- Normal Anatomy
- Muscle Strain
- Cervical Disc Herniation
- Lumbar Stenosis
- Cervical Stenosis
- Degenerative Disc Disease
- Cervical and Thoracic Myelopathy
- Cauda Equina Syndrome
- Spinal Fracture
- Spinal Cord Tumor
- Tethered Cord
The spine is divided into three sections:
Each section of the spine contains different structures that stabilize the spine and permit movement. The spine is made up of the spinal cord and nerves, vertebrae, intervertebral disc, joints, muscles and ligaments. Failure of any of these structures can lead to pain, loss of movement or neurological deficit.
- The spinal cord runs through the spinal canal and nerves exit into the arms and legs.
- The vertebrae are the bones that give the spine its shape. They protect the spinal cord and nerves.
- The intervertebral discs are shock absorbers that sit between the vertebrae. It contains a nucleus pulposus, which is its soft, inner core and the annulus which is the outer tough cartilage.
- There are many joints in the spine. Facet joints connect the vertebrae and allow for movement.
- Numerous ligaments connect the vertebrae.
- Muscles stabilize the spine and contract to permit movement.
There are numerous paraspinal muscles and ligaments that can cause or contribute to back pain. These muscles provide structural support for the spine and assist in movement. A muscle strain occurs when fibers become stretched or torn. A ligament sprain is a similar finding, with similar symptoms. The pain is typically localized in the back and may worsen with movement. Muscle spasm can lead to significant pain and stiffness in the neck and back.
Muscle strains and ligament sprains can be managed conservatively, with medications and activity modification. Physical therapy programs will focus initially on exercises that minimally stress the back and then on exercises that condition the trunk muscles.
Cervical Disc Herniation
The intervertebral disc is made up of a fibrous outer layer called the annulus fibrous and a soft inner layer called the nucleus pulposus. In the cervical spine, each of the seven vertebral bodies is separated by an intervertebral disc. The cervical disc can be bulging, when it extends beyond the peripheral limits of the disc space. It can also be herniated, when the soft inner portion displaces outside of its normal boundaries. Disc herniations can compress a spinal nerve root, causing pain, numbness or weakness into one of the arms. This type of pain is called radiculopathy. Large herniated discs may also cause compression of the spinal cord, which can lead to difficulty walking and feeling off balance.
The diagnosis of cervical disc herniation is similar to the process for lumbar disc herniation. The presentation of the patient symptoms combined with clinical examination is the first approach. Then an MRI scan is ordered to visualize the disc material and nerve structures. If you are unable to have an MRI, a myelogram and CT scan will be ordered.
Conservative treatments include medications and physical therapy. Surgery may also be indicated, when conservative treatments fail or if you develop a neurological deficit.
Lumbar stenosis is a narrowing of the spinal canal, which results from a combination of ligament thickening, joint overgrowth, disc bulging and a change in the curvature of the spine. It can cause back pain with radiculopathy. The symptoms typically increase with walking and are alleviated with rest.
The first step in making a diagnosis of lumbar stenosis is the clinical examination and discussion with your physician your symptoms. Imaging studies are likely ordered, such as an MRI scan and possibly and x-ray. If you are not able to have an MRI, a myelogram and CT scan will be ordered. Sometimes, an EMG and nerve conduction study is also ordered. This test is performed by a trained clinician who delivers electrical stimulation to the muscles and nerves in the legs to evaluate for any nerve damage.
Conservative treatments include medications, physical therapy and injections. Surgery may be necessary to decompress the spinal cord and nerves.
Cervical stenosis is a narrowing of the spinal canal in the upper region, which results from a combination of ligament thickening, joint overgrowth, disc bulging and a change in the curvature of the spine. It can cause neck pain with radiculopathy and/or myelopathy. Patients may begin to drop objects from their hands and walk with a discoordinated gait. A change in bowel or bladder function may also occur.
The clinical examination of a patient with cervical stenosis provides important information to the physician about any possible pressure on the spinal cord. Imaging studies include MRI scans, to view the spinal cord and nerves, and also x-rays to see the bony structures in this region. If you are unable to have an MRI scan, a myelogram and CT scan are necessary to view the nerves.
Conservative treatments include medications, physical therapy and injections. Surgery may be necessary to decompress the spinal cord and nerves.
