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Understanding Spinal Anatomy
If you learn more about your back anatomy, you can understand how treatments help relieve or locate your pain.
The spine is a very complex mechanical structure that is highly flexible yet very strong.
In the normal spine there is always some type of physical demand being placed on it. The primary functions of the spine include:
- Protecting the spinal cord, nerve roots, and internal organs
- Providing flexibility of motion
- Providing structural support
- Providing balance for upright posture
The spine bears the load of the head, shoulders, arms, and upper body. Weight is distributed to the hips and legs. The spine attempts to keep the body's weight balanced evenly over the pelvis.
Spinal Cord and Nerve Roots
The brain and spinal cord make up the central nervous system. It is located below the brain stem. The spinal cord functions as a sophisticated network that carries information from the outer elements of the body (skin, muscles, ligaments, joints) through the sensory tracts, to the central "computer," the brain. Data are processed there, and new information, such as muscle control, is sent out through the motor tracts of the cord.
The Lumbar Spine
The spine is made up of bones and shock absorbing discs that support the body and protect the spinal cord and nerves. Back pain is often caused by damage to the lumbar spine.
Common Spinal Problems
A disc can protrude (herniated) and press on a nerve. Vertebrae can also develop bone spurs, which can narrow the spinal canal (stenosis). Common types of lumbar spinal surgery include:
- Laminotomy or Laminectomy
Part of the lamina is removed relieveing pressure on a nerve or to allow access to a bone spur or disc
Part of a disc is removed releiving pressure on a nerve root
Two vertebrae are joined with bone grafts; metal implants or plates may be used to add stability
Regions of the Spine
There are 33 vertebrae in the spine. Anatomically, the spine is divided into four regions:
- Top seven vertebrae (C1-C7) that form the neck are the cervical spine
- Upper back, or thoracic spine, has 12 vertebrae, labeled T1-T12
- Lower back, or lumbar spine has five vertebrae, labeled L1-L5
- Sacrum and coccyx (tailbone) are nine fused vertebrae forming a solid bone labeled S1
Curves of the Spine
When viewed from the front or back, the normal spine is in a straight line, with each vertebra sitting directly on top of the other. When viewed from the side, the normal spine has three gradual curves:
- The neck has a lordosis; it curves toward the back
- The thoracic spine has a kyphosis; it curves toward the front
- The lumbar spine also has a lordosis
Although the vertebrae have slightly different appearances as they range from the cervical spine to the lumbar spine, they all have the same basic structures.
The anterior arch is called the vertebral body. Discs connect one vertebral body to another to allow motion of the spine and cushion it.
Together, the vertebral bodies and discs bear about 80 percent of the load to the spine. The posterior arch consists of the pedicles, laminae, and processes.
The pedicles are two short cylinders of bone that extend from the vertebral body. If the spine becomes unstable, the pedicles may compress the nerve root, causing pain or numbness. Laminae are two flattened plates of bone that form the walls of the posterior arch.
Located between each vertebra, intervertebral discs make up 1/4 of the height of the spinal column. The discs act as shock absorbers and allow movement. Movement at a single disc level is limited, but all of the vertebrae and discs combined allow for a significant range of motion.
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As a result of the natural wear and tear that occurs with aging, certain parts of the spine start to wear out. This process makes some of the anatomic structures of the spine, bones, intervertebral discs, ligaments, and muscles less flexible and less resistant to injury.
The intervertebral discs are composed of a soft gel-like center, and a tough outer lining that surrounds the disc. The intervertebral disc creates a joint between the vertebral bodies that allows them to flex, extend, rotate, and move with each other.
When the outer lining that surrounds the disc tears, the soft center squeezes out through the opening, creating a "herniated", "slipped", or "ruptured disc". This can compress nerves leading to pain that starts in your hip or buttocks and extends down your leg. The pain is worse when you're sitting and generally affects only one hip and leg. Other symptoms may include:
- Minor or severe pain
- Numbness in the leg or foot
For treatment options, see anterior cervical discectomy, fusion with plating, posterior forminotomy with disc excision, lumbar discectomy, and TLIF.
