Back Surgery: Is it Right for You - Softcover

Edwin Haronian

Softcover

ISBN 10: 0757002765 ISBN 13: 9780757002762

Publisher: SQUARE ONE PUBLISHING, 2008

Synopsis

With all the misleading information out there on back problems, even doctors have conflicting views on the best treatments. But it is the decision you make that counts. The problem has always been finding the facts necessary to make a wise choice-or it was, until now. Dr. Edwin Haronian has put together a guide that looks at both the conditions and the procedures, surgical and nonsurgical, and answers common questions about back problems.

Back Surgery begins by examining the anatomy of the back. It then discusses common conditions that result in pain, and the latest and most effective treatments available, from acupuncture to medication to surgery. Included are pre-op and post-op suggestions, as well as a program designed to prevent future back problems. Here are all the facts you need to make the choice that's best for you.

About this title

About the Author

Edwin Haronian, MD, received his medical degree from Wayne State University School of Medicine, and served his residency at the State of New York Sciences Center in Brooklyn, New York. While there, Dr. Haronian was involved in groundbreaking research that helped introduce new spinal implant techniques. He was later selected as a fellow in spinal surgery at the renowned Kerlan-Jobe Orthopaedic Clinic in Inglewood, California. Today, Dr. Haronian heads one of the fast-growing orthopedic practices in the Los Angeles area.

Excerpt. © Reprinted by permission. All rights reserved.

BACK SURGERY

Is It Right for You?By Edwin Haronian

Square One Publishers

Copyright © 2008 Edwin Haronian
All right reserved.
ISBN: 978-0-7570-0276-2

Contents

Acknowledgments.........................................................ixIntroduction............................................................1PART ONE Deciding Whether Back Surgery Is for You1. Understanding Your Back..............................................72. Determining the Cause of Your Back Problem...........................193. Nonsurgical Treatment Options........................................374. Surgical Options.....................................................55PART TWO Before and After Your Back Surgery5. Preparing for Surgery................................................896. Your Successful Recovery.............................................111PART THREE A Healthy Back for Life7. Preventing Future Back Problems......................................1318. Psychology and Back Pain.............................................149Conclusion..............................................................161Selected References.....................................................165Resource List...........................................................167Index...................................................................169

Chapter One

Understanding Your Back

Trying to make a decision about back surgery without fully understanding the anatomy and function of your back is like attempting to drive a car to a faraway destination without a road map. In this chapter, we'll take a guided tour of your back. Then, we'll learn about the essential roles your back plays in your life as a house for your nerves, as your body's electrical signal highway, as your body's core, and as the key structure behind your ability to move and flex.

ANATOMY - TAKE A TOUR OF YOUR BACK

If you are like most people, you have probably always taken your back for granted. You may not even think of it as a discrete body part, like an arm or leg. Nothing, however, could be further from the truth. Your back is, in fact, one of the most complex, delicate, and essential parts of your body.

The back is a general term used to describe the spine and its surrounding muscles, as well as the nerves, discs, and bones that make up this complex structure. The word spine is not used uniformly, even in the medical community; I will use it to refer collectively to the bones, ligaments, muscles, nerves, and discs that constitute the back. I will use the term spinal column to indicate the bony architecture of the back-specifically, the tower of bony segments called vertebrae. Each vertebra is separated from the next by a disc, which acts like a cushion, and it is this structure that allows the spinal column to move. But it's the spinal cord that, along with your brain, makes up the central nervous system (CNS).

Spinal Cord

Just where does the spinal cord start? The spinal cord is like an extension cord of the brain. The lower part of the brain becomes the spinal cord and enters a canal-called the spinal canal-within the spinal column. The spinal cord and the spinal nerve roots reside within the spinal canal and are covered by a thin membrane called the dura. Actually, the dura covers the brain, the entire spinal cord, and the nerves before they exit the spine. The dura is like an envelope that keeps the fluid surrounding the nerves in place. This fluid is called the cerebrospinal fluid (CSF).