When one vertebral body is moved in relation to another, it is termed spondylolisthesis. Spondylolisthesis can be due to degenerative changes, trauma or congenital abnormalities in the bony architecture of the spinal column. Degenerative spondylolisthesis occurs over time, as a process of intersegmental instability. Fractures in certain parts of the vertebral body can also lead to instability. Congenital malformations in the neural arch, specifically the pars interarticularis, lead to spondylolysis and slippage. Patients with spondylolisthesis present with back pain and/or extremity pain that may change with bending.
X-rays will confirm the presence of spondylolisthesis. These may be ordered with you bending forwards and backwards to evaluate for movement at the level of the spondylolisthesis. The MRI scan will show the nerves and possible compression. In addition, a CT scan may be ordered to evaluate for possible congenital defect in the bone that can lead to spondylolisthesis.
Conservative treatments include medications, bracing, physical therapy and injections. Surgery may be necessary to decompress the spinal cord and nerves with spinal fusion.
A congenital failure of the neural arch to form together is termed spondylolysis. These patients have a defect in the pars interarticularis region of the vertebrae. Spondylolysis leads to slippage, or spondylolisthesis. Often, patients are asymptomatic. However, back pain with or without radiculopathy may develop.
The best test to visualize spondylolysis is a plain CT scan. X-rays and MRI scans can suggest spondylolysis, but the CT scan is a more definitive test.
The treatment of spondylolysis is often conservative, including medications, physical therapy and sometimes a brace. Surgery, when indicated, involves a fusion procedure to stabilize the region.
Scoliosis refers to an abnormal S-shaped curvature that occurs in the lateral direction. Scoliosis can be congenital, and some individuals require corrective fusions in childhood. However, scoliosis can also be degenerative as a result of degenerative disc disease and ligament laxity. Scoliosis can lead to back pain and extremity pain, if spinal nerves are compressed.
Scolioisis is best seen on an x-ray. A CT scan can be used to further evaluate the direction of rotation of each of the bones. Often, a CT scan is also used for surgical planning in cases of fusion. MRI scans are used to evaluate for nerve compression.
Treatment for scoliosis begins with conservative measures, including physical therapy, medications and sometimes bracing. Pain management consultation for injections is also considered. If a patient has failed the above treatment options, surgical strategies can be discussed. The choice of surgical intervention depends on the patient’s symptoms and also the degree of scoliosis and stenosis. There are some cases in which the nerves can be decompressed with a minimally-invasive approach. There are some cases, however, where a fusion procedure is required to stabilize the spine after the nerves have been decompressed.
Degenerative Disc Disease
Disc degeneration occurs as the disc loses collagen and begins to collapse. Loss of the disc material contributes to decrease in motion at this level and pain. In addition, as the disc space narrows, the endplates of the adjacent vertebral bodies develop sclerosis and osteophytes. These changes can also produce back pain. Disc degeneration can also lead to disc herniation. Back pain is difficult to treat surgically, and conservative treatment is the first line approach.
Disc degeneration can be appreciated on MRI scans as “black discs”. The MRI will also show any possible nerve compression. X-rays are also useful tests in this condition, and they will show collapsed disc spaces.
Medications, physical therapy and injections can be used to achieve relief of chronic back pain associated with degenerative disc disease.
Cervical and Thoracic Myelopathy
Myelopathy occurs when there is compression of the spinal cord due to narrowing of the canal. When the compression occurs in the cervical spine, patients typically have a combination of spinal cord and nerve root compression. There may be weakness and wasting of the hand muscles, with slow hand and finger movements. Fine motor movements may appear to be clumsy. Due to the spinal cord compression, patients also typically have weakness in the legs and difficulty walking. The leg reflexes may be spastic. Urinary urgency is also common. When the compression occurs in the thoracic spine, patients may lack the symptoms in the hands and arms. Predominant complaints are typically leg weakness and difficulty walking with urinary urgency. Myelopathy can be caused by severe stenosis secondary to arthritis, which is more likely to occur in the cervical spine. However, spinal tumors can also lead to myelopathy.
Clinical presentation of myelopathy is often the first step in diagnosis. The MRI will confirm the diagnosis, and is often necessary to visualize the severity of the stenosis. Myelogram with CT scan can be done if MRI is not able to be performed.
