Bellapianta Orthopedics Neck Injuries

Almost everyone will experience back and neck pain at some point in their lives. This pain varies from one person to the next. It can range from mild to severe, and can be short-lived or long-lasting.

Just getting older also plays a role in many back and neck conditions. As we age, our spines age with us. Aging causes degenerative changes that can start in our 30s — or even younger — and can make us prone to back and neck pain, especially if we overdo our activities. These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in their back!

Understanding your spine and how it works can help you better understand some of the problems that occur from aging or injury.

Cervical Disk Degeneration (Spondylosis)

In cervical disk degeneration (which typically occurs in people 40 and older), the normal jelly-like center of the disk degenerates, and the space between the vertebrae narrows. As the disk space narrows, added stress is applied to the joints of the spine causing further wear and degenerative disease.

The cervical disk may also protrude and put pressure on the spinal cord or nerve roots when the outer rim of the disk weakens. This is known as a herniated cervical disk. Cervical disk herniation can lead to pain, numbness, tingling, and weakness in the arms and legs.

Cause

Neck pain may result from abnormalities in the soft tissues — the muscles, ligaments, and nerves — as well as in bones and disks of the spine. The most common causes of neck pain are soft-tissue (muscle and ligament) abnormalities due to injury (a strain or sprain) or prolonged wear and tear (commonly known as arthritis). In rare instances, infection or tumors may cause neck pain. In some people, neck problems may be the source of pain in the upper back, shoulders, or arms.

Neck Sprain

The seven bones of the spinal column in your neck (cervical vertebrae) are connected to each other by ligaments and muscles—strong bands of tissue that act like thick rubber bands. A sprain (stretch) or tear can occur in one or more of these soft tissues when a sudden movement, such as a motor vehicle collision or a hard fall, causes the neck to bend to an extreme position.

Symptoms

A person with a neck sprain may experience a wide range of possible symptoms, including:

Pain, especially in the back of the neck, that worsens with movement
Pain that peaks a day or so after the injury, instead of immediately
Muscle spasms and pain in the upper shoulder
Headache in the back of the head
Increased irritability, fatigue, difficulty sleeping, and difficulty concentrating
Numbness in the arm or hand
Neck stiffness or decreased range of motion (side to side, up and down, circular)
Tingling or weakness in the arms

Warning Signs

Some symptoms may indicate a more serious neck injury. You should seek immediate medical attention if you have neck pain that is:

Consistent and persistent
Severe
Accompanied by pain that radiates down the arms and legs
Accompanied by a headache and numbness, tingling, or weakness in the arms and legs

Treatment

All sprains or strains, no matter where they are located in the body, are treated in a similar manner. Neck sprains, like other sprains, will usually heal gradually, given time and appropriate treatment. You may have to wear a soft collar around your neck to help support the head and relieve pressure on the ligaments so they have time to heal.

Pain relievers such as aspirin or ibuprofen can help reduce the pain and any swelling. Muscle relaxants can help ease spasms. You can apply an ice pack for 15 to 30 minutes at a time, several times a day for the first 2 or 3 days after the injury. This will help reduce inflammation and discomfort. Although heat, particularly moist heat, can help loosen cramped muscles, it should not be applied too quickly.

Other treatments may be helpful as your injury starts to improve. These treatments should not be started, however, without the supervision of your doctor. They include:

Massaging the tender area
Ultrasound therapy
Cervical (neck) traction
Aerobic and isometric exercise
Most symptoms of neck sprain will go away in 4 to 6 weeks. However, severe injuries may take longer to heal completely.

Cervical Spondylosis (Arthritis of the Neck)

Neck pain can be caused by many things—but is most often related to getting older. Like the rest of the body, the disks and joints in the neck (cervical spine) slowly degenerate as we age. Cervical spondylosis, commonly called arthritis of the neck, is the medical term for these age-related, wear-and-tear changes that occur over time.

Cervical spondylosis is extremely common. More than 85 percent of people over the age of 60 are affected. The condition most often causes pain and stiffness in the neck—although many people with cervical spondylosis experience no noticeable symptoms. In most cases, cervical spondylosis responds well to conservative treatment that includes medication and physical therapy.

Cause

Cervical spondylosis arises from degenerative changes that occur in the spine as we age. These changes are normal and they occur in everyone. In fact, nearly half of all people middle-aged and older have worn disks that do not cause painful symptoms.

Disk Degeneration and Bone Spurs

As the disks in the spine age, they lose height and begin to bulge. They also lose water content, begin to dry out and weaken. This problem causes settling, or collapse, of the disk spaces and loss of disk space height. Eventually, the cushioning qualities of the disks begins to decrease.

As the facet joints experience increased pressure, they also begin to degenerate and develop arthritis, similar to what may occur in the hip or knee joint. The smooth, slippery articular cartilage that covers and protects the joints wears away.

If the cartilage wears away completely, it can result in bone rubbing on bone. To make up for the lost cartilage, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth — called bone spurs — may narrow the space for the nerves and spinal cord to pass through (stenosis). Bone spurs may also lead to decreased range of motion in the spine.

