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Chronic Back & Neck Pain
Studies show that upwards of 80% of Americans will suffer from back or neck pain at some point in their life.  In most cases, this pain will subside with rest and over the counter medications.  However, when this pain lasts more than a few days or does not respond to over the counter medications, it may be considered chronic.  Chronic pain is the type of pain that limits your ability to carry out your activities of daily living and affects your overall quality of life.  It is at this point that you should contact a specialist to diagnose your specific condition.
Lumbar Herniated Disc
What is a Lumbar Herniated Disc?
Lumbar Herniated Disc, also known as slipped disc or ruptured disc, is a condition in which the spinal disc begins to protrude into the spinal canal.  This protrusion of the disc can irritate the surrounding nerve roots of the spine and cause localized or radiating pain.

What are the Symptoms?
Many patients will show visible disc herniations on an MRI but never experience pain or symptoms and others will experience chronic symptoms that include:

  • Lower back pain
  • Muscle spasms
  • Stiffness
  • Sciatica
  • Numbness or tingling the legs
Cervical Herniated Disc
What is a Cervical Herniated Disc?
Cervical Herniated Disc, also known as slipped disc or ruptured disc, is a condition in which the spinal disc begins to protrude into the spinal canal. This protrusion of the disc can irritate the surrounding nerve roots of the spine and cause localized or radiating pain.
What are the Symptoms?
Many patients will show visible disc herniations on an MRI but never experience pain or symptoms and others will experience chronic symptoms that include:

  • Neck pain
  • Shoulder pain
  • Muscle spasms
  • Stiffness
  • Radiculopathy
  • Numbness or tingling the arms and fingers
Sciatica
What is Sciatica?
Despite being commonly used as a term to describe radiating pain in the buttocks and legs, Sciatica is not an actual diagnosis and is instead a symptom of an underlying spinal condition.  The sciatic nerve is the longest continuous nerve in the body and extends from the lumbar spine through the back of each leg.  When a spinal disc, a piece of bone or other process irritate this nerve it can cause the radiating pain that is referred to as Sciatica.

The most common conditions that cause Sciatica are:

  • Lumbar Disc Herniation
  • Lumbar Spinal Stenosis
  • Degenerative Disc Disease
  • Spondylolisthesis
  • Spondylosis
  • Spinal Arthritis

What are the Symptoms?
Sciatic pain usually occurs at one side of a person’s body and it is very unlikely that if affects both sides of the body.  The most common symptoms of sciatica are:

  • Burning or radiating pain in the lower back, buttocks, hips or legs
  • Weakness in the legs or feet
  • Numbness in the legs or feet
Spinal Stenosis
What is Spinal Stenosis?
Spinal Stenosis is a condition in which the spaces in the spinal cord begin to narrow which consequently increases pressure on the spinal cord and the nerves of the spine.  Almost all cases of Spinal Stenosis occur in the lumbar spine (lower back). Spinal Stenosis can occur in the cervical spine, yet is far less likely. Spinal Stenosis causes the impingement of one or more spinal nerve roots, which is the cause of the pain associated with Spinal Stenosis.

What are the Symptoms?
The symptoms of Spinal Stenosis can include:

  • Lower back pain
  • Muscle spasms
  • Stiffness
  • Sciatica
  • Numbness or tingling the legs
Cervical Radiculopathy
What is Cervical Radiculopathy?

Similar to Sciatica, Cervical Radiculopathy is a term used to describe radiating pain that originates in the cervical spine (neck) and radiates into the extremities but is not an actual diagnosis.  When a spinal disc, a piece of bone or other process irritates a nerve in the cervical spine it can cause the radiating pain that is referred to as Radiculopathy.

What are the Causes?

Cervical Radiculopathy is always caused by an underlying cervical spine condition and the most common conditions that result in Cervical Radiculopathy are:

  • Cervical Disc Herniation
  • Degenerative Disc Disease
  • Spondylolisthesis
  • Spondylosis
  • Scoliosis
  • Spinal Arthritis
Spondylolisthesis
What is Spondylolisthesis?
The term Spondylolisthesis is formed by the Greek words “spondylos” and “listhesis”, meaning ‘spine’ and ‘to slide or slip’, respectively. As these words themselves explain, Spondylolisthesis is a condition in which a vertebrae in the spine slides over to the vertebrae below it. It most commonly occurs in the lumbar spine.

