Back disorders are among the most frequent reasons for patients to visit their physician or to stay in a hospital. There can be many different causes for back pain, because the human spine is a very complex structure. Pain can be caused by a variety of diseases including arthritis in the joints, damaged discs, pinched nerves, tumors, infections, or fractures.
Before you undergo any treatment, it is extremely important to thoroughly investigate the causes of the pain and find the source of the pain. After this, a number of different therapeutic options and surgical interventions are available.
Over a period of decades, the specialists at RIWOspine and Richard Wolf have been working together with physicians and hospitals throughout the world developing innovative methods for minimally invasive spine surgery and pain therapy. The goal is to reduce the time required for treatment and make rehabilitation faster and more comfortable.
Back pain can manifest in many different ways. Your physician will determine whether your pain is localized or if it radiates to other areas. The clinician will also establish whether you have additional symptoms which may be due to a disease of the spinal column. These may include symptoms ranging from changes in sensation or motor function, to numbness in the arms and legs, or even symptoms of paralysis.
Some back pain which is localized in the torso, nape of the neck or buttocks can originate from muscles and tendons. Stresses can arise as a result of overuse, inappropriate use or even lack of movement which are in turn capable of leading to strain, shortening or inflammation of muscles and tendons.
Disorders related to wear and tear rank among the most frequently occurring diseases of the spinal column. As people get older, the structures in the vertebral column change and will therefore be frequently responsible for pain which may occur in the back and in the arms and legs.
The intervertebral discs play an important role. They are made up of an outer fibrous ring and an inner gel-like center. As part of the aging process, and due to wear and tear, the elasticity of the material is reduced and the outer ring becomes brittle. If the stress on the disc is suddenly increased, the inner nucleus of the intervertebral disc can be pressed outward and exert pressure on the nerve structures.
When the disc protrudes onto a nerve, we refer to this as a disc herniation. A great deal of pain is typically experienced in the limbs (arms in the case of the cervical spine, legs in the case of the lumbar spine) because the compressed nerves connect the spine to these extremities. If the pressure exerted on the nerve structures becomes too great, this can even lead to symptoms ranging from sensory disturbances to paralysis.
The changes to discs related to wear and tear and aging can also affect the stability of the spinal column. The increased movement of the individual vertebral segments results in an increased load on the bony parts which causes them to grow and become deformed (otherwise referred to as osteoarthritis, spondylosis, or spondylarthrosis) and may cause abnormal curvature of the spine (degenerative scoliosis). These degenerative changes can in turn lead to constrictions of the spinal canal known as spinal canal stenosis.
Constriction of the supply blood vessels is frequently associated with spinal canal stenosis and can result in a range of different complaints that develop over time. Symptoms may develop to a greater or lesser degree and can range from back pain, pain in the legs or arms, and muscle tension, to disturbances of the bladder or rectum (incontinence) and/or sexual dysfunction.
Instabilities can also lead to a slipped vertebra (spondylolisthesis) in which one vertebra slides forward relative to the next vertebra. Back pain and possibly symptoms similar to spinal canal stenosis may be generated in this condition.
Back pain is also very typical for degenerative diseases of the facet joints or sacroiliac joints. This pain also arises as a result of wear and tear and aging in the spinal column. The small vertebral joints (facet joints) and sacroiliac joints are subject to greater stresses due to instabilities. These stresses can cause inflammation due to osteoarthritis (similar to the knee and hip) resulting in mild to severe back pain.
In addition to the medical conditions and their causes already described, there are other diseases of the spinal column that generate pain. These include tumors, fractures, infections, and congenital or genetic malformations.
When you have a consultation with your physician, you will ask you detailed questions about your symptoms and you will be given a thorough physical examination. If this does not provide sufficient information to clearly localize the cause of your pain, it may be necessary to make use of diagnostic imaging procedures. Typically, your physician will initially order an x-ray image of your spinal column.
X-ray images are particularly suited to showing the condition of the higher density bony structures, such as the vertebrae. X-rays of the spine taken from the front and the side allow a physician to assess the overall alignment and condition of the spine, as well as to look for some specific conditions. Your doctor will be able to determine if you have changes related to wear and tear (such as arthritis of the facet joints), scoliosis (curvature of the spine), spondylolisthesis (slipped vertebrae), fractures, and reduction in the height of the vertebral disc possibly leading to narrowing of the openings for nerves.
If more detailed x-ray images of required, your physician may order a CT scan. In order to perform a CT scan, the patient lies inside a large circular machine that takes a series of x-ray images every few millimeters. These images combined to provide a more detailed 3-D perspective of the bony structures.
In some cases, especially when an MRI cannot be performed, your surgeon may request that a myelogram or CT myelogram be performed. In this procedure, contrast is injected around the spinal cord and x-rays or a CT scan is performed. The contrast highlights some disease of the spinal cord, including herniations, stenosis or tumors.
What is not readily visible when using x-rays is soft tissue, such as nerves, the disc, muscles, and ligaments. In order to assess these, your physician may order an MRI scan. An MRI is similar to a CT scan, but uses magnetic fields instead of x-rays to generate the 3-D images. An MRI can be helpful in identifying and locating soft tissue structures and problems such as disc herniations, hypertrophied (overgrown) ligaments, bony openings, and their possible impingement on nerve structures. An MRI will also help identify tumors or infections.
