closed and the procedure is completed.

Lumbar Herniation (Lower Back)

A microdiscectomy is a minimally invasive surgical decompression procedure that is typically performed on both the thoracic and lumbar spine to address disc herniations. A small incision is made in the midline of the back until the joint of the spine, the facet, is reached. A small portion of the joint is removed to visualize the spinal nerve and disc herniation. The disc herniation is removed and once the nerve is free of compression, the incision is closed.  

Endoscopic discectomy is a minimally invasive surgical decompression surgery that uses specialized instrumentation in order to perform the disc removal. A small incision is made on the midline of the back and a specialized imaging tool, called a fluoroscope is used to confirm that the correct vertebral level has been targeted for the procedure. After the incision is made a thin wire, called the guide wire, threaded through until it hits bone. A series of small cylindrical tubes are then placed over the guide wire to open the incision. A specialized retractor, a light source, and surgical instruments are place down these tubes and the disc material is removed to alleviate pressure on the nerve root. Once this is completed, the retractor is readjusted to target the opposite side of the spine and more disc material is removed.

The procedures listed above are decompressive surgeries only, meaning that the herniated disc or tissues compressing the nerve are removed and no instrumentation is left in place. A stabilization procedure may be performed in combination with a discectomy. For example, in a case involving spondylolisthesis, a slipped vertebrae, a stabilization may be used to prevent worsening further mal-alignment. The benefit of these procedures includes less pain medication, lower chances of infection, less scarring, faster recovery, and same-day discharge.

Overview

The spine is made up of 33 bones called vertebrae and divided into four regions: cervical (neck), thoracic (mid back), lumbar (lower back), and sacrum. In the movable regions of the spine which are the cervical, thoracic, and lumbar spine, each vertebra is connected to another vertebra via a joint called the facet joint. There is a pair of facet joints on each vertebra, one on the right and one on the left which function like other joints in the body, such as the knee. The facet joints are filled with a lubricant called synovial fluid and lined with cartilage to allow for a smooth, gliding motion in the spine while also preventing excess motion under extreme flexion, rotation, or shear forces. Being joints, the facet joints in your spine are subject to wear and tear and the development of arthritis over time. As the cartilage around the joints begins to degrade, the joints begin to lose stability and emit pain, a condition known as Facet Joint Syndrome or Facet Joint Disease.

Types

Every spinal vertebra has an upper and lower facet joint and a lower facet joint that connects it to the vertebra above and below. Like other joints in the body, such as the knee or the shoulder, facet joints are covered with a cartilage material that allows them to slide and by a small sac of synovial fluid that bathes the joint and adds moisture. The facet joints slide, enabling motion in the spine, but also limit excessive motion, especially with bending and twisting. 

Any of the three spinal regions may be affected by facet joint syndrome, but the thoracic spine is generally immune because its main functions are related to structure, support, and protection instead of to motion. The cervical and lumbar spines are highly flexible, making them more prone to facet joint syndrome. The cervical spine has a wide range of motion and is a common site for facet joint syndrome due to the range of motion and frequency of movement in the neck. The lumbar spine is also commonly afflicted by facet joint syndrome due to the range of motion, frequency of movement, and body weight-related stress placed on the lumbar spine. 

Cervical Facet Joint Syndrome (Neck)

There are seven cervical vertebrae in the neck. Each is connected to two other vertebrae via facet joints, except the first cervical vertebrae. These joints add some motion to the cervical spine, but also limit extremes in range of motion to prevent injury. Over time and with more movements, the facet joints begin to wear. The body tries to repair the damage, developing bone spurs to try to prevent motion at the damaged joint, but bone spurs can create more pain with motion leading to cervical facet joint syndrome.

Lumbar Facet Joint Syndrome (Lower Back)

There are five lumbar vertebrae in the lower back. Each is connected to two other vertebrae via facet joints. This helps works with intervertebral discs to add motion in the spine while also preventing extremes of motion and further damage to the spine. Over time, with repetitive movement, and/or increased weight, the smooth joint surface roughens and the body tries to repair the damage by creating bone spurs that stop motion at the joint. These bone spurs then create pain with motion and lead to lumbar facet joint syndrome.

Causes

Facet joint syndrome is a degenerative disease in the spinal vertebrae’s facet joints. Like other joints in the body, the facet joints are covered in a cartilage and surround by a sac of synovial fluid that bathes the joint. There are multiple causes of facet joint syndrome, but they all lead to breakdown of a facet joint. This occurs most frequently in the cervical and lumbar spine due to the flexibility and motion at these areas. 