What are the Symptoms?
The condition varies from mild to severe. Therefore, the symptoms and signs can be different too.

Some of these symptoms may be:

  • Lower back pain
  • Stiffness
  • Muscle tightness
  • Weakness in legs
  • Numbness or tingling in legs
Compression Fractures
What is a Compression Fracture?
Spinal Compression Fractures are characterized by several small fractures or “cracks” in the vertebrae of the spine.  Over time, these fractures begin to weaken the vertebrae and result in spinal instability as well as pain.  Spinal Compression Fractures are a progressive condition and are generally the result of osteoporosis or other bone disorders.
Spondylosis
Spondylosis is a term that describes a reduction in the space between two spinal discs. This decreased space often leads to the exiting nerve root becoming irritated or impinged. In more severe cases, the shock absorbing intervertebral discs will completely wear away causing bone on bone contact. This can often lead to spinal fractures and bone spurs.

 

Because Spondylosis can occur both in the cervical and lumbar spine the symptoms may vary depending on the location of the condition.

The most common symptoms of Cervical Spondylosis are:

  • Pain in the neck
  • Pain that radiates into the shoulders and arms (Radiculopathy)
  • Numbness and tingling in the arms and hands
  • Pain that radiates throughout the neck, tingling in the shoulders, arms, hands and
  • Decreased range of motion when raising your arms or a sharp pain when you attempt to raise your arms

The most common symptoms of Lumbar Spondylosis are:

  • Low back pain
  • Pain that radiates through the buttocks and legs (Sciatica)
  • Numbness in the legs or feet
  • Decreased strength and mobility in the legs
  • Inability to walk more than a short distance
Pinched Spinal Nerve
What is a Pinched Nerve?

 

A pinched nerve in the spine is a term that is loosely used to describe nerve compression caused by a herniated disc, a bulging disc, spinal bone spurs and various other conditions that affect the spine.  This can occur in either the cervical or lumbar region of the spine and the symptoms can vary depending upon the location.  It is important to seek the advice of a spine specialist if symptoms are present because, left untreated, these symptoms can become permanent.

Symptoms of a Pinched Spinal Nerve Include:

  • Pain in the neck
  • Pain in the lower back
  • Pain that radiates into the arms (Cervical Radiculopathy)
  • Pain that radiates into the buttocks and legs (Sciatica)
  • Numbness or tingling in the arms or legs
  • Difficulty standing for long periods
  • Difficulty grasping objects
  • Headaches
Cervical Disc Herniations
Dr Virella has vast experience in the surgical and non-surgical treatment of herniated cervical discs. Arm pain from a cervical herniated disc is one of the more common cervical spine conditions treated by spine specialists. Most of the time this condition is treated non-surgically. It usually develops in the 30 – 50-year-old age group. Although a cervical herniated disc may originate from some sort of trauma or injury to the cervical spine, the symptoms, including arm pain, commonly start spontaneously.

 

The arm pain from a cervical herniated disc results because the herniated disc material pinches or presses on a cervical nerve, causing pain to radiate along the nerve pathway down the arm. Along with the arm pain, numbness and tingling can be present down the arm and into the fingertips. Muscle weakness may also be present due to a cervical herniated disc.

Symptoms of a Cervical Herniated Disc

A cervical herniated disc will typically cause pain patterns and neurological deficits as follows:

C4 – C5 (C5 nerve root) – Can cause weakness in the deltoid muscle in the upper arm. Does not usually cause numbness or tingling. Can cause shoulder pain.
C5 – C6 (C6 nerve root) – Can cause weakness in the biceps (muscles in the front of the upper arms) and wrist extensor muscles. Numbness and tingling along with pain can radiate to the thumb side of the hand. This is one of the most common levels for a cervical disc herniation to occur.
C6 – C7 (C7 nerve root) – Can cause weakness in the triceps (muscles in the back of the upper arm and extending to the forearm) and the finger extensor muscles. Numbness and tingling along with pain can radiate down the triceps and into the middle finger. This is also one of the most common levels for a cervical disc herniation (see Figure 1).
C7 – T1 (C8 nerve root) – Can cause weakness with the handgrip. Numbness and tingling and pain can radiate down the arm to the little finger side of the hand.
The majority of the time, the arm pain from a cervical herniated disc can be controlled with medication, and conservative (non-surgical) treatments alone are enough to resolve the condition.
Once the arm pain does start to improve it is unlikely to return, although it may take longer for the weakness and numbness/tingling to improve. If the arm pain gets better it is acceptable to continue with conservative treatment, as there really is no literature that supports the theory that surgery for cervical disc herniation helps the nerve root heal quicker.
All treatments for a cervical herniated disc are essentially designed to help resolve the arm pain, and usually, the weakness and numbness/tingling will resolve with time.

If conservative modalities fail, then surgery may be an option. This may involve a procedure such as a foraminotomy, where the bone is shaved and the herniated disc removed to make room for the pinched nerve or may involve either an anterior or posterior decompression and/or fusion.

Cervical Spondylosis
Dr. Virella is a specialist in the treatment of cervical spondylosis. He will be happy to answer all of your questions regarding the details of your specific condition at the time of your visit to our office. Cervical spondylosis is a common degenerative condition of the cervical spine. It is most likely caused by age-related changes in the intervertebral disks. Clinically, several syndromes, both overlapping and distinct, are seen. These include neck and shoulder pain, suboccipital pain and headache, radicular symptoms, and cervical spondylotic myelopathy (CSM). As disk degeneration occurs, mechanical stresses result in osteophytic bars, which form along the ventral aspect of the spinal canal.

 

Frequently, associated degenerative changes in the facet joints, hypertrophy of the ligamentum flavum, and ossification of the posterior longitudinal ligament occur. All can contribute to impingement on pain-sensitive structures (eg, nerves, spinal cord), thus creating various clinical syndromes. Spondylotic changes are often observed in the aging population. However, only a small percentage of patients with radiographic evidence of cervical spondylosis are symptomatic.

Treatment is usually conservative in nature; the most commonly used treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), physical modalities, and lifestyle modifications. Surgery is occasionally performed. Many of the treatment modalities for cervical spondylosis have not been subjected to rigorous, controlled trials. Surgery is advocated for cervical radiculopathy in patients who have intractable pain, progressive symptoms, or weakness that fails to improve with conservative therapy. Surgical indications for cervical spondylotic myelopathy remain somewhat controversial, but most clinicians recommend operative therapy over conservative therapy for moderate-to-severe myelopathy.

A 48-year-old man presented with neck pain and predominantly left-sided radicular symptoms in the arm. The patient’s symptoms resolved with conservative therapy. T2-weighted sagittal MRI shows ventral osteophytosis, most prominent between C4 and C7, with reduction of the ventral cerebrospinal fluid sleeve.

PATHOPHYSIOLOGY
Cervical spondylosis is the result of disk degeneration. As disks age, they fragment, lose water and collapse. Initially, this starts in the nucleus pulposus. This results in the central annular lamellae buckling inward while the external concentric bands of the annulus fibrosis bulge outward. This causes increased mechanical stress at the cartilaginous end plates at the vertebral body lip.

Subperiosteal bone formation occurs next, forming osteophytic bars that extend along the ventral aspect of the spinal canal and, in some cases, encroach on nervous tissue.These most likely stabilize adjacent vertebrae, which are hypermobile as a result of the lost disk material. In addition, hypertrophy of the uncinate process occurs, often encroaching on the ventrolateral portion of the intervertebral foramina.1 Nerve root irritation also may occur as intervertebral discal proteoglycans are degraded.

Ossification of the posterior longitudinal ligament, a condition is often seen in certain Asian populations, can occur with cervical spondylosis. This condition can be an additional contributing source of severe anterior cord compression.

Cervical spondylotic myelopathy occurs as a result of several important pathophysiological factors. These are static-mechanical, dynamic-mechanical, spinal cord ischemia, and stretch-associated injury. As ventral osteophytes develop, the cervical cord space becomes narrowed; thus, patients with congenitally narrowed spinal canals (10-13 mm) are predisposed to developing cervical spondylotic myelopathy.