What is Stenosis?
Spinal stenosis describes a narrowing of various parts of the body. Cervical stenosis is a degenerative disease where the spinal canal and neural foramina narrow and compress the spinal cord and nerve roots. This disorder is most common in people over 50; however, genetics and congenital factors may predispose a person for stenosis.
Symptoms of Spinal Stenosis
Symptoms can vary a great deal. There may be no symptoms at all since narrowing of the channels in the vertebrae does not always compress the spinal cord or nerve
Cervical Spinal Stenosis
This can cause pain in the neck and shoulders and may be occasional or chronic ranging from mild to severe including:
- Radiating down your arm or hand
- Causing headaches, numbness, or muscle weakness
- Affecting the nerves that control your balance
- Clumsiness or a tendency to fall
- Partial or complete incontinence
For treatment options, see decompressive cervical laminectomy and cervical laminectomy with laminoplasty.
Lumbar Spinal Stenosis
Lumbar stenosis causes pain or cramping in your legs when you stand for long periods of time or when you walk. The discomfort usually eases if you bend forward or sit down, but comes back when you stand upright. Lumbar laminectomy, hemilaminectomy and X-Stop laminoplasty are treatment options.
Degenerative Disc Disease
Degenerative disc disease (DDD) is part of the natural process of aging. As we age, our intervertebral discs lose their flexibility, elasticity, and shock absorbing characteristics.
The ligaments that surround the disc become brittle and they are easily torn. At the same time, the gel-like center of the disc starts to dry out and shrink. Not everyone who has degenerative changes has pain. Every patient is different, and it is important to realize that not everyone develops symptoms as a result of DDD.
What is Spondylolysis?
Cervical spondylolysis is a disorder that narrows the spinal canal in the neck compressing the spinal cord or spinal nerve roots. It's a fracture or defect in a portion of the bone between the back joints, allowing one vertebral body to slide forward on the next.
It often affects middle-aged and older adults who have degenerative discs and vertebrae in their neck. When a spondylolysis is present, the back part of the vertebra and the facet joints simply are not connected to the body, except by soft tissue. Treatment options include decompressive lumbar lamiinectomy and fusion with pedicle screws and TLIF.
Sciatica and the Sciatic Nerve
Sciatica is a condition caused by compression or trauma of the sciatic nerve and common during pregnancy. Sciatica is made worse when you cough or if someone lifts your leg up while you are laying down. Symptoms may begin abruptly or gradually, are usually irritated by movement, and worsen at night.
What is Scoliosis?
Scoliosis however causes abnormal curves in the spine. The curves often look like the letter “S” or “C,” and they primarily affect the thoracic or lumbar regions.
Most of the time, scoliosis has little impact on a person’s appearance or well-being. Occasionally, scoliosis can cause large abnormal curves that are clearly visible to the eye. Such pronounced curves can cause pain, and in rare cases affect lung and heart function. Scoliosis usually develops during childhood, but it sometimes affects adults as well.
Trauma and Injuries
Back Pain: Trauma
It is impossible to predict how badly someone's spine has been injured before a doctor has evaluated them. Therefore, everyone who is involved in an accident that could have damaged their back is treated as if they do have a spinal injury.
Most people are familiar with the backboards that paramedics use to transport accident victims. Cervical collars are placed on all accident victims, they are secured on a backboard, and then taken to a hospital for further evaluation.
Sprains and Strains
Most acute pain in the back results from sustaining a mild strain. Sprains and strains in your lower back usually happen during a sudden and stressful injury, causing stretching or tearing of the muscles, tendons, or ligaments.
If you have this condition you may also suffer from painful muscle spasms, which can occur during your daily activities or at night while you're sleeping. The pain is usually limited to five or ten days.
