Richmond Spine Interventions
and Pain Center
14404 Sommerville Ct
Midlothian, Virginia 23113
Ph: (804) 378-1800
Fax: (804) 378-5400
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Disc Degeneration and Pain
The spinal column consists of the vertebral bones and the discs which are located in between them. Intervertebral discs are fibro-cartilage rings supporting and providing mobility to the vertebral bones. The disc is a tough, outer ring called the annulus, with a soft inner filling of jelly like material called the nucleus pulposus. Together, the vertebrae and their associated discs form the vertebral column. No disc exists between the skull and first, and between the first and second cervical vertebrae.
A young, healthy disc has a large amount of water. As the disc ages, it slowly loses this water content, becoming dry and "desiccated". This is easily discerned by a radiologist using Magnetic Resonance imaging (MRI). A disc can more rapidly degrade and lose water content due to overload caused by obesity, various forms of active trauma, and due to exceeding it's mechanical limits by heavy lifting. Various means have been used to describe disc pathology. The general term disc herniation is one of them. A disc can undergo many different types of distortion and disruption. Discs can crack or fissure, bulge, protrude, extrude; and fragment and sequester outside the vertebral column. The term "slipped disc" is inaccurate, and a disc does not slip out of place. One vertebra can shift out of place above or below another, but this is shifting is not the result of the disc displacing, but bone and/or ligament disrupting or being absent since birth.
Disc herniation is defined as inner disc material penetrating the outer ring or annulus. Therefore, based on both the symptoms and signs produced, all of the aforementioned can be considered such. However, despite popular belief, most patient symptoms are caused by chemical irritation causing an inflammatory response. Unless actually massively impinging upon a nerve root or the spinal cord, mechanical displacement of the invertebral disc rarely causes symptoms and signs. When it does, the resulting clinical findings are so obvious that surgery is mandated. These findings include loss of bowel and bladder function, dense loss of sensation, and/or striking weakness or paralysis of the legs and arms. This represents the most severe form of what is called spinal stenosis, or narrowing of the inside of the spinal canal.
MOST symptomatic disc pathology does NOT necessitate surgery. The majority of symptomatic disc pathology responds to conservative therapy. Physical therapy in particular. That which does not can usually be managed with epidural steroid and or other types of epidural medication injections. Epidural injections are in general very safe, effective procedures when performed by clinicians well experienced in this technique.(8-9)
MOST IMPORTANT OF ALL, MOST DISC PATHOLOGY FOUND ON RADIOLOGIC STUDIES IS ASYMPTOMATIC. That is, most of us walk around in our everyday lives with disc pathology and never even know it. Men are slightly more likely than women to have disc pathology. Disc pathology increases with age. Symptomatic disc pathology also increases with age.(2-7)
The best way to avoid symptomatic disc problems is to maintain a healthy life style, exercising and pursuing abdominal, upper back and shoulder strengthening, and avoiding prolonged obesity and situations that naturally overload the spine.
Article by Dr. John Sherry II
1. Intradural Cervical Disc Herniation: Report of Two Cases and Review of the Literature; Jie Pan, MCh; Lijun Li, MD; Lie Qian, MD; Honglin Teng, MD; Bin Shen, MCh; Jun Tan, MD; Wei Zhou, MD; Mingjie Yang, MCh; Spine. 2011;36(15):E1033-E1037. © 2011
2. Jensen MC, et al. “MRI imaging of the lumbar spine in people without back pain.” N Engl J Med – 1994; 331:369-373
3. Boden SD et al. “Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation.” J Bone Joint Surg Am 1990; 72A:403-408
4. Weishaupt D et al. “MRI of the lumbar spine: Prevalence of intervertebral disc extrusion and sequestration, nerve root compression and plate abnormalities, and osteoarthritis of the fact joints in Asymptomatic Volunteers.” Radiology – 1998; 209:661-666
5. Boos N, et al. “1995 Volvo Award in clinical science: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations.” Spine – 1995; 20:2613-2625
6. Powell MC, et al. “Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women.” Lancer – 1986; 2:1366-7
7. Boos N, et al. “Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity.” Spine 2000; 25:1484
8. Abdi S, Datta S, Trescot AM, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician. 2007;10(1):185-212.
9. Botwin KP, Gruber RD, Bouchlas CG, et al. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Ach Phys Med Rehabil. 2001;81(8):1045-1050.
Spinal Stenosis: What is it?
You've experienced back and/or leg pain that's been bothering you now for a month or more. You go to your doctor, and after he/she exams you, they send you for an MRI of your lumbar spine. After completing this study, you return to their office and are told you that you have spinal stenosis.