Age-related hypertrophy of the ligamentum flavum and thickening of bone may result in further narrowing of the cord space. Additionally, degenerative kyphosis and subluxation are fairly common findings that may further contribute to cord compression in patients with cervical spondylotic myelopathy. Dynamic factors relate to the fact that normal flexion and extension of the cord may aggravate spinal cord damage initiated by static compression of the cord. During flexion, the spinal cord lengthens, resulting in it being stretched over ventral osteophytic bars. During extension, the ligamentum flavum may buckle into the cord, pinching the cord between the ligaments and the anterior osteophytes.

Spinal cord ischemia also most likely plays a role in cervical spondylotic myelopathy. Histopathologic changes were seen in persons with cervical spondylotic myelopathy frequently involve gray matter, with minimal white matter involvement%u2014a pattern consistent with the ischemic insult. Ischemia most likely occurs at the level of impaired microcirculation.

Stretch-associated injury has recently been implicated as a pathophysiologic factor in cervical spondylotic myelopathy. The narrowing of the spinal canal and abnormal motion seen with cervical spondylotic myelopathy may result in increased strain and shear forces, which can cause localized axonal injury to the cord.

FREQUENCY
International Cervical spondylotic myelopathy is the most common cause of nontraumatic spastic paraparesis and quadriparesis. In one report, 23.6% of patients presenting with nontraumatic myelopathic symptoms had cervical spondylotic myelopathy.

Race
Cervical spondylosis may affect males earlier than females, but this is not true in all studied populations.

Sex
Irvine et al defined the prevalence of cervical spondylotic myelopathy using radiographic evidence. In males, the prevalence was 13% in the third decade, increasing to nearly 100% by age 70 years. In females, the prevalence ranged from 5% in the fourth decade to 96% in women older than 70 years. Another study examined patients at autopsy. At age 60 years, half the men and one-third of the women had significant disease. A 1992 study noted that spondylotic changes are most common in persons older than 40 years. Eventually, greater than 70% of men and women are affected, but the radiographic changes are more severe in men than in women.

History
The various clinical syndromes seen with cervical spondylosis manifest quite differently.
Intermittent neck and shoulder pain, or cervicalgia, is the most common syndrome seen in clinical practice. This can be a frustrating problem for physicians and patients because often the patient has no associated neurologic signs. When neurologic deficits are present, diagnostic imaging can often help define the cause. When they are not present, however, imaging findings are not usually helpful because the incidence of radiologic abnormalities is quite high in persons in this age group, even in asymptomatic patients.
A large part of the problem is that the source of pain in this situation is poorly understood. This syndrome is possibly related to compression of the sinovertebral nerves and the medial branches of the dorsal rami in the cervical region.

The neck pain experienced with cervical spondylosis is often accompanied by stiffness, with radiation into the shoulders or occiput, that may be chronic or episodic with long periods of remission.
One-third of patients with cervicalgia due to cervical spondylosis present with a headache, and greater than two-thirds present with unilateral or bilateral shoulder pain. A significant amount of these patients also presents with the arm, forearm, and/or hand pain.

Another poorly understood clinical syndrome seen with cervical spondylosis is a chronic suboccipital headache. Although the C1 thru C3 dermatomes are represented on the head and it would seem likely that occipitoatlantal and atlantoaxial degeneration would cause pain in these areas, no contributions to these joints occur from the dorsal rami of C1-C3. In addition, the greater occipital nerve cannot usually be compressed by bony structures. Regardless, headaches can be the dominant symptom in a patient with degenerative cervical disease. The headaches are usually suboccipital and may radiate to the base of the neck and the vertex of the skull.
Perhaps more thoroughly understood than the above-discussed syndromes is radiculopathy associated with cervical spondylosis. The most commonly involved nerve roots are the sixth and seventh nerve roots, which are caused by C5-C6 or C6-C7 spondylosis, respectively. Patients usually present with pain, paresthesias or weakness, or a combination of these symptoms. The vast majority of these patients present without a history of trauma or other recalled precipitated cause. The pain is usually in the cervical region, the upper limb, shoulder, and/or interscapular region. At times, the pain may be atypical and manifest as chest pain (pseudoangina) or breast pain. Usually, the pain is more frequent in the upper limbs than in the neck, although it is frequently present in both areas. Cervical radiculopathy is not usually associated with myelopathy.