Risk Factors

Age is the most common risk factor for cervical spondylosis. The condition is extremely common in patients who are middle-aged and older.

Other factors that may increase your risk for developing cervical spondylosis and neck pain include:

Genetics—a family history of neck pain and spondylosis
Smoking—clearly linked to increased neck pain
Occupation—jobs with lots of repetitive neck motion and overhead work
Depression or anxiety
Previous injury or trauma to the neck

Symptoms

For most people, cervical spondylosis causes no symptoms. When symptoms do occur, they typically include pain and stiffness in the neck. This pain can range from mild to severe. It is sometimes worsened by looking up or looking down for a long time, or by activities in which the neck is held in the same position for a prolonged period of time—such as driving or reading a book. The pain usually improves with rest or lying down.

Other symptoms may include:

Headaches
Grinding or popping noise or sensation when you turn your neck
In some cases, cervical spondylosis results in a narrowing of the space needed for the spinal cord or nerve roots. If this occurs, your symptoms may include numbness and weakness in the arms, hands, and fingers
Trouble walking, loss of balance, or weakness in the hands or legs
Muscle spasms in the neck and shoulders

Cervical Fracture (Broken Neck)

There are seven bones that make up the cervical vertebrae (neck). They support the head and connect it to the shoulders and body. A fracture, or break, in one of the cervical vertebrae is commonly called a broken neck.

Cervical fractures usually result from high-energy trauma, such as automobile crashes or falls. In elderly people, ground-level falls, such as falling off a chair, can result in a cervical fracture. Athletes are also at risk. A cervical fracture can occur if:

A football player "spears" an opponent with his head
An ice hockey player is struck from behind and rams into the boards
A gymnast misses the high bar during a release move and falls
A diver strikes the bottom of a shallow pool

Any injury to the vertebrae can have serious consequences because the spinal cord, the central nervous system's connection between the brain and the body, runs through the center of the vertebrae. Damage to the spinal cord is very serious and can result in paralysis or death. Injury to the spinal cord at the level of the cervical spine can lead to temporary or permanent paralysis of the entire body from the neck down.

Emergency Response

In a trauma situation, the neck should be immobilized until X-rays are taken and reviewed by a physician. Emergency medical personnel will assume that an unconscious individual has a neck injury and respond accordingly. The victim may experience shock and either temporary or permanent paralysis.

Conscious patients with an acute neck injury may or may not have severe neck pain. They may also have pain spreading from the neck to the shoulders or arms, resulting from the vertebra compressing a nerve. There may be some bruising and swelling at the back of the neck. The physician will perform a complete neurological examination to assess nerve function and may request additional radiographic studies, such as magnetic resonance imaging (MRI) or computed tomography (CT), to determine the extent of the injuries.

Treatment

Treatment will depend on which of the seven cervical vertebrae are damaged and the kind of fracture sustained.

A minor compression fracture can be treated with a cervical brace worn for 6 to 8 weeks until the bone heals.
A more complex or extensive fracture may require traction, surgery, 2 to 3 months in a rigid cast, or a combination of these treatments.

Prevention

Improvements in athletic equipment and rule changes have reduced the number of sports-related cervical fractures. You can help protect yourself and your family if you:

Always wear a seat belt when you are driving or are a passenger in a car.
Never dive in a shallow pool area, and be sure that young people are properly supervised when swimming and diving.
Wear the proper protective equipment for your sport and follow all safety regulations, such as having a spotter and appropriate cushioning mats.
For elderly people, conduct a home inspection to ensure a safe environment. Small changes, like taping down rugs and placing assistive devices near toilets and showers/tubs, can help reduce the risk of falls.

Cervical Spondylotic Myelopathy
(Spinal Cord Compression)

Cervical spondylotic myelopathy (CSM) is a neck condition that arises when the spinal cord becomes compressed—or squeezed—due to the wear-and-tear changes that occur in the spine as we age. The condition commonly occurs in patients over the age of 50.

Because the spinal cord carries nerve impulses to many regions in the body, patients with CSM can experience a wide variety of symptoms. Weakness and numbness in the hands and arms, loss of balance and coordination, and neck pain can all result when the normal flow of nerve impulses through the spinal cord is interrupted.

Cause

Cervical spondylotic myelopathy (CSM) arises from degenerative changes that occur in the spine as we age. These degenerative changes in the disks are often called arthritis or spondylosis.

Cervical Disk Degeneration

Bone spurs. As the disks in the spine age, they lose height and begin to bulge. They also lose water content, begin to dry out, and become stiffer. This problem causes settling, or collapse, of the disk spaces and loss of disk space height.

As the disks lose height, the vertebrae move closer together. The body responds to the collapsed disk by forming more bone—called bone spurs—around the disk to strengthen it. These bone spurs contribute to the stiffening of the spine. They may also make the spinal canal narrow—compressing or squeezing the spinal cord.

Herniated disk. A disk herniates when its jelly-like center (nucleus pulposus) pushes against its outer ring (annulus fibrosus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When a herniated disk bulges out toward the spinal canal, it can put pressure on the spinal cord or nerve roots.

As disks deteriorate with age, they become more prone to herniation. A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Other Causes of Myelopathy

Myelopathy can arise from other conditions that cause spinal cord compression, as well. Although these conditions are not related to disk degeneration, they may result in the same symptoms as CSM.

Rheumatoid arthritis. Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In rheumatoid arthritis, immune cells attack the synovium, the thin membrane that lines the joints.

As the synovium swells, it may lead to pain and stiffness and, in severe cases, destruction of the facet joints in the cervical spine. When this occurs, the upper vertebra may slide forward on top of the lower vertebra, reducing the amount of space available for the spinal cord.

Injury. An injury to the neck—such as from a car accident, sports, or a fall—may also lead to myelopathy.

For example, a "rear end" car collision may result in hyperextension, a backward motion of the neck beyond its normal limits, or hyperflexion, a forward motion of the neck beyond its normal limits. Because these types of injuries often affect the muscles and ligaments that support the vertebrae, they may lead to spinal cord compression.

Symptoms

Typically, the symptoms of CSM develop slowly and progress steadily over several years. In some patients, however, the condition may worsen more rapidly.

Patients with CSM may experience a combination of the following symptoms:

Tingling or numbness in the arms, fingers, or hands
Weakness in the muscles of the arms, shoulders, or hands. You may have trouble grasping and holding on to items.
Imbalance and other coordination problems. You may have trouble walking or you may fall down. With myelopathy, there is no sensation of spinning, or "vertigo." Rather, your head and eyes feel steady, but your body feels unable to follow through with what you are trying to do.
Loss of fine motor skills. You may have difficulty with handwriting, buttoning your clothes, picking up coins, or feeding yourself.
Pain or stiffness in the neck

Burners and Stingers

Burners and stingers are injuries that occur when nerves in the neck and shoulder are stretched or compressed after an impact. These injuries are common in contact or collision sports, and are named for the stinging or burning pain that spreads from the shoulder to the hand. A burner or stinger can feel like an electric shock or lightning bolt down the arm.

In most cases, burners and stingers are temporary and symptoms quickly go away.

Cause

An injury to the brachial plexus can cause a burner or stinger. This often happens when the head is forcefully pushed sideways and down. This bends the neck and pinches the surrounding nerves.

Risk Factors

Athletes who engage in contact sports are more likely to suffer a burner or stinger. These injuries often occur with a fall onto the head, such as in a wrestling takedown or a football tackle. In fact, tackling or blocking in American football is the athletic activity that most often causes burners or stingers. Football defensive players and linemen frequently suffer this injury.

Spinal stenosis. In addition to playing contact sports, a small spinal canal may put you at greater risk for a burner or stinger. Athletes with recurrent stingers or burners may have smaller spinal canals than players who do not suffer recurrent injury. This condition is called spinal stenosis.

Symptoms

Burner and stinger symptoms typically occur in one arm only. They usually last seconds to minutes, but in some cases they can last hours, days, or even longer. The most common symptoms of a burner or stinger include:

A burning or electric shock sensation
Arm numbness and weakness immediately following the injury
A warm sensation

Low Back Pain

Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.

Cause

There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.

Overactivity. One of the more common causes of low back pain is muscle soreness from overactivity. Muscles and ligament fibers can be overstretched or injured. This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this stiffness and soreness in the low back and other areas of the body that usually goes away within a few days.

Disk Injury. Some people develop low back pain that does not go away within a few days. This may mean there is an injury to an intervertebral disk.

Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.

Herniated disk. A disk herniates when its jelly-like center (nucleus) pushes against its annulus. If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.

Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is called sciatica.

A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Disk degeneration. With age, intervertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints — the small joints located between each vertebra on the back of the spine — to rub against one another. Pain and stiffness result. Smoking has also been found to accelerate disk degeneration.

This wear and tear on the facet joints is referred to as osteoarthritis, also known as spondylosis. It can lead to further back problems, including spinal stenosis.

Spondylolisthesis. (Spon-dee-low-lis-THEE-sis) Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae can move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.

Spinal Stenosis. Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves. When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone (arthritis) in your facet joints to help support the vertebrae. Over time, this bone overgrowth (called spurs) can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.

Scoliosis. Scoliosis is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly pain, weakness, or numbness in the legs if pressure on the nerves is involved.

Compression Fracture. Vertebral compression fractures are a common cause of back pain in the elderly. As we get older, our bones become weaker and more likely to break, a condition called osteoporosis. In people with osteoporosis, minor trauma — such as sitting forcefully on a hard chair or toilet, or a gound-level fall — can cause bones in the spine to break, resulting in extreme back pain when moving.

Additional Causes. There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always present regardless of your activity level or position, you should consult your primary care doctor.

Symptoms

Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.

Most people find that reclining or lying down improves their low back pain, no matter the underlying cause.

People with low back pain often find their pain worsens when:

Bending and lifting
Sitting
Standing and walking

They may also experience:

Back pain that comes and goes, and often follows an up and down course, with good days and bad days.
Pain that extends from the back into the buttock or outer hip area, but not down the leg.
Sciatica. This includes buttock and leg pain, and even numbness, tingling, or weakness that extends down to the foot. Although sciatica is commonly associated with a herniated disk, it is possible to have sciatica without back pain.

Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor. Other red flag symptoms include weakness in your legs, and loss of bladder and bowel control.

Herniated Disk in the Lower Back

In many areas, nonessential orthopaedic procedures that were postponed due to COVID-19 have resumed. For information: Questions and Answers for Patients Regarding Elective Surgery and COVID-19. For patients whose procedures have not yet been rescheduled: What to Do If Your Orthopaedic Surgery Is Postponed.

A herniated disk is a condition that can occur anywhere along the spine, but most often occurs in the lower back. It is sometimes called a bulging, protruding, or ruptured disk. It is one of the most common causes of lower back pain, as well as leg pain or “sciatica.”

Between 60% and 80% of people will experience low back pain at some point their lives. Some of these people will have low back pain and leg pain caused by a herniated disk.

Although a herniated disk can be very painful, most people feel much better with just a few weeks or months of nonsurgical treatment.

Cause

A herniated disk is most often the result of natural, age-related wear and tear on the spine. This process is called disk degeneration.

In children and young adults, disks have high water content. As people age, the water content in the disks decreases and the disks become less flexible. The disks begin to shrink and the spaces between the vertebrae get narrower. This normal aging process makes the disks more prone to herniation.

A traumatic event, such as a fall, can also cause a herniated disk.

Risk Factors

Certain factors may increase your risk of a herniated disk. These include:

Gender. Men between the ages of 20 and 50 are most likely to have a herniated disk.
Improper lifting. Using your back muscles instead of your legs to lift heavy objects can cause a herniated disk. Twisting while you lift can also make your back vulnerable. Lifting with your legs, not your back, may protect your spine.
Weight. Being overweight puts added stress on the disks in your lower back.
Repetitive activities that strain your spine. Many jobs are physically demanding. Some require constant lifting, pulling, bending, or twisting. Using safe lifting and movement techniques can help protect your back.
Frequent driving. Staying seated for long periods, plus the vibration from the car engine, can put pressure on your spine and disks.
Sedentary lifestyle. Regular exercise is important in preventing many medical conditions, including a herniated disk.
Smoking. It is believed that smoking lessens the oxygen supply to the disk and causes more rapid degeneration.

Symptoms

In most cases, low back pain is the first symptom of a herniated disk. This pain may last for a few days, then improve. Other symptoms may include:

Sciatica. This is a sharp, often shooting pain that extends from the buttock down the back of one leg. It is caused by pressure on the spinal nerve.
Numbness or a tingling sensation in the leg and/or foot
Weakness in the leg and/or foot
Loss of bladder or bowel control. This is extremely rare and may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed. It requires immediate medical attention.

Cervical Radiculopathy (Pinched Nerve)

Cervical radiculopathy, commonly called a "pinched nerve," occurs when a nerve in the neck is compressed or irritated where it branches away from the spinal cord. This may cause pain that radiates into the shoulder and/or arm, as well as muscle weakness and numbness.

Cervical radiculopathy is often caused by "wear and tear" changes that occur in the spine as we age, such as arthritis. In younger people, it is most often caused by a sudden injury that results in a herniated disk. In some cases, however, there is no traumatic episode associated with the onset of symptoms.

In most cases, cervical radiculopathy responds well to conservative treatment that includes medication and physical therapy.

Cause

Cervical radiculopathy most often arises from degenerative changes that occur in the spine as we age or from an injury that causes a herniated, or bulging, intervertebral disk.

Degenerative changes. As the disks in the spine age, they lose height and begin to bulge. They also lose water content, begin to dry out, and become stiffer. This problem causes settling, or collapse, of the disk spaces and loss of disk space height.

As the disks lose height, the vertebrae move closer together. The body responds to the collapsed disk by forming more bone—called bone spurs—around the disk to strengthen it. These bone spurs contribute to the stiffening of the spine. They may also narrow the foramen—the small openings on each side of the spinal column where the nerve roots exit—and pinch the nerve root.

Degenerative changes in the disks are often called arthritis or spondylosis. These changes are normal and they occur in everyone. In fact, nearly half of all people middle-aged and older have worn disks and pinched nerves that do not cause painful symptoms. It is not known why some patients develop symptoms and others do not.

Herniated disk. A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive nerve root, causing pain and weakness in the area the nerve supplies.

A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Symptoms

In most cases, the pain of cervical radiculopathy starts at the neck and travels down the arm in the area served by the damaged nerve. This pain is usually described as burning or sharp. Certain neck movements—like extending or straining the neck or turning the head—may increase the pain. Other symptoms include:

Tingling or the feeling of "pins and needles" in the fingers or hand
Weakness in the muscles of the arm, shoulder, or hand
Loss of sensation
Some patients report that pain decreases when they place their hands on top of their head. This movement may temporarily relieve pressure on the nerve root.

Spondylolysis and Spondylolisthesis

Spondylolysis (spon-dee-low-lye-sis) and spondylolisthesis (spon-dee-low-lis-thee-sis) are common causes of low back pain in children and adolescents.

Spondylolysis is a weakness or stress fracture in one of the vertebrae, the small bones that make up the spinal column. This condition or weakness can occur in up to 5% of children as young as age 6 with no known injury. A stress fracture can occur in adolescents who participate in sports that involve repeated stress on the lower back, such as gymnastics, football, and weightlifting. In some cases, the stress fracture weakens the bone so much that it is unable to maintain its proper position in the spine — and the vertebra starts to shift or slip out of place. This condition is called spondylolisthesis.

Cause

Overuse. Both spondylolysis and spondylolisthesis are more likely to occur in young people who participate in sports that require frequent overstretching (hyperextension) of the lumbar spine — such as gymnastics, football, and weightlifting. Over time, this type of repetitive activity can weaken the pars interarticularis, leading to fracture and/or slippage of a vertebra.

Genetics. The lower lumbar spine has a risk of developing stress weakness at the location of a spondylolysis in all children, adolescents, and adults who walk upright. Doctors believe that some people may be born with vertebral bone that is thinner than normal — and this may make them more vulnerable to fractures.

Symptoms

In many cases, patients with spondylolysis and spondylolisthesis do not have any obvious symptoms. The conditions may not even be discovered until an X-ray is taken for an unrelated injury or condition.

When symptoms do occur, the most common symptom is lower back pain. This pain may:
Feel similar to a muscle strain
Radiate to the buttocks and back of the thighs
Worsen with activity and improve with rest
In patients with spondylolisthesis, muscle spasms may lead to additional signs and symptoms, including:
Back stiffness
Tight hamstrings (the muscles in the back of the thigh)
Difficulty standing and walking

Spondylolisthesis patients who have severe or high-grade slips may have tingling, numbness, or weakness in one or both legs. These symptoms result from pressure on the spinal nerve root as it exits the spinal canal near the fracture.

Epidural Steroid Injection Treatment

Epidural steroid injections (ESIs) are a common treatment option for many forms of lower back pain and leg pain. They have been used for decades and are considered an integral part of the nonsurgical management of sciatica and lower back pain.

The injection is named an epidural steroid injection because it involves injecting a local anesthetic and a steroid medication directly into the epidural space that surrounds the spinal cord and nerve roots.

The goals of an epidural steroid injection are to:

Control pain by reducing inflammation in and around the nerve roots
Improve mobility and function in the lower back and legs1
Allow the patient to participate in and make progress with a comprehensive physical therapy and rehabilitation program
In the course of one’s care program, in most cases, an epidural steroid injection may be recommended after a series of nonsurgical treatments, such as medications and physical therapy,2 have been tried, and before surgery is considered.
The role of the injection is typically to provide sufficient pain relief to allow a return to everyday activities and to make progress in physical therapy.

Benefits

Most practitioners will agree that an epidural injection can be beneficial during an acute episode of back and/or leg pain. The main drawbacks of the injections are that they are not always effective, and when effective, the pain relief tends to be temporary, ranging from one week to one year. Typically, if the initial injection is effective, up to 3 injections may be given in one year.

When administered in the lumbar epidural space, steroid injections may have the following benefits:

Reduce nerve pain and inflammation. Steroids decrease the production of inflammatory chemicals and reduce the sensitivity of nerve fibers to pain, generating fewer pain signals.
Limit oral medication. Pain relief from these injections may help limit or eliminate the need for oral medications,4 some of which may have side effects when taken long-term.
Continue or re-engage in physical therapy. This injection may provide sufficient pain relief to allow a patient to progress with a rehabilitative physical therapy program.1
Postpone surgery. Pain relief experienced from lumbar epidural steroid injections may help postpone surgery, and if physical therapy is effective, it may eliminate the need for surgical intervention.

Effectiveness

Available research indicates generally favorable results, with 70% to 90% of patients experiencing pain relief from these injections, lasting for a week to a year. If a good first response is seen, a second injection may be considered when the improvement from the first injection begins to taper off. Typically, up to 3 injections may be given over a 12-month period.

Uses

Lumbar epidural injections are typically used in the treatment of conditions that cause irritation and/or inflammation of spinal nerve roots with associated lower back and leg pain. Most common lower back conditions treated include:

Lumbar Herniated disc(s)
Lumbar Degenerative disc disease
Lumbar Spinal stenosis

Less commonly, localized back pain (axial back pain) and neurogenic claudication (back pain and leg pain that occurs while walking) may be treated with these injections.

Nerve Block Treatment

A selective nerve root block (SNRB) injection or just nerve block injection is used to both diagnose and treat an inflamed spinal nerve. A medication, typically, an anesthetic or anesthetic with steroid is administered near the spinal nerve as it exits the intervertebral foramen (bony opening between adjacent vertebrae). The medication reduces inflammation and numbs the pain transmitted by the nerve.

How Selective Nerve Root Block Injections Work

When used for treatment purposes, steroids are usually mixed with anesthetics or used alone in selective nerve root block injections. Steroids in nerve blocks work by a combination of the following mechanisms:

Inhibits the action of certain enzymes such as phospholipase A that causes neural irritation and pain
Block specific fibers (C fibers) within the nerve that results in lesser pain transmitted to the brain
Decreases the permeability of nerve fibers to receive blood, decreasing pain transmission
Through these mechanisms, the pain signals transmitted by the target nerve may be reduced.
Before administering the injection, the skin over the treatment site is cleaned to prevent infection. Usually, a small amount of contrast dye is injected first in order to identify if the needle is in the proper location near the target nerve and to avoid injecting into a blood vessel

Due to anatomic variations in every patient, fluoroscopy or ultrasound guidance is almost always used to locate the nerve. The injection may recreate the usual pain that has been experienced by the patient.

Success Rates

Studies evaluating the success of selective nerve root block injections have reported the following:

In the cervical spine, 1 injection resulted in 57% of patients reporting significant improvement in pain and functional outcome at 6 months.
In the lumbar spine, 1 injection resulted in 46% of patients reporting significant improvement in pain and functional outcome at 1 year.

Some patients, however, may experience no pain relief or short-term relief for a few weeks. The therapeutic effect can sometimes be delayed by a few days or weeks as the steroid becomes more effective. The pain-relieving effects of selective nerve root block injections are usually higher in patients who participate in strengthening exercises and physical therapy. It is advised to restart therapies according to the physician’s instructions once pain reduction occurs.

Uses

Selective nerve root block injections are used to treat an inflamed nerve root caused by a herniated disc, degenerative changes in the vertebrae such as bone spurs causing nerve compression, and/or conditions such as scoliosis. In any of these conditions, there may be a chemical irritation or pinching of the nerve due to mechanical compression.

Multiple nerve blocks may be performed if more than one nerve is suspected of causing pain.

Risks and Complications

Although rare, a few risks are possible with selective nerve root block injections, including:

Infection
Bleeding
Allergic reactions
Spinal cord damage
Pneumothorax (or collapsed lung with thoracic injections)

Some patients may also experience temporary muscle weakness after a nerve block. This weakness occurs if the medication flows to the motor fibers of the nerves, numbing them. The weakness typically resolves in a few hours and is not harmful.

Platelet-Rich Plasma Therapy Treatment

Platelet-rich plasma therapy, sometimes called PRP therapy or autologous conditioned plasma (ACP) therapy, attempts to take advantage of the blood's natural healing properties to repair damaged cartilage, tendons, ligaments, muscles, or even bone.

When treating osteoarthritis with platelet-rich plasma, PRP is injected directly into the affected joint. The goal is to:

Reduce pain
Improve joint function
Possibly slow, halt, or even repair damage to cartilage

Platelet-rich plasma is derived from a sample of the patient's own blood. The therapeutic injections contain plasma with a higher concentration of platelets than is found in normal blood.

What is plasma?

Plasma refers to the liquid component of blood; it is the medium for red and white blood cells and other material traveling in the blood stream. Plasma is mostly water but also includes proteins, nutrients, glucose, and antibodies, among other components.

What are platelets?

Like red and white blood cells, platelets are a normal component of blood. Platelets alone do not have any restorative or healing properties; rather, they secrete substances called growth factors and other proteins that regulate cell division, stimulate tissue regeneration, and promote healing. Platelets also help the blood to clot; a person with defective platelets or too few platelets will bleed excessively from a cut.

Minimally Invasive Spine Surgery

Spine surgery is traditionally done as "open surgery." This means that the area being operated on is opened with a long incision to allow the surgeon to view and access the anatomy. In recent years, however, technological advances have allowed more back and neck conditions to be treated with a minimally invasive surgical technique.

Because minimally invasive spine surgery (MISS), does not involve a long incision, it avoids significant damage to the muscles surrounding the spine. Typically, this results in less pain after surgery and a faster recovery.

The indications for minimally invasive spine surgery are the same as those for traditional open surgery. Spine surgery is usually recommended only when a period of nonsurgical treatment — such as medications and physical therapy — has not relieved the painful symptoms caused by your back problem. In addition, surgery is only considered if your doctor can pinpoint the exact source of your pain, such as a herniated disk or spinal stenosis.

There are numerous minimally invasive techniques. The common thread between all of them is that they use smaller incisions and cause less muscle damage. Minimally invasive techniques can be used for common procedures like lumbar decompression and spinal fusion. Decompression relieves pressure on spinal nerves by removing portions of bone or a herniated disk. Spinal fusion corrects problems with the small bones of the spine (vertebrae). The basic idea is to fuse together the painful vertebrae so that they heal into a single solid bone. This article focuses on decompression and spinal fusion with a minimally invasive technique.

Description

Minimally invasive spine surgery (MISS) is sometimes called less invasive spine surgery. In these procedures, doctors use specialized instruments to access the spine through small incisions.

In a traditional open surgery, the doctor makes an incision that is 5 to 6 inches long, then moves the muscles to the side in order to see the spine. With the muscles pulled to the side, the surgeon can access the spine to remove diseased and damaged bone or intervertebral disks. The surgeon can also easily see to place screws, cages, and any bone graft materials necessary to stabilize the spinal bones and promote healing.

One of the major drawbacks of open surgery is that the pulling or "retraction" of the muscle can damage both the muscle and the surrounding soft tissue. Although the goal of muscle retraction is to help the surgeon see the problem area, it typically affects more anatomy than the surgeon requires. As a result, there is greater potential for muscle injury, and patients may have pain after surgery that is different from the back pain felt before surgery. This can lead to a lengthier recovery period. The larger incision and damage to soft tissues may also increase both blood loss and the risk for infection.

Minimally invasive spine surgery was developed to treat spine problems with less injury to the muscles and other normal structures in the spine. It also helps the surgeon to see only the location where the problem exists in the spine. Other advantages of MISS include smaller incisions, less bleeding, and shorter stays in the hospital.

Procedure

MISS fusions and decompression procedures (such as diskectomy and laminectomy) are performed using many different approaches. The most commonly used technique involves using a tubular retractor. During the procedure, a small incision is made and the tubular retractor is inserted through the skin and soft tissues down to the spinal column. This creates a tunnel to the small area where the problem exists in the spine. The tubular retractor holds the muscles open (rather than cutting them) and is kept in place throughout the procedure.

The surgeon accesses the spine using small instruments that fit through the center of the tubular retractor. Any bone or disk material that is removed exits through the retractor, and any devices necessary for fusion — such as screws or rods — are inserted through the retractor. Some surgeries require more than one retractor or more than one incision.

In order to see where to place the incision and insert the retractor, the surgeon is guided by fluoroscopy. This method displays real-time x-ray images of the patient's spine on a screen throughout the surgery. The surgeon typically views the important structures of the spine during surgery using a microscope.

At the end of the procedure, the tubular retractor is removed and the muscles return to their original position. This limits the muscle damage that is more commonly seen in open surgeries.

New techniques for minimally invasive spine surgery continue to evolve. For example, some surgeons are now using an endoscope (a small camera similar to that used in knee and shoulder surgery) to access the problem area in the spine.

The most common types of anesthesia used for MISS are general (you are asleep for the entire operation) and regional (you may be awake, but you will have no feeling from your waist down).

Common Minimally Invasive Spine Surgeries

MIS Lumbar Diskectomy

A herniated disk in the lower back that pinches a nerve may cause severe leg pain, numbness, or weakness.

To surgically relieve these symptoms the disk is removed. This procedure is called a diskectomy.

For the surgery, the patient is positioned face-down and a small incision is made over the location of the herniated disk. The surgeon inserts the retractor and removes a small amount of the lamina bone. This provides the surgeon with a view of the spinal nerve and the disk. The surgeon carefully retracts the nerve and removes only the damaged disk.

This minimally invasive technique can also be used for herniated disks in the neck. The procedure is done through the back of the neck and is called an MIS posterior cervical foraminotomy/diskectomy.

MIS Lumbar Fusion

A standard open lumbar fusion may be performed from the back, through the abdomen, or from the side. Minimally invasive lumbar fusions can be done the same way.

A common MISS fusion is the transforaminal lumbar interbody fusion (TLIF) Using this technique, the surgeon approaches the spine a little bit from the side, which reduces how much of the spinal nerve must be moved.

Sometimes the surgeon will use additional bone graft besides the patient's own bone to improve the likelihood of healing.

Minimally invasive spinal fusion is also commonly performed from the side. Two procedures that use a side approach are extreme lateral interbody fusion (XLIF) and direct lateral interbody fusion (DLIF). The benefit of these lateral fusion surgeries is that they do not injure the muscles in the back and they do not tug or pull on the nerves in the spinal canal.

A newer variation of this technique is used in an oblique lateral interbody fusion (OLIF). Like XLIF and DLIF, the incision for OLIF is made on the side. Instead of using a direct lateral approach to the spine, however, OLIF approaches the spine obliquely, sparing the psoas muscle (the muscle on the side of the spine). The outcomes of these three lateral approaches are similar.

Complications

As with any operation, there are potential risks associated with MISS. The complications of MISS are similar to those of open spinal fusion surgeries; however, some studies show a reduced infection rate for MISS. Before your surgery, your doctor will discuss each of the risks with you and will take specific measures to help avoid potential complications. The potential complications of MISS include:

Infection. Antibiotics are given to the patient before, during, and often after surgery to lessen the risk of infections.
Bleeding. A certain amount of bleeding is expected, but this is not typically significant.
Pain at graft site. A small percentage of patients will experience persistent pain at the bone graft site.
Recurring symptoms. Some patients may experience a recurrence of their original symptoms.
Pseudarthrosis This is a condition in which there is not enough bone formation and a spinal fusion does not completely heal. If this occurs, a second surgery may be needed in order to obtain a solid fusion. Patients who smoke are more likely to develop a pseudarthrosis.
Nerve damage. It is possible that the nerves or blood vessels may be injured during these operations. These complications are very rare.
Blood clots. Formation of blood clots in the legs is another uncommon complication after surgery. They pose a significant danger if they break off and travel to the lungs.

Recovery

Minimally invasive procedures can shorten hospital stays. The exact length of time needed in the hospital will vary with from patient to patient and with the individual procedure but, in general, MISS patients go home on the same day or in 1 to 2 days. Most patients having traditional surgery stay in the hospital for 3 to 5 days.

Because minimally invasive techniques do not disrupt muscles and soft tissues, it is believed that postoperative pain is less than pain after traditional open procedures. Although you should still expect to feel some discomfort, advancements in pain control now make it easier for your doctor to manage and relieve your pain.

To help you regain strength and speed your recovery, your doctor may recommend physical therapy. This will depend on the procedure and your general physical condition. Specific exercises will help you become strong enough to return to work and daily activities.

If you have had a fusion procedure, it may be several months before the bone is solid. Your comfort level, however, will often improve much faster. During this healing time, the fused spine must be kept in proper alignment. You will be taught how to move properly, reposition, sit, stand, and walk.

The time it takes to return to your daily activities after MISS depends upon your individual procedure and condition. Your doctor will evaluate you after your surgery to make sure that your recovery is progressing as expected.

Cervical Spondylotic Myelopathy Surgery

When symptoms of cervical spondylotic myelopathy (CSM) persist or worsen despite nonsurgical treatment, your doctor may recommend surgery.

The goal of surgery is to relieve symptoms by "decompressing," or relieving pressure on, the spinal cord. This involves removing the pieces of bone or soft tissue (such as a herniated disk) that may be taking up space in the spinal canal. This relieves pressure by creating more space for the spinal cord.

Candidates for Surgery

Candidates for surgery include patients who have progressive neurologic changes with signs of severe spinal cord compression or spinal cord swelling. These neurologic changes may include:

Weakness in the arms or legs
Numbness in the hands
Fine motor skill difficulties
Imbalance issues
Gait changes

Patients with severe or disabling pain may also be helped with surgery.

Patients who experience better outcomes from cervical spine surgery often have these characteristics:

Younger age
Shorter duration of symptoms
Single, rather than multiple, areas of spinal cord involvement
A larger area available for the spinal cord

Surgical Procedures

The four surgical procedures commonly performed to treat CSM are:

Anterior Cervical Diskectomy and Fusion
Anterior Cervical Corpectomy and Fusion
Laminectomy
Laminoplasty

The procedure your doctor recommends will depend on a number of factors, including your overall health and the type and location of your problem.

Depending on the procedure, surgery for CSM is performed either from the front of the neck (anterior) or the back (posterior). In some cases, both anterior and posterior approaches may be necessary to address spinal cord compression and instability. Each approach has advantages and disadvantages, as shown in the table below. Your doctor will talk with you about which approach is best in your case and about the risks and benefits of surgery.

Spinal Fusion

Whether an anterior or posterior approach is used, procedures for CSM often include spinal fusion to help stabilize the spine. Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the vertebrae so that they heal into a single, solid bone.

Fusion eliminates motion between the degenerated vertebrae and takes away some spinal flexibility. The theory is that if the painful spine segments do not move, they should not hurt. The degree of limitation that you experience will depend upon how many spine segments or "levels" of your spine were fused.

All spinal fusions use some type of bone material, called a bone graft, to help promote the fusion. The small pieces of bone are placed where disk or bone has been removed. Sometimes larger, solid pieces are used to provide immediate structural support to the vertebrae.

In some cases, the doctor may implant a spacer or synthetic "cage" between the two adjoining vertebrae. This cage usually contains bone graft material to allow a spinal fusion to occur between the two vertebrae.

After the bone graft is placed or the cage is inserted, your doctor will use metal screws, plates, and rods to increase the rate of fusion and further stabilize the spine.

Bone graft sources. Bone graft material is used to fill in the space left after a disk is removed. It is also placed along the sides of the vertebrae to assist the fusion. A bone graft is primarily used to stimulate bone healing. It increases bone production and helps the vertebrae heal together into a solid bone.

The bone graft will come from either your own bone (autograft) or from a donor (allograft). If an autograft is used, the bone is usually taken from your hip area. Harvesting a bone graft requires an additional incision during your surgery. It lengthens surgical time and may cause increased pain after the operation. Your doctor will talk to you about the advantages and disadvantages of using an autograft versus an allograft.

Anterior Approach

An "anterior" approach means that the doctor will approach your neck from the front. He or she will operate through a 1- to 2-inch incision along the neck crease. The exact location and length of your incision may vary depending on your specific condition.

Anterior cervical diskectomy and fusion. During this procedure, your doctor will remove the problematic disk and any additional bone spurs, if necessary, and then stabilize the spine through spinal fusion. Typically, a plate with screws is added to the front of the spine for added stability.

An anterior cervical diskectomy and fusion from the side (left) and front (right). Plates and screws are