Spinal Cord Injuries
A spinal cord injury occurs when the cord itself is crushed, stretched, or torn. Unfortunately, this is still an injury that can not be reversed or cured. These injuries can incredibly devastating to the patient and their families. A lot of research is being done on how to care for someone immediately after they have had a spinal cord injury, and also what kind of rehabilitation is best for them.
Neck Pain: Trauma
Cervical spine injuries occur during motor vehicle accidents, in rough contact sports, after a fall, or by hitting your head against a hard surface, such as when diving into a pool that is too shallow. These accidents can cause a range of injuries from mild cases of whiplash to paralysis in parts of the body.
Whiplash is a hyperextension injury to the neck. Though the neck is a very flexible structure, it can be injured when the weight of the head exceeds the neck's ability to control its motion. A jerking motion can cause over-stretching and tearing of the neck muscles and ligaments and can cause the discs between the neck vertebrae to bulge, tear, or rupture.
Fractures and Dislocations
Cervical spine fractures and dislocations are serious injuries because there is the potential for damage to the spinal cord if the patient is not taken care of cautiously. They need early medical attention in order to produce a painless, stable neck and prevent pressure on the spinal cord and/or nerves. When the neck is injured in very violent accidents, the bones in the neck can be broken or pulled forcefully out of alignment.
What are Spinal Tumors?
Most primary tumors are caused by out-of-control growth of cells in the spinal column or neural tissues. Spinal tumors that are the result of cancer spreading from other parts of the body are called secondary or metastatic tumors. All secondary tumors are malignant because they originated from cancerous tumors elsewhere in the body.
Spinal tumors are also classified by the part of the spine where they are located. These classifications are called cervical, thoracic, lumbar and sacrum. A spinal tumor may be within the spinal canal or next to the spinal canal.
Symptoms of Tumors
The principal symptom of a spinal tumor is non-mechanical back pain, which is a constant pain that does not improve with rest or lying down. Mechanical back pain due to muscle strains or disc injury usually worsens with activities such as sitting, bending, and walking and gets better with rest or lying down. Other symptoms include:
- Partial Paralysis
- Spinal Deformity
- Difficulty with incontinence
Symptoms of spinal tumors generally develop slowly and worsen over time unless they are treated.
No matter what the cause, the weakness, numbness, or pain that you feel is disrupting your life. You may find it hard to work, exercise, or keep up with your daily errands. If no improvement from conservative treatments such as physical therapy or epidural steroid injection, then surgery may be an option.
To confirm your diagnosis and locate the source of your pain, your doctor may order certain tests. X-rays show the vertebrae. Myelograms help to evaluate the subarachnoid space of the lumbar spine. CTs, which locate bleeding, MRIs, and EMGs may be taken to assist in diagnosis. An EMG shows muscle or nerve damage.
Neck pain and symptoms caused by a cervical spine disorder are very common. The different parts of the cervical spine are normally well balanced and able to handle movement, stress, and strain of the body.
However, when the different parts of the cervical spine are injured or start to wear out, your neck can be a significant source of pain and discomfort.
Anterior Cervical Discectomy and Fusion
Your disc problem may be corrected by a discectomy. This is the surgical removal of the disc that’s putting pressure on a nerve, causing pain.
What is Anterior Cervical Discectomy?
This operation relieves the pressure placed on nerve roots and/or the spinal cord. Through a small incision near the front of the neck, the surgeon removes disc material and/or a portion of the bone around the nerve roots and spinal cord.
Why Is It Necessary?
Pressure placed on nerve roots or the spinal cord by a herniated disc or bone spur may irritate these neural structures and cause:
- Pain in the neck and/or arms
- Lack of coordination
- Numbness or weakness in the arms, forearms or fingers
Pressure placed on the spinal cord as it passes through the neck (cervical spine) can be serious. This is becuase most of the nerves for the rest of the body have to pass from the brain through the neck.
A small incision is made and your surgeon exposes the source of the neural compression. Disc material and, sometimes, a portion of the bone around the nerve roots and spinal cord is removed to make more room.