Cervical spondylotic myelopathy is the most common cause of nontraumatic paraparesis and tetraparesis. The process usually develops insidiously.

In the early stages, patients often present with neck stiffness. Patients also may present with stabbing pain in the preaxial or postaxial border of the arms. Patients with a high compressive myelopathy (C3-C5) can present with a syndrome of “numb, clumsy hands,” for which the patient describes difficulty writing, a loss of manual dexterity, nonspecific and diffuse weakness, and abnormal sensations. Those patients with a lower myelopathy typically present with a syndrome of weakness, stiffness, and proprioceptive loss in the legs. These patients often exhibit signs of spasticity.
Weakness or clumsiness of the hands may be seen in conjunction with weakness in the legs. Motor loss in the hands with relative sparing of the legs, however, is a relatively rare syndrome. Symptoms are commonly asymmetric in the legs.

Loss of sphincter control and urinary incontinence are rare; some patients, however, report urinary urgency, frequency, and/or hesitancy.

Cervical spondylotic myelopathy significantly affects patients’ quality of life. A recent study reported that greater than one-third of patients with cervical spondylotic myelopathy have anxious or depressed moods related to their decreased mobility.

Another syndrome that may be seen in relation to cervical spondylosis is central cord syndrome. This syndrome typically occurs when an elderly patient experiences an acute hyperextension injury with preexisting acquired stenosis due to ventral osteophytes and infolding of redundant ligamentum flavum, resulting in acute cord compression. Patients usually present with a history of a blow to the forehead. The syndrome consists of greater upper extremity weakness than lower extremity weakness, varying degrees of sensory disturbances below the lesion, and myelopathic findings such as spasticity and urinary retention.
Rarely, dysphagia or airway dysfunction has been reported secondary to cervical spondylosis. Dysphagia may occur when large anterior osteophytes cause mechanical compression of the esophagus or periesophageal inflammation causes motion over the osteophytes. Conservative therapy with anti-inflammatory medications and other modalities has been advocated for mild-to-moderate cases of dysphagia, while surgery has been reserved for more severe cases.

Physical
Examination findings include neck pain, radicular signs, and myelopathic signs. Patients with neck pain from spondylosis often present with neck stiffness. This is a nonspecific sign, and other causes of neck pain and stiffness (eg, myofascial pain, intrinsic shoulder pathology) must be considered and excluded.
If the history is compatible with cervical radiculopathy, carefully search for signs of muscle atrophy in the supraspinatus, infraspinatus, deltoid, triceps, and first dorsal interosseus muscles.
Winging of the scapula also may be present because it can occur with C6 or C7 radiculopathy. Palpate all muscles because this may allow earlier detection of wasting than visualization can provide. If weakness is detected in either 1 myotomal distribution or 2-3 peripheral nerves, peripheral nerve injury can likely be excluded as the cause. Muscle testing is important because muscle findings have more specificity than sensory or reflex findings.

Perform a detailed sensory and reflex examination in every patient who presents with a history suggestive of cervical spondylosis. Note that radicular findings often do not adhere strictly to textbook dermatomal charts. Patients often experience more pain proximally in their limbs, while, distally, paresthesias dominate.
Look for physical evidence of other causes of radiculopathy-type symptoms (eg, tenderness lateral to the neck in the supraclavicular fossa, Tinel sign).
The neck compression test (Spurling test or sign), if positive, is useful when assessing a patient for cervical radiculopathy.

This test is best performed by having the patient actively extend his or her neck, laterally flex, and rotate to the side of the pain while sitting. Next, use careful compression by slight axial loading. This maneuver works by narrowing the ipsilateral neural foramina during flexion and rotation, while the initial extension causes posterior disk bulging.