Aging

The facet joints are constantly in motion and as a person ages they are subjected to a lot of wear and tear. The joint continues to move while the lining cartilage begins to thin and the synovial fluid becomes less lubricating. This leads to facet joints rubbing bone over bone, increasing the amount of friction they experience with movement. The joint develops inflammation and may produce bone spurs, or bony growths, attempting to stop further motion and limit further damage. This is the most common cause for facet joint syndrome which typically occurs in older individuals.

Weight

Extra weight on the body adds more stress on the spine, particularly on the lumbar region. If excess fat is concentrated in the abdomen, it pulls the lumbar spine forward, creating a more extended position of the lumbar spine. This extended position places stress on the intervertebral discs and on the facet joints, as they provide the necessary flexibility for the spine. Under extra stress, the cartilage around the facet joints begins to thin until the joints are rubbing bone on bone. The body’s defense to the thinning cartilage, is the development of bone spurs or bony growths, to stop further motion and limit further damage. With increased weight, facet joint syndrome can occur in younger individuals because age-related changes are accelerated.

Injury

The spine is involved in most movements, including those in high impact activities and repetitive tasks. Specific injuries can lead to facet joint syndrome, but it is more often caused as a result of repetitive tasks or injuries. During sports and high impact activities (e.g. running, ATV riding) as well as during repetitive tasks (e.g. bending, lifting, and twisting at work) places the facet joints under more stress. The surrounding cartilage begins to wear and the synovial fluid thins, which reduces its ability to lubricate the joint. This allows the joints to move bone on bone with added friction. The body tries to keep the joint from moving and sustaining further damage by developing bone spurs, or bony growths. Just as with additional weight, this can also accelerate age-related joint causes of facet joint syndrome.

Symptoms

Symptoms caused by facet joint syndrome range from mild to severe. The symptoms are often similar to those of other spinal conditions, making facet joint disease difficult to pinpoint as source for neck or back pain without the proper diagnosis procedure. Symptoms can be localized or radiating depending on the location of the diseased facet joint.

Cervical Facet Joint Disease (Neck)

The main symptoms of cervical facet joint syndrome are neck pain or stiffness. Neck pain and stiffness often lead to decreased range of motion and, potentially, cracking or popping sounds as the spine moves. Pain tends to be worse upon awakening in the morning, but will likely decrease throughout the day. There are often headaches as well, that start in the neck and radiate into the head though it is uncommon to have radiating symptoms into the shoulders, arms, and hands, as with other spinal conditions. Sitting with the neck bent slightly down may provide some pain relief. Pain may occur only on occasion without clear triggers. It typically will resolve on its own and will likely recur without any warning.

Lumbar Facet Joint Disease (Lower Back)

Low back pain or stiffness is a common symptom in the lumbar spine facet joint disease. Pain tends to change with motion in the spine; generally it increases while leaning back (extension) and decrease while leaning slightly forward at the waist. Radiating symptoms into the buttocks and back of the legs can be common, but it is rare for any symptoms to radiate to the front of the legs or to the feet. Episodes of facet joint pain are usually intermittent and may not have a triggering activity. Often, the pain may subside with conservative or no intervention, though episode can increase in frequency and duration if untreated.

Diagnosis

The first step in diagnosis is a clinic visit for a detailed history and physical examination. History determines the types of symptoms, duration of symptoms, factors that worsen or improve symptoms, prior treatments, and any other relevant medical problems or surgeries. Physical exam will typically consist of inspection and palpation (or pressing) over the area with pain. Other physical exam techniques include motor strength of upper and lower extremities, reflexes, range of motion, and walking.

Based on the information that is obtained during the history and physical examination, further evaluation with imaging studies may be necessary for proper diagnosis. X-rays are 2D scans that are typically obtained first to look at the overall alignment of the spine. Often, arthritic changes in the facet joints can be seen on x-ray imaging. Advanced 3D imaging studies, such as Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans, are also essential to proper diagnosis. More frequently, a CT scan is more beneficial with facet joint syndrome because this shows the bony elements of the spine better than an MRI would. The CT can help detect bone spur formation, increases in facet joint size (facet hypertrophy), inflammation within the joint, and the affected vertebrae. MRI is also commonly used to evaluate the soft tissue elements of the spine, such as the discs and nerves. Advanced imaging may also show other spinal disease that may be contributing to facet joint syndrome.

Cervical Facet Joint Syndrome (Neck)

Evaluation of the cervical spine starts with inspection of the spine itself to look for any changes in posture, muscle bulk, alignment, or skin. Active and passive range of motion is tested as well; facet joint syndrome generally leads to decreased range of motion in the neck. Active range of motion is motion examines how far the patient can move their neck in each direction comfortably. Passive range of motion is the same comfort test, but with the physician moving the patient’s neck. Palpation, or pressing, over the spine generally reveals pain in certain areas of the neck and spasms of the neck muscles may also be felt. Motor strength and sensation throughout the arms and legs generally test normal since there are few to no radiating symptoms with facet joint syndrome in the cervical region.