So, exactly what is spinal stenosis in layman's terms?
Stenosis in medical terms literally means an abnormal narrowing of a bodily canal or passage. Like most medical terms, it is derived from Latin. This word actually being derived from "New" Latin that itself derives originally from the greek word stenos, meaning narrow.
It's practical meaning is narrowing of the canal running within the bony spine. Specifically, narrowing of the canal that holds the spinal cord and it's surrounding fluid filled sac. In addition, nerve roots coming off the spinal cord are in part contained within this space.
With narrowing, pressure can be put on the contents noted above sitting in the canal. In addition, swelling caused by normal intervertebral disc breakdown, so called "normal wear and tear", can put pressure on these contents or various regions of them. In fact, it is the latter that most likely causes the symptoms people experience. The former, mechanical compression, can certainly play a role. However, the symptoms generated from this kind of mechanical situation are almost always due slowly evolving extreme narrowing, or from acute, rapidly occurring narrowing that is experienced in severe trauma.
Given the fact that most of the symptoms of spinal stenosis come from swelling and inflammation, it comes as no surprise that a great deal of published, peer reviewed medical literature involving treatment of symptoms from spinal stenosis with various types of techniques designed to reduce this swelling and inflammation have resulted in significant clinical benefit. These studies being done being evidence based, and typically well controlled. There only draw back being that they usually involve a small sample size (group of patients).
What types of procedures have shown success? Probably the most studied and heard about, epidural steroid injections performed under some sort of imaging guidance, using an approach that delivers medicine to the area of the spinal canal closest to the disc (the front or anterior epidural space).
Another technique with a high success rate and longer lasting results is called epidural adhesiolysis. This involves the placement of a catheter into the epidural space into its front or anterior portion, using either imaging or an epiduroscope, and then injecting medicine in a targeted fashion while guiding the catheter tip to the areas where greatest scar tissue from inflammation is noted. Usually this scar tissue (being the actual adhesion that is being broken or "lysed") is noted during the initial portion of the procedure. However, there are occasions when the "inflammation" is actually so severe that the radiologist notes it a previously performed MRI of the spine. Although this is rare, the author has actually treated a half dozen patients during his career with these MRI findings. The outcome is typically dramatic when this is the case, and this has been my experience.
Medicines used in the procedures noted above that benefit people with inflammatory related spinal stenosis symptoms are not limited to steroids. Surprisingly, simply using balanced sterile saline solution can be of great benefit. This because the injecting of such solutions allows for "hydro dissection" of the adhesion. Water pressure itself breaks some of the scarring. Steroid and other medications used certainly can have great benefit as well. What's interesting is that steroid doesn't need to be used for these procedures to be beneficial.
Another type of spinal stenosis is "congenital". This means that the person was born with it. It also means that their canal is narrower on a statistical basis then most other humans studied by radiologists. It doesn't necessarily mean anything else. It may or may not lead to symptoms later on in life. For it to be symptomatic early on, it likely is associated with other types of birth anomalies or some sort of severe traumatic event.
The fact is, a great deal of the findings on imaging studies, be they X-ray, Magnetic Resonance Imaging, Computer Tomography or otherwise, do not cause symptoms. This is important for the layperson to note as occasionally, a well intentioned clinician may see these findings as significant when they are not. Therefore, if you have symptoms and someone recommends a procedure or surgery, first make sure you fully understand what your diagnosis is and what your options are. This is important and it's also part of modern informed consent. The most important point of all I can make of this as a doctor, I quote from the beginning of the Hippocratic Oath, "First do no harm".
Article by Dr. John Sherry II
What is Spondylosis?
What is it?
Merriam-Webster Dictionary Definition: Any of various degenerative diseases of the spine.
thefreedictionary.com: Degeneration of the spinal column, especially a fusion and immobilization of the vertebral bones.
The term is used by many medical professionals as a synonym for spinal osteoarthritis and more specifically, for spondyloarthropathy. In this article, my aim is to focus on arthritis (arthrosis) involving the zygophyseal joints of the spine. At this point, you are probably asking yourself, "zygo…what?".
Let's go all the way back to the beginning, and start off by defining what ARTHRITIS is. Literally, and most simplistically, inflammation of a anatomic/physiologic joint connecting (articulating) structure. Arthritis itself is a huge subject. There are literally dozens of kinds of arthritis. Many of us are familiar with rheumatoid or autoimmune arthritis and know of family members that suffer from it. This is caused by the joints in your body being attacked by your immune system. Degenerative arthritis, on the other hand, is the result of wear and tear, and sometimes added to by trauma. Degenerative and post traumatic spinal arthritis involving the zygapophyseal joints is the focus of this article. It should be noted that traumatic arthritis is not synonymous in the medical world with degenerative arthritis, even though there is no doubt that both contribute to varying degrees in causing symptoms.