Fusing vertebrae in the cervical curve may help ease neck and arm pain. Two or more vertebrae in your neck are fused, usually through the back of the neck, or through both the front and back. The surgery generally takes from one to four hours.
The removal of a portion of the vertebra and bordering intervertebral discs is a corpectomy. It’s used to treat decompression of the cervical spinal cord and spinal nerves. A bone graft, with or without a metal plate and screws, is used to reconstruct the spine and provide stability.
Indication for Operation
In some patients, the cervical spinal canal can be narrowed by bone spurs that develop from the back of the vertebral body or the ligament behind it. It may be necessary to remove one or more vertebral bodies. The discs above and below may also be removed because the area cannot be decompressed with only an anterior cervical discectomy.
Bone Graft and Bone Banks
To fuse the spine, very small pieces of extra bone are needed. Called bone graft, this acts as the “cement” that fuses the vertebrae together. Bone graft generally comes from a bone bank.
Bone banks collect, evaluate, and store bone, which comes from human donors who are recently deceased. Donors are checked for their cause of death and medical history. The bone is tested and treated before it is used as graft. The risk of getting a disease from bone graft is minimal.
You will be positioned on your back during surgery. A small incision is made on either side of the neck. A longer "up and down" incision may be required for multiple corpectomies.
The cervical spine is widely exposed by separating the spaces between the normal tissues. The discs above and below the vertebrae involved are removed. The middle portion of the vertebrae is removed, some of which is saved for use in the fusion.
Bone is placed to increase the distance the bony defect and provide support to the front of the spine. The bone fuses into the remaining vertebrae. A metal plate and screws provide extra support. Absorbable sutures and sometimes staples are used to close the incisions. A cervical collar may or may not be required for use after surgery.
Cervical foraminotomy is an operation to enlarge the space where a spinal nerve root exits the cervical spinal canal to relieve the symptoms of a "pinched nerve."
Indications for Operation
Compression of the nerve roots can cause neck pain, stiffness, and pain radiating into the shoulder, arm, and hand, as well as numbness, tingling and/or weakness in the arm and hand. Protruding or ruptured discs, bone spurs, and thickened ligaments or joints can all cause narrowing of the space. If conservative treatments have not helped, you may be a candidate for surgery.
The surgeon makes an incision in the back of the neck. Some surgeons use a surgical microscope during the procedure to magnify the area.
Small instruments are used to carefully remove soft tissues within the neural foramen. The surgeon takes out any small disc fragments that are present and scrapes off nearby bone spurs. This way, tension and pressure are taken off the nerve root. The muscles and soft tissues are put back in place, and the skin is stitched together. You may be placed in a soft collar after surgery to keep the neck positioned comfortably.
An incision is made on the back of the neck. A groove is cut down one side of the cervical vertebrae creating a hinge. The other side of the vertebrae is cut all the way through. The tips of the spinous processes are removed to create room for the bones to pull open like a door.
The back of each vertebrae is bent open like a door on its hinge, taking pressure off the spinal cord and nerve roots. Small wedges made of bone are placed in the opened space of the door. The door of the vertebrae swings shut, and the wedges stop it from closing all the way. The spinal cord and the nerve roots rest comfortably behind the door.
Anterior cervical instrumentation is used to hold the motion segments of the neck together so that they can fuse.
After the disc is removed, a space remains between the vertebral bodies. The disc space can be fused. Instrumentation holds this construct together so that the bone grafts do not slip out until it heals.
Cervical stenosis can place pressure on the spinal cord. If most of the compression is in the back, this condition can be treated with a posterior cervical laminectomy. The objective of this procedure is to remove the lamina (and spinous process) to make more room.
The incision is in the midline of the back of the neck. The lamina with the spinous process can then be removed as one piece (like a lobster tail). Removal of these allows the spinal cord to float backwards and gives it more room. In general, after the laminectomy most patients can expect to regain:
- Improved walking capabilities
- Less or no numbness in their hands
Persistent pain in your low back or leg caused by disc problems can be frustrating because it limits your ability to move and do the things you enjoy. To manage, you may have followed your doctor’s conservative treatment plan:
- Physical Therapy
The pain won’t go away, but surgery can help with your problem.