When a patient presents with myelopathy secondary to cervical or thoracic stenosis, often surgery is necessary to prevent further damage to the spinal cord. Sometimes steroids are used to decrease swelling before surgery. The type of surgical procedure depends on the location of the stenosis, but often involves decompression.
Cauda Equina Syndrome
The cauda equina is a group of nerve endings in the lower end of the spinal column. During development, the bony structures of the spinal column lengthen at a faster rate than the spinal cord. In most adult persons, the spinal cord ends at the level of the L1-L2 vertebrae. From this point, the cauda equina occupies the remainder of the spinal column. With compression of the cauda equina, patients have disturbance of the urinary and anal sphincters, saddle anesthesia, lower extremity weakness and sexual dysfunction. Patients also may have absent reflexes in the legs. Compression of the cauda equina can result from a large disc herniation, tumor, trauma or epidural hematoma.
Clinical presentation is crucial in the diagnosis of cauda equina syndrome. In order to avoid a delay in treatment, the physician will have a high suspicion of the diagnosis based on your signs and symptoms. MRI scan is often ordered STAT to avoid a treatment delay.
Surgical decompression is necessary and ideally should be performed early to avoid long term deficit.
There are many different types of spinal fractures.
Compression fractures appear as a loss of height in the vertebral body. These fractures are commonly related to osteoporosis, but malignancy can also predispose an individual to develop compression fractures by weakening the bony matrix of the spinal column. These kinds of fractures more commonly occur in the thoracic and lumbar regions of the spine. Patients typically have pain in the middle to lower back and can be tender to the touch. They may or may not have radiculopathy. Often these patients can be treated conservatively, with bracing, medications and physical therapy. There is also a surgical procedure, called kyphoplasty, which can be performed if conservative treatment is ineffective. When there is a significant amount of compression, patients may require more extensive surgery to stabilize the fracture.
Fractures in the cervical spine can fall into many different classifications. Often, these are traumatic fractures. Patients require a thorough neurological assessment to evaluate for any deficits or possible spinal cord injury. Treatment will depend on the type of fracture. Most patients require immobilization and/or surgical stabilization.
Spinal Cord Tumor
Spinal cord tumors may be classified into one of the following groups:
- Extradural—Arise outside the spinal cord and dural sac
- Intradural extramedually—Arise inside the dural sac, but outside the spinal cord; often these are tumors that involve spinal membranes
- Intramedullary—Arise in the substance of the spinal cord
Most primary spinal tumors are benign and present when they become large enough to compress a nerve or the spinal cord, producing radiculopathy or myelopathy. Malignant primary spinal tumors are less common, but can occur. Metastatic spinal tumors can also arise from malignancy elsewhere in the body.
Diagnosis of spinal cord tumor is often made with MRI scans. CT scans are useful, especially in diagnosis of extradural tumors that invade bone tissue. Based on the type of tumor, additional studies may be ordered to evaluate additional areas for involvement.
Treatment of spinal cord tumor is dependent on the type of tumor and clinical presentation. In many cases, surgical resection is the best approach. With any type of tumor surgery, the goal of surgical resection is to remove as much of the tumor as is safely possible and spare functional neural tissue. Radical resection can often be achieved in benign tumor types. A limited resection or biopsy combined with multidisciplinary medical treatments may be recommended for malignant tumors. We work closely with both medical oncologists and radiation therapists to maximize the possibility of complete recovery.
In most people, the spinal cord and nerves float freely inside the dural sac surrounded by cerebrospinal fluid. In tethered cord syndrome, the spinal cord remains attached to the inside of the spinal membranes which limits its movement. It begins during development, as the spinal canal grows at a rate faster than the cord. If the spinal cord remains attached, the nerve tissues become stretched and this interferes with their function. Patients with tethered cord typically present in childhood, and tethered cord can have associated cutaneous findings. However, although less common, tethered cord patients can first present in adulthood. Patients may have difficulty walking, weakness in their legs, bladder dysfunction or lower back pain.
The diagnosis of tethered cord syndrome depends on MRI scan. Clinical presentation increases suspicion for this diagnosis.
Treatment for symptomatic tethered cord syndrome is surgical separation of this attached region.