Spondyloarthropathies include many types of autoimmune and genetic subtypes. Fusing or ankylosing of the spine, perhaps the most infamous among them. Ankylosing Spondylitis is the name of this genetic disorder. While many kinds of entities, immune and otherwise, can effect the joints we are discussing, for the sake of brevity this article is limited to the degenerative and traumatic forms that are most commonly encountered.
So you've have an inflamed joint. What does this have to do with the Zygo… thing? The zygapophyseal (alternative spelling zygapophysial) joints, also called apophyseal or facet joints, are the surfaces coming together and articulating the roof (back, dorsal or posterior) sections of each vertebrae. These joints therefore allow for flexibility but also provide stability to the spine. They do so by connecting each vertebrae to adjacent vertebrae above and below at spinal roof's outer edges. This occurs in paired, symmetrical fashion along the entire length of the spine. Exceptions being the connection of the skull and first vertebra, and the first and second vertebrae. Even the sacrum, the large central bone between the rear portion of your pelvic blades, those that you sit on, has these joints. However, they are fused shortly after birth in most individuals. Sitting just below and away from each joint is the articular pillar (pedicle). Coming off of the edge formed by the pillar and upper portion of each joint is a wing shaped structure extending outward called the transverse process. Muscles attach to the transverse process, and not all vertebrae have them. Nearby and partially below the transverse process sits the opening for each nerve root on each side of the spine. These openings are called foramina [Latin for little window]. The zygapophyseal joints form the majority of the roof (dorsal or posterior) surface of this opening as they connect the respective roofs of each vertebrae. The floor (ventral or anterior) aspect of this opening is formed by the upper outer portions of each vertebral body, and by the vertebral discs sandwiched respectively between each vertebral body.
The vertebral disc, when it herniates, can compromise the foramina (little window) as well as the spinal canal. Enlargement of the zygapophyseal joint due to inflammation can do the same from above. Therefore, the nerve root can become impinged as the foramina narrows. This is called foramina stenosis (Greek root meaning narrowing). The same process can occur within the spinal canal, containing the spinal cord. Below lumbar vertebrae number one, the spinal cord ends and nerve roots are found sitting as they drop down and exit the spine. When impingement occurs within this large central canal, it is called spinal stenosis. Both foraminal and spinal stenosis, individually or in combination, can cause serious problems. These include pain, weakness, and when occurring rapidly, loss of sensation and paralysis.
The enlarging zygapophyseal joint can also literally push its upper partner forward (ventrally or anterior). This shifting of one vertebrae above the other in an posterior to anterior or dorsal to ventral direction is called listhesis. This can cause further problems as it alters spinal postural mechanics and also narrows the foraminal opening. Listhesis can also be caused by trauma, birth defects in the spine, and other disorders.
Inflammation of the zygapophyseal joint, caused by damage to or loss of it's internal cartilage and joint edges, is an often overlooked cause of pain. There are many ways to go about treating pain caused by this intra-articular pathology. Diagnosis isn't always clear at the onset as a great deal of back and neck pain ends up recovering with limited or no intervention at all.
When pain in any part of the spine persists for weeks, it is best addressed by a physician. In many cases, physical therapy can be of tremendous benefit. In addition, medications such as ibuprofen and treatment with heat alternating with ice packs can be of great benefit. If the pain continues to persist for months, it's time to involve a physician expert in spinal pain. Imaging studies are likely to be a waste of time as X-rays, CT scans and/or MRIs can readily reveal degenerative pathology having absolutely nothing to do with the cause of pain. That is to say, imaging can reveal arthritis but it can just as easily reveal normal appearing spine. Due to limitations inherent in imaging studies, they may easily miss abnormalities in the zygapophyseal joint that will eventually appear on these same studies, but years later. Tenderness over zygapophyseal joints on physical exam correlates highly with these joints being the source of pain. However, even this is not fool proof. Carefully performed, X-ray guided local anesthetic blockade of the small nerves going to these joints is the gold standard. The term for this kind of nerve block is Median Branch Block. Even this is not perfect, but is far more likely to yield to successful treatment and management of chronic pain that can be caused by these joints. In addition to physical therapy and regular postural muscle strengthening exercises, treatment with a technique deriving from Median Branch Blockade, Radiofrequency neural branch ablation, when indicated can provide substantially longer duration pain reduction. Without some sort of muscle strengthening and maintenance routine, the results of this procedure significantly shorter in duration.
Article by Dr. John Sherry II