Standard diagnostic tools also include procedures for measuring muscle and nerve activity. The methods used for this purpose are electromyography (EMG) and electroneurography (ENG). In EMG, a small electrode is inserted in the muscle to measure electric current during muscle activity to determine if the muscle is impaired. In ENG, surface electrodes are used to measure the speed of signal conduction in nerves, with abnormal results possibly indicating disc herniation, spinal canal stenosis, or possible inflammatory or degenerative nerve disease.
The diagnostic process involves close contact between the spine specialist and the radiologists and neurologists. They all have a specialized part to play in the diagnosis and therapy of your disease.
Your physician will carry out a full diagnostic investigation in order to determine the underlying causes of your pain. The clinician will then work out a treatment regimen that is based on your diagnosis and individual needs. If your disease is due to wear and tear, treatment will always start with conservative measures, such as medication, physical therapy, or injections. However, if these therapies do not lead to lasting relief, interventional procedures or spine surgery will need to be considered. In some cases, the extreme nature of the symptoms (e.g. signs of paralysis) may indicate an immediate need for surgical intervention in order to prevent long-term damage to the nerves or spine.
Many cases of disc herniation, which initially cause a large amount of pain and possible neurological deficits in the arms or legs, correct themselves over time and surgery is not required. Conservative therapy, including patience, pain medication and physical therapy, may be sufficient to achieve a positive outcome.
If pain medication does not prove to be effective, an epidural injection may be helpful. This procedure involves a thin cannula being guided into the space around the spinal column and directly to the affected nerve root where an anesthetic and anti-inflammatory drug is then injected.
If conservative therapy and the epidural injection prove to be ineffective, a surgical procedure, preferably a minimally invasive procedure, is then usually recommended.
Over recent years, new technologies have enabled a trend toward minimally invasive treatment methods. These technologies have been made possible by the development of new instruments and the advancement of optical and video technologies in the medical field.
In the treatment of wear and tear related diseases of the spinal column, it is important to realize that it is not possible to stop the process of aging, nor slow down the wear and tear process. Even major surgical interventions do not provide a definitive solution for these diseases, but are often accompanied by a series of additional problems, such as scarring or impairment of the biomechanics of the spine. This can in turn result in the generation of new pain.
When using minimally invasive techniques, also referred to as “keyhole surgery”, the access port to the spine is smaller than in conventional surgery, and the tissue from the skin incision down to the spine is left mostly undamaged. By using specialized instruments, the surgeon is able to perform the intervention directly at the actual site of the problem with very little other trauma. After the operation has been performed, you will see only a small scar on your skin and you will also have less pain than with a longer incision and larger access port.
Richard Wolf has collaborated with leading spine surgeons to develop methods of operating on disc herniations that are even less invasive than existing operations. An endoscope can be guided directly to the disc herniation through a skin incision of only 8 mm without damaging the adjacent structures. Special instruments are used to remove the disc herniation and the resulting release of pressure on the nerve can be directly monitored. These operations can be carried out under local or general anesthesia. Most patients are free of pain immediately after the operation and are then able to return quickly to their everyday routine and to work.
These full-endoscopic methods are available in many hospitals and surgery centers. Ask your attending physician whether you are a candidate for endoscopic spine surgery.
The same conservative treatment plan also applies in the case of spinal canal stenosis. Surgery should only be performed if all conservative and interventional measures have not proved effective over a sufficient period of time.
When surgery is performed, all bony parts which are directly pressing on the nerve and vessel structures must be removed. If extensive spinal canal stenoses are present at multiple vertebrae levels, the intervention is frequently performed through use of an open operation. However, there are many cases in which the stenosis is limited locally. Full-endoscopic procedures can then be used with the advantages of a minimally invasive procedure. Technology has been developed to remove constricting bony tissue bone efficiently through the endoscope under direct visualization. You should ask your attending physician about these methods.
Wear and tear and aging can lead to arthrosis in the small spine joints (facets) and this can lead to back pain. Joint replacements are not currently an option for facet joints, as they are in the knee or hip. One option for addressing the symptoms is an injection, either into the facet joint with anesthetic and anti-inflammatory drugs. Alternatively, an anesthetic injection can target the nerves (called medial branch nerves) that conduct pain signals from the facet back to the spine and brain. With successfully localized injections, you will no longer experience pain radiating from the facet joint, but the effects will last only a short time.
Another, longer lasting, option is a medial branch Radio Frequency Ablation (RFA) in which the medial branch nerves are lesioned with an RF probe. A thin cannula is inserted through the skin (percutaneously) under x-ray control, and the tip of an RF probe is located near the medial branch nerves. Energy is pulsed through the probe, resulting in a lesion of the nerve that prevents conduction of the pain signals. This intervention can be carried out under local anesthetic.
In a more definitive treatment, your surgeon can use an endoscope in a minimally invasive surgery to identify and deactivate the nerves. A small endoscope is inserted through a 7mm working channel, and the endoscope is used to identify the location of the medial branch. An RF probe reliably targets the medial branch under visualization, and the nerve is directly cut for longer lasting pain relief.
The physician who you trust…
Naturally enough, your contact is your attending family physician who will refer you to an out-patient consultation with an orthopedic specialist or neurosurgeon for further treatment after all the available diagnostic options have been exhausted. These consultants have been trained and are specialized in the treatment of diseases of the spinal column. After detailed examinations have been carried out, your specialist will institute the diagnostic and therapeutic measures that are necessary in your particular case.
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You are warmly invited to find out more information on the Internet, at suitable events or in brochures about the opportunities available and about alternative treatments for your particular spine disorders. There are now lots of different media and information that you can access.
You should always adopt a critical approach to this information and it always pays to obtain a second opinion. After all, this is ultimately all about your health and well-being.
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