Pressure on the Nerve
When a disc weakens, the outer rings may not be able to contain the material in the center of the disc. This material may bulge against or squeeze through a tear in the outer rings and press against a nerve, causing pain in your lower back and leg.
Lumbar Epidural Steroid Injection
Your doctor may have suggested you have an epidural steroid injection (ESI) for a variety of reasons.
A Way to Relieve Pain
An ESI won’t stop all low back and leg pain, but can reduce and break the cycle. This cycle may begin when back pain makes it hard to move. By getting you back on your feet, the injection can help speed your recovery. Some people may feel more relief than others, and more than one injection is sometimes necessary.
A Tool for Diagnosis
An ESI can help locate the source of pain by briefly numbing specific nerve roots. If you feel no relief, it may mean the source is at another level or something other than inflammation is causing the pain. Injection results may be used to help plan surgery.
Possible Injection Sites
For pain relief, the injection is done in the epidural space, the area that surrounds the nerves within the spinal canal. Medicine is injected directly into a specified nerve root to locate the pain souce.
Your Injection Procedure
This outpatient procedure is often done in a hospital or an outpatient surgery center. Before your injection, your doctor will ask you questions about your health. An ESI has certain risks and complications including:
- Nerve damage
- Bone graft shifting out of place
- Bones not fusing
- Blood clots in legs
- Spinal Fluid leak
During the Procedure
The injection takes a few minutes, but extra time is needed to get ready. You may be given medicine before the injection to help you relax. Monitoring devices may be attached to your chest or side to measure your heart rate, breathing, and blood pressure.
The site is cleaned and covered with sterile towels. Medicine is given to numb the skin. If fluoroscopy is to be used, a contrast dye may be injected into your back. This helps get a better image. A local anesthetic (for numbing), steroids (for reducing inflammation), or both are injected into the epidural space.
This procedure removes a small portion of the lamina from the spine to relieve pressure on the lower back’s nerve roots. This greatly reduces symptoms. These surgeries are not cure-alls, but they are especially good at reducing leg pain.
Once you are given anesthesia, an incision is made near the center of your lower back. Part of the lamina is removed from the vertebra above and below the pinched nerve. The small opening created is sometimes enough to take pressure off the nerve. In most cases, disc matter or a bone spur that is pressing on the nerve is also removed. Once the nerve is free of pressure, the incision is closed with stitches or surgical staples.
What is Lumbar Microdiscectomy?
Lumbar microdiscectomy is an operation that involves using a microscope. Providing magnification and illumination, the microscope allows for a smaller incision. Only a portion of the herniated disc, which is pinching one or more nerve roots, is removed.
Why is it done?
Pressure placed on one or more nerve roots may irritate the neural structures and cause:
- Debilitating leg pain
- Weakness and/or numbness in the legs and/or feet
- Bowel/bladder incontinence
Patients who suffer from these symptoms as a result of a pinched nerve are potential candidates for this operation.
While lying on your stomach, a small incision is made in your lower back and microsurgical instruments are then inserted. Once your pinched nerve is located, the extent of the pressure on the nerve is determined. The herniated portion of the disc is removed as well as any disc fragments that have broken off. The amount of effort required to complete the microdiscectomy depends on:
- Size of the disc herniation
- Number of fragments present
- Difficulty in finding and removing these fragments
- When a spinal nerve root(s) is pinched
- Leg pain which limits your normal daily activities
- Weakness in your leg(s) or feet
- Numbness in your legs
- Difficulty in walking or standing
Decompressive Lumbar Laminectomy
This is a decompression performed by removing the lamina and the spinous process. This is usually recommended only when specific conditions are met:
- A spinal nerve root(s) is pinched
- Leg pain which limits your normal daily activities
- Weakness in your leg(s) or feet
- Numbness in your legs
- Difficulty in walking or standing
Positioned on your stomach or side, a small incision is made in the lower back. This allows the surgeon to see the pinched nerves. The surgeon exposes the vertebrae by spreading apart the muscles and tissue.