While this maneuver has a low sensitivity for cervical radiculopathy, it has a specificity of nearly 100%. Other useful tests are the axial manual traction test and the shoulder abduction test.
In cervical spondylotic myelopathy, the most typical examination findings are suggestive of upper motor dysfunction, including hyperactive deep tendon reflexes, ankle and/or patellar clonus, spasticity (especially of the lower extremities), the Babinski sign, and the Hoffman sign.
The Hoffman sign is a reflex contraction of the thumb and index finger after nipping the middle finger. Although this sign is usually present with corticospinal tract dysfunction, unlike the Babinski sign, it can also be present in generalized hyperreflexic states and in neurosis. It also may be found (usually bilaterally and incomplete) in persons without cervical spondylotic myelopathy.

Thus, this sign is only valuable if it is associated with other upper motor neuron – related findings. The Hoffman sign is best elicited by positioning the patient’s hand at rest and then stabilizing the proximal phalanx between the examiner’s index and middle finger; with the examiner’s thumb, the patient’s distal middle finger is flicked downward. The sensitivity of this examination maneuver may be increased by examining the patient during multiple full flexions or extensions of the neck (dynamic Hoffman sign).
Another occasionally useful test is the pectoralis muscle reflex.

This is elicited by tapping the pectoralis tendon in the deltopectoral groove, which causes adduction and internal rotation of the shoulder if hyperactivity is present. A positive result suggests compression in the upper cervical spine (C2-C4).

If the patient exhibits diffuse hyperreflexia, then the jaw jerk may distinguish an upper cervical cord compression from lesions that are above the foramen magnum.
In patients with cervical spondylotic myelopathy, weakness is most commonly seen in the triceps and/or hand intrinsic muscles, where upper extremity symptoms typically begin. Wasting of the intrinsic hand musculature is also a typical finding.

A thorough examination of patients’ hands should be performed. By having the patient make a fist and release it 20 times in 10 seconds, impairment or clumsiness may be observed that may suggest cervical spondylotic myelopathy.

The finger escape sign may also be present. To assess this, the patient holds his or her fingers extended and adducted. If the ulnar digits drift into abduction and flexion within 30-60 seconds, cervical spondylotic myelopathy may be present.

A classic finding with an examination of the lower extremities is a proximal motor weakness, most commonly in the iliopsoas, followed by the quadriceps femoris; distal weakness is a less common finding. The finding of lower extremity weakness and lower extremity upper motor neuron signs but absent upper extremity symptoms and signs should trigger a workup for thoracic cord pathology.

Examine gait during any neurologic examination whenever possible. Patients with cervical spondylotic myelopathy typically exhibit a stiff or spastic gait, especially later in the course of their disease.
Another helpful sign is the Lhermitte sign.

This consists of electric shock – like sensations that run down the center of the patient’s back and shoot into the limbs during flexion of the neck.

This sign is not specific for cervical spondylotic myelopathy and classically is attributed to posterior column dysfunction. Other causes of the Lhermitte sign include multiple sclerosis, tumors, and other compressive pathology.

Sensory abnormalities in cervical spondylotic myelopathy have a variable pattern upon examination.
Loss of vibratory sense or proprioception in the extremities can occur, particularly in the feet. Spinothalamic sensory loss may be asymmetric.

Diabetes mellitus or other metabolic causes of peripheral neuropathy can confound the sensory examination. Perform a complete motor examination. Wasting of the intrinsic hand musculature is a classic finding in persons with cervical spondylotic myelopathy.

Causes
In addition to age and possibly sex, several risk factors have been proposed for cervical spondylosis.

Repeated occupational trauma (eg, carrying axial loads, professional dancing, gymnastics) may contribute. The role of occupational trauma is controversial, especially in terms of worker’s compensation claims and other related medicolegal clauses.
Familial cases have been reported; a genetic cause is possible.

Smoking also may be a risk factor.

Conditions that contribute to segmental instability and excessive segmental motion (eg, congenitally fused spine, cerebral palsy, Down syndrome) may be risk factors for spondylotic disease. Cervical spondylotic myelopathy may be responsible for functional declines in patients with athetoid cerebral palsy.