Lumbar Facet Joint Syndrome (Lower Back)

Evaluation of the lumbar spine is similar to the cervical spine. The lumbar spine will first be inspected for any changes in posture, muscle bulk, alignment, or skin. Only active range of motion is tested, likely showing a reduced range of motion and pain, especially in the extended position. With palpation, or pressing, over the lumbar spine and musculature, the physician may feel tenderness or muscle spasms. Pain may radiate into the buttocks and back of the thighs, but strength and sensation in the legs will likely be normal since facet joint syndrome usually does not affect the spinal nerve roots.

Conservative Treatment

 

Lifestyle Modification

One of the main causes of facet joint syndrome is excess weight, which accelerates age related changes in the facet joints with added stress from trying to keep the spine in alignment. Weight loss through a low-calorie diet and/or exercise regimen can remove added stress on the facet joint. Even though the arthritic changes including loss of cartilage lining and bone spur formation is irreversible, the reduced weight can decrease pain and slow the progression.

Altering repetitive occupational and leisure activities may be necessary to accommodate the symptoms associated with facet joint syndrome. A change in jobs may be necessary to avoid worsening symptoms due to full labor or heavy-duty work. When changing jobs is not an option, working with equipment that may be an adjunct, proper lifting technique, use of a back brace, and proper rest breaks may all be necessary. Changing positions and avoiding extended periods of sitting may also be effective ways of reducing symptoms.

Alternative Therapy

Alternative therapies include massage, chiropractic care, and acupuncture. These may also be referred to as manual therapies as they address spine with hands on technique. Massage relieves tension in the muscles surrounding the spine caused by abnormalities in walking and by changes in posture due to pain from inflamed facet joints. Chiropractic care helps to adjust the spine through range of motion of the neck and specific stretches/movements of the neck. Acupuncture may also provide pain relief as muscles are stimulated electrically.

Physical Therapy/Exercise

Physical therapy focuses on changing body mechanics to improve posture and gait, as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Physical therapy may also use manual treatments, such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit.

A home exercise program may be used in conjunction with or instead of formal physical therapy. A low impact exercise regimen can help strengthen the muscles, especially the core, which can support the spine to reduce back and neck pain from facet joint inflammation.  In order to prevent injuries, home exercise regimens are best done under physician supervision.

Medications

There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of facet joint syndrome. Some of these medications include Acetaminophen (Tylenol), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, and, topical medications.

Facet Joint Injections/Facet Blocks

Facet joint injections, commonly called facet blocks, supply steroidal medication to specific facet joints in the spine via a specialized needle. The medication is used to reduce inflammation and the associated pain at the joint. Relief can last up to several months, but injections can only be done up to three times in one year to avoid muscle or tendon breakdown.

 

Surgical Treatment

Cervical

An anterior cervical discectomy and fusion (ACDF) is a minimally invasive surgical stabilization procedure. This is performed through a small incision on the front of the neck. The surgeon moves the thin neck muscles until the spinal column is reached and the old disc and any disc fragments or bone spurs around the nerve root are removed. A special implant with bone graft is then placed in the space where the removed disc was, with screws to secure the implant. At the conclusion of this procedure, the specific disc level is fused and motion is no longer possible at this level.

Lumbar

Transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that fixes the appropriate disc level in the lumbar spine with a specialized implant. This procedure is performed through a small incision on the midline of the lower back. After reaching the spine, small amounts of bone are removed to reach the nerve roots, and if necessary, compression is removed from the nerve until the disc space is reached. The disc is removed and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space for support. The screws are connected via rods, fusing the spinal level, and motion is no longer possible, preventing further motion, inflammation, and pain.

A lateral lumbar interbody fusion (XLIF) is a minimally invasive lumbar spine surgery that requires special positioning with the patient’s left side upward. A small incision is made on the left, between the hip and the ribs. A thin wire, called a guide wire, is placed and sequentially larger, cylindrical tubes, called dilators, are placed through the psoas muscle to reach the left side of the spine. Once the spine is reached, the disc is then completely removed. A special implant is sized, filled with bone graft, and placed in the empty disc space. Screws are placed through the implant into the upper and lower vertebral body, to provide stability for the implant. This will fuse and stabilize the level to prevent further motion. The XLIF can only be performed on certain levels in the lumbar spine because the space between the hip and lowest rib is limited, but XLIF is preferred when bony anatomy does not allow for other approaches, when disease is confined to the facet joints without any nerve root compression, or when prior lumbar surgeries have left scarring or hardware that make it difficult to approach from the back.

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