A section of the vertebra is removed. An opening is cut in order to reach the spinal canal. The surgeon removes bone spurs (osteophytes) and any rough edges on the intervertebral disc. This enlarges the spinal canal and relieves pressure on the nerves. If necessary, the surgeon performs a spinal fusion with instrumentation to help stabilize the spine.
What is Spinal Fusion?
Spinal fusion permanently connects two or more bones in your spine. This limits the movement of these bones, which may help relieve your pain. Your back or neck won’t be quite as flexible, but you may feel more flexible because you can move with less pain.
Fusing the Vertebrae
Normally, the vertebrae fit together, but move separately. Sometimes vertebrae move too much, squeezing nerves and causing pain.
Risks and Complications
The risks and possible complications of spinal fusion surgery include:
- Spinal Headache
- Bleeding (rare)
- Infection (rare)
Anterior & Posterior Lumbar Fusion
Anterior lumbar fusion is done through an incision in your stomach area, while posterior fusion is through your back. The graft is put between the vertebrae in the disc space or between the transverse processes. The surgery may take from three to eight hours.
Bone graft is packed between the transverse processes on the sides of the vertebrae. Occasionally, other nearby parts of the vertebrae are fused as well. The disc between the vertebrae is removed. Bone graft is packed in the now-empty space between the vertebrae. In time, the graft and the bone around it will grow into a solid unit.
If You Need Extra Support
Instrumentation may be used to help steady your spine while it fuses. These supports are not removed. Your surgeon may use one or more types of support. Most commonly used with cervical fusion is a plate support.
An interbody fusion is the uniting of two bony segments, whether a fracture or a vertebral joint. Normally within four months, the grafts unite with the vertebrae above and below to form one piece of bone. The reasons are to:
- Remove the degenerative disc
- Separate vertebral bodies, as they were before the disc degenerated
- Keep them in position by interposing several pegs of bone (bone graft)
The portion of the vertebra that covers the spinal cord is removed. This relieves some of the pressure on the spine. Then any bone that may be pinching the nerve roots is removed. Bone grafts are added and rods are secured to hold the discs in place.
The Artificial Disc
The artificial disc received formal approval by the FDA in 2004 and it represents the best alternative to date for spinal fusion surgery. A common aspect of all artificial discs is that they are designed to retain the natural movement in the spine by duplicating the shock-absorbing and rotational function of the discs we have at birth.
Bone fuses more effectively where there is little motion. Instrumentation works by limiting motion at the fused segment and can be placed posteriorly in the pedicles, posterior interbody, or anteriorly.
Pedicle Screws for Posterior Fusion
These provide a means of gripping onto a vertebral segment from behind. The screws are placed at two or three consecutive spine segments and then a short rod connects them.
After the bone graft grows, the screws and rods are no longer needed for stability and may be safely removed with another surgery. However, most surgeons do not recommend removal unless the pedicle screws cause discomfort.
Posterior and Transforaminal Fusion
Most cages are placed anteriorly, but can also be put in the back of the spine, called a posterior lumbar interbody fusion (PLIF), through a midline incision in the back.
A transforaminal lumbar interbody fusion (TLIF) is another approach performed by removing the facet and accessing the disc through the foramen. A laminectomy, facetectomy, and retraction of the nerves are necessary to allow access to the disc. The cages can be made of titanium, carbon fiber, or composite material.
X-Stop is a prosthetic titanium device placed between the spinous processes. In this outpatient procedure, the device is placed in the spine.
How It Works
A small opening is made in the back and the device is placed inside. The procedure takes about 30 minutes. This gives more room to the roots and spinal canal, alleviating symptoms.