Lumbar Disc Herniation

Dr. Virella has performed several thousand surgeries for the treatment of herniated lumbar discs. In most instances, Dr. Virella will choose one of the many minimally invasive techniques available for your condition. This usually involves making an incision less than a centimeter and introducing a series of tubes which essentially “push” the muscle fibers out of the way along their natural planes. He then will use a highly sophisticated microscope and specialized instruments to gently shave away bone spurs which are usually compressing the nerve. These techniques function as a series of coordinated efforts to free up the nerve and ultimately remove the herniated piece of disc which is pinching upon the nerve. After the herniated fragment is removed, these specialized tubes are gently removed from the field allowing the muscle fibers to come back to their normal anatomic position, leaving the normal anatomy intact. After your surgery, a Band-Aid is placed on the incision and you can usually return to work the next day. As little as five years ago this same surgery would have commonly involved a large midline three-inch incision and a procedure that essentially “burns” and ultimately destroys the same muscle fibers which are spared in the minimally invasive approach. Most patients would have traditionally required a two to three day hospital stay with lots of pain requiring the use of intravenous morphine. Thanks to the minimally invasive approach these tissue destroying surgeries, are for the most part, considered a thing of the past.

 

Your back, or spine, is made up of many parts. Your backbone, also called your vertebral column, provides support and protection. It consists of 33 vertebrae (bones). There are discs between each of the vertebra that act like pads or shock absorbers. Each disc is made up of a tire-like outer band called the annulus fibrosus and a gel-like inner substance called the nucleus pulposus. Together, the vertebrae and the discs provide a protective tunnel (the spinal canal) to house the spinal cord and spinal nerves. These nerves run down the center of the vertebrae and exit to various parts of the body.

Your back also has muscles, ligaments, tendons, and blood vessels. Muscles are strands of tissues that act as the source of power for movement. Ligaments are the strong, flexible bands of fibrous tissue that link the bones together, and tendons connect muscles to bones and discs. Blood vessels provide nourishment. These parts all work together to help you move about.

A herniated disc most often occurs in the lumbar region (low back). This is because the lumbar spine carries most of the body’s weight. Sometimes the herniation can press on a nerve, causing pain that spreads or radiates to other parts of the body. The amount of pain associated with a disc rupture often depends upon the amount of material that breaks through the annulus fibrosus and whether it compresses a nerve.

Lumbar Spinal Stenosis
The term “spinal stenosis” is heard quite frequently in retirement communities because of the concentration of the elderly in that populace. “Spinal stenosis” is primarily an aging process. Many years ago it was called creeping paralysis. It was accepted that if one got old enough, one could acquire it and have to ‘live and die with it.’

 

The two words are separated primarily for clarification. “Spinal” giving the location, and “stenosis” meaning the condition. Stenosis is derived from the Greek meaning, “narrowing of a normally larger opening.” The term ‘stenosis’ is widely used in medicine for different parts of the body.

The primary area discussed here is stenosis of the spine, which can occur in the cervical, thoracic, or lumbar region. We will address the lumbar area in this article because of the greater percentile that we see.

Lumbar Spinal Stenosis

There are three motion segments between two lumbar vertebral bodies – one being the well known “disc” or “shock-absorber space” between two vertebral bodies, and the lesser known two “facet joints” that adjoin just posterior to the disc space. These two joints are similar to most other joints in our bodies. The facet joints are where one vertebrae actually touches or connects to the vertebrae above or below with a thin layer of cartilage that is in between the bony surfaces. Each lumbar vertebral body has four joints, with two joints superior or toward the head and two joints inferior or toward the feet. Two are on the right side of the body and two are on the left side of the body. Two adjoining vertebral bodies joined together continue up the spine.

Factors making ‘person predisposed to acquiring spinal stenosis can start in the womb as a result of genetics or congenital problems acquired from the mother. Generally, any of these factors result in lower back problems early in life and can continue to progressively worsen with time and gravity. There are many perfectly normal backs after childhood developments that are mechanically ruined due to many self-destructive modes, but not all self controlled. Some of these being poor posture, poor body mechanics, overweight, physical abuse, smoking, poor diet, all the way to many disease processes that we have no control over, such as osteoarthritis, rheumatoid arthritis, osteoporosis, scoliosis, and lordosis (sway back). The end result in many of these problems is spinal stenosis on the left, right, central, or all of the above, at any one given joint segment, primarily in the lumbar spine.