There are actually thirty-one pairs of spinal nerves that begin in the spinal cord. Therefore, the spinal cord can most simply be defined as a collection of nerve fibers. These fibers carry messages or impulses to and from the brain, allowing you to do everything from lifting your foot off a sharp piece of glass to smiling for the camera. The nerves are divided into major types-cervical, thoracic, lumbar, and sacral-and leave the spinal column at locations that are similarly named.

Sections of the Spine

There are four main sections to your spine: the cervical spine (neck), the thoracic spine (midback), the lumbar spine (lower back), and the sacrum/coccyx (pelvis). The cervical spine has seven bones. The first one is called C1, the second C2, and so forth. The first and second bones in the cervical spine are also called the atlas (C1) and the axis (C2). The thoracic spine has twelve bones. They are called T1, T2, T3, etc. The lumbar spine has five bones, which are larger than the other bones of the spine, since they carry much of the body weight. These are numbered L1 to L5. The sacrum and the coccyx are part of the pelvis and, for the sake of our discussion, can be regarded as one big bone at the lowest part of the spine.

If you look at a normal spine from front or back, it has a straight alignment from top to bottom. If you look at it from the side, however, you see that the spinal column is not a straight column of bones stacked on top of each other. In order to maintain flexibility and balance, each segment of the spine has a specific curvature. See Figure 1.1, on the next page.

The cervical spine and the lumbar spine are normally placed in lordosis (a curve with its concavity directed backward), while the thoracic spine is normally placed in kyphosis (a curve that is directed forward). Normal cervical lordosis and normal thoracic kyphosis are from twenty to forty degrees. In the lumbar spine, lordosis is normally thirty to fifty degrees. These curvatures are extremely significant. A change in the angles of these curves can occur for many reasons. In the cervical spine, degenerative arthritis-a process characterized by the degeneration (deterioration) of the cartilage, the formation of osteophytes (outgrowths of bone) in the joint, and inflammation-can lead to disc collapse and cause reversal of the normal lordosis into kyphosis. Fractures in the thoracic spine from osteoporosis-loss of bone tissue resulting in brittle bones-can increase the kyphosis curve, causing the humpback deformity that commonly affects senior citizens. Reversal of lordosis in the lumbar spine can occur because of the destruction of normal bone by a fracture, or by a disease like cancer. Loss of lordosis in the lumbar spine can result in flat back syndrome, which is a painful condition.

Flat back syndrome causes imbalance in the muscular structures of the lumbar spine. It was commonly seen after operations performed two or three decades ago, when the significance of lordosis in the lumbar spine was not appreciated by spine surgeons and the implants used in surgery did not allow doctors to maintain these curves of the spine. A very common implant used thirty years ago was the Harrington rod, which made the lower back very straight. There have been substantial improvements in the technology of implants over the years. Today we have implants that are strong and flexible, allowing your spine surgeon to maintain the curves of the back, even after surgery.

Cervical Spine

The cervical spine-the highest level of the spine-houses and protects the spinal cord as it leaves the skull. The cervical spine also supports the head and is involved in movements of the neck and the head, such as rotation, forward flexion, and backward extension. The axis (the second bone in the cervical spine, or C2) has an upward projection called the dens, which makes a second joint with the ring-shaped atlas (the first bone in the cervical spine, or C1), the structure upon which the skull sits. This joint is responsible for most of the rotation of the head, known as atlanto-axial rotation. See Figure 1.2 for a helpful illustration.

Most of the cervical vertebrae (C2-7) have small canals on either side. These canals, called the transverse foramens, house an artery called the vertebral artery. This artery is essential in supplying blood to parts of the brain. Again, refer to Figure 1.2.

The vertebrae, discussed and illustrated on pages 12 to 13, are connected by small joints called facet joints. On each side of the cervical vertebrae, between each facet joint, there is an area of bone called a lateral mass. This bony area is where spinal surgeons place screws when fusion surgery-the removal of an abnormal disc and the fusion of the surrounding vertebrae-is attempted from the rear of the cervical spine.

Injury to the spinal cord at the level of the cervical spine can be devastating or even deadly. The upper part of the spinal cord controls our breathing, and if a fracture places pressure over that area, we can stop breathing and potentially die as a result. The higher the injury, the worse its outcome. The lower the injury to the spinal cord, the more functions are preserved. A person who has an injury to the spinal cord at the C4 vertebra, for example, will not be able to breathe on his own. An injury at the C5 vertebra, by contrast, may allow the person to breathe and shrug his shoulders.

Thoracic Spine

The ribs attach in the front of the chest (anteriorly) to the breastbone (sternum), and in the back (posteriorly) to the thoracic vertebral bones. For this reason, the thoracic spine is very rigid (less mobile), as is the rib cage, which houses the heart and the lungs. The spinal cord in the area of the thoracic spine is essential for the functions of the lower body. Injury to the spinal cord at the level of the thoracic spine can lead to paralysis of the lower extremities and disorders of the bowel, bladder, and sexual functions.

At each level of the thoracic spine, a spinal nerve exits the spine and wraps around the rib cage. Any pressure on a nerve in the area (for example, from a disc herniation or a tumor) can result in pain that encircles the chest. This can lead to a false diagnosis of indigestion or a heart attack.

Problems in the thoracic spine are uncommon compared with those in the more mobile cervical and lumbar spines. Disc herniations-protruding or bulging discs-are common in the lumbar spine, for example, whereas in the thoracic spine they are rare.

Lumbar Spine

The lumbar spine is the lowest mobile section of the spinal column. It has five segments. Due to its mobility, the lumbar spine is subject to many problems, such as strains, disc herniations, and even fractures. The most common disc to degenerate (i.e., to deteriorate from wear and tear) and herniate is the L4-5 disc. The next most common disc to suffer from disc degeneration and herniation is the L5-S1 disc.

Sacrum/Coccyx

The sacrum and the coccyx-the latter of which is the remnant of a tail we used to have millions of years ago-constitute the lowest part of the spine. They are parts of the pelvis, which houses important structures such as the ovaries, the uterus, the bladder, and some of the abdominal contents.

The end of the spinal cord, called the conus medullaris, is located at the L1 or L2 vertebra. However, many spinal nerves continue to pass down along the spinal canal before exiting the spinal column. A collection of such spinal nerves distal to (lower than) the conus is called the cauda equina. It is located in the lumbosacral area. A massive disc herniation in this area can cause inability to control bowel and bladder functions. This condition is an emergency and is called cauda equina syndrome.

Vertebrae

The spinal column is made of many bony segments known as vertebrae, which maintain mobility and flexibility and provide protection to the nerves and the spinal cord. The vertebrae are similar in shape, but they vary in size according to the amount of weight they carry. Each vertebra within a section of the spine has a specific name and number. Your spine surgeon will usually localize a disc herniation using these designations. As previously mentioned, the most common level at which we encounter disc herniations is the L4-5 disc space. This simply means that the disc between the fourth lumbar (L4) vertebra and the fifth lumbar (L5) vertebra has herniated. A disc herniation in the neck is described in a similar manner. The most common level for a disc herniation in the neck is the C5-6 level. This refers to a disc herniation between the fifth cervical (C5) vertebra and the sixth cervical (C6) vertebra.

Each vertebra has a large, oval section in the front called the vertebral body. The rear (posterior) part of each vertebra has bony projections called processes. The spinous process is the fairly sharp, bony structure in the rear of the vertebra. If you touch the middle of your back, you can feel these projections. Only the vertebrae in the thoracic and the lumbar spine have transverse processes, which extend to the sides of the vertebrae. All of these features are illustrated in Figure 1.3.

The lamina is like the roof of the spinal canal. It is the bone to which some of the muscles over your spine attach. At the upper border of the lamina starts a cylindrical bony canal that connects the rear of the vertebra to the front. This bony canal is called the pedicle. The pedicles are very strong and make up the borders of the spinal canal.

As discussed, the vertebrae are connected by small joints called the facet joints, which give the spine flexibility. The facet joint, in the rear part of your spine, along with the disc in the front, allows some motion at each segment. The facet joint is similar to other joints in your body, like the knee or the shoulder. As in the case of these other joints, facet joints can be affected by arthritis, and, if arthritis occurs, these joints can place pressure on nerves and cause pain, numbness, or weakness. On magnetic resonance imaging (MRI) studies, a radiologist will call this facet hypertrophy. Other terms used to describe this condition are facet syndrome or facet arthropathy.

Discs

Many of the problems that occur in your spine stem from the discs. See Figure 1.4 for an illustration. Each disc, which is shaped like a miniature automobile tire, is situated in the front (anterior) of the spine, between two vertebral bodies, and acts as a cushion. The disc has an outer envelope called the annulus. Attached to the annulus are many small nerves that can transmit pain signals to the brain. The annulus is the part of the disc that is commonly injured, causing the common disorder known as low back pain, also called discogenic pain.

The inner part of the disc is called the nucleus pulposus. It has a softer consistency and can protrude outward through tears that occur in the annulus. This is commonly referred to as a herniated disc, herniated nucleus pulposus, or HNP. Unlike the annulus, the nucleus pulposus does not have any nerve endings. The nucleus causes problems when it herniates and places pressure on an adjacent nerve. Research has also shown that there are chemicals within the nucleus that can irritate a nerve by causing inflammation if they come into contact with it. If you have pain radiating from the spine, but the MRI does not show pressure on any nerves, you may be having pain caused by the chemicals that are released from the nucleus pulposus and not from pressure of the disc on the nerve root.

Neural Foramen

The neural foramen is the tunnel through which the nerves leave the spinal column. See Figure 1.4 on page 14. It is made up of two half circles. The upper vertebra possesses one half of the circle and the lower vertebra possesses the other half. Put together, the two half circles of the tunnel make a canal through which the nerves pass out of the spinal column. The greater the distance between the two vertebrae, the larger the canal. The distance between the vertebrae depends on the height of the discs. Any process that decreases the height of the disc, such as degeneration or infection of the disc (discitis), can cause reduction in the diameter of the neural foramen, which in turn places pressure on the spinal nerve. This problem is known as foraminal stenosis. You can get foraminal stenosis from a disc bulge within the neural foramen, enlargement of the ligamentum flavum (see page 16), disc collapse, or arthritic enlargement of the facet joint. Any of these can produce pain, numbness, or weakness along the course of a particular nerve.

The plural of neural foramen is neural foramina. You will find both terms used throughout this book.

Ligaments

Ligaments are tough sheets of fibrous tissue that connect one bone to another. This connection makes our body resilient and strong, while allowing mobility and flexibility. If the force of an accident or fall is strong enough, ligaments can tear and, unfortunately, they don't heal as quickly as bones. Whiplash injuries involve damage to ligaments, which is why it takes a long time for pain from whiplash to go away.

Because there is little calcium in ligaments, they don't show up on X-ray studies. An MRI is a better test to check for damage to ligaments, but even an MRI does not show all ligament tears. The extent of the injury depends on the location of the damaged ligament and its function. If the ligament is very important, damage to it can cause abnormal movement between two bones, and this abnormal relationship of bones can sometimes be seen on an X-ray or CT (Computed Tomography) scan.

(Continues...)

Excerpted from BACK SURGERYby Edwin Haronian Copyright © 2008 by Edwin Haronian. Excerpted by permission.
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Edition details

• Publisher: SQUARE ONE PUBLISHING
• Publication date: 2008
• Language: English
• ISBN 10: 0757002765
• ISBN 13: 9780757002762
• Binding: Paperback
• Number of pages: 304