This leads us to ask, “what does spinal stenosis effect, or what effects does spinal stenosis have?” Primarily we are looking at the central part of the dural sac and/or the right and left nerve roots that exit between the two vertebral bodies. Each root gets its name by passing over the vertebral body and exiting through an opening between the two adjoining bodies called the “foramen,” i.e. the L.5 root passes over the 5th lumbar vertebral body and exits L5-S1 foramen. One degenerative scenario would be that the disc collapses over time thus causing the facet joints to become inflamed or angry with their normal joint space being reduced. One motion segment cannot be disrupted without affecting the other two. When this occurs the inflammation causes spurring around the entire facet joint which causes it to become larger, thus invading the central part of the spinal canal, as well as, the root foramen, which lies just beneath the facet joint. Stenotic problems can then occur.

Then we have progressive subtle loss of motor or muscular use of one or both of our lower extremities or parts of those extremities. This occurs slowly, so that an aged person can hardly tell that it is happening until they have a fall or complain of weakness in one or both of their legs. It is tolerable for some and accepted as the aging process by others. Sometimes a cane or walkers are supplemented to help ambulate. It is when the leg pain begins that people become alarmed about their condition, Then, fearing that they may have cancer or some other destructive problem, they elect to seek medical attention.

The diagnostic work-up is obtained through physical exam, a thorough medical and life history, x-rays, MRI – if deemed necessary, CAT scan – if available, and blood tests that help us to bring about a diagnosis. Based on the patient’s medical condition at that time, a treatment plan is decided upon and begun, starting with the most conservative methods of physical therapy, epidural, and medications. If all else fails to resolve the problem, surgery may be considered.

If all the conservative modalities have been utilized and the symptoms of spinal stenosis are still debilitating and affecting a patient’s life then surgery may be an option to restore the patient back to their activities of normal living. The specific surgery recommended usually depends on many factors which include the patient age, comorbid conditions, history, physical examination and radiologic findings. Most commonly a lumbar laminectomy is selected as the procedure of choice to treat this condition. A lumbar laminectomy includes removing the hypertrophied ligamentum flavum and lamina thus restoring the normal tubular configuration of the thecal sac. This procedure also functions to decompress the nerve roots which are frequently compressed by the thickened ligament and hypertrophied medial facet complex. In certain cases, the lumbar laminectomy may be performed minimally invasive through the tubular retraction system. Dr. Virella will analyze your specific case, prior to rendering a surgical opinion; you will be offered the most minimally invasive approach available to treat your specific condition.

Nervous or Apprehensive about taking the first step?

People all over the world delay their treatments due to long-term anxieties and fears surrounding spine surgery and treatments in general. Our practice has worked with many patients over the years and we understand these valid concerns. If you have these general concerns, please click below to read “A Letter To Patients From Dr. Virella“.

Read: A Letter To Patients From Dr. Virella

Relieving your pain should not be a cause for anxiety, and we take every step possible to make sure our patients are comfortable, secure and relaxed from their first visit to their last. Remember, there is nothing scary about taking back control of your life and relieving your pain. Our practice is highly organized and provides step-by-step guided help the entire way to keep you relaxed with your focus where it should be- on you.

You’ve already taken the first step by searching for the right doctor and can soon be on a path to a pain-free life. Call our practice today (805-270-2038or request a callback to come and visit with me. We will sit down together and discuss your concerns. Then, I will provide you with a thorough analysis and review of a suggested care path and treatment options.

I pride myself in being extremely attentive to my patients, using extreme caution and putting to work my experience (of nearly two decades) in conservative treatments and minimally invasive procedures that have given thousands of patient their lives back. I have spent my life designing a new approach to spine treatments that reduce any anxieties of my patients by providing them with a comprehensive strategy that makes sense and is proven.

Don’t let your pain get worse by delaying getting the help you need. Neglecting needed treatment will (almost certainly) make your situation worse. We hope you decide to take control of your pain and your life. We welcome and look forward to meeting you and having the opportunity to shares our skills and successes with you. Thank you for taking the time to read and we hope to see you soon.

ANTHONY A. VIRELLA M.D., F.A.C.S

Take The First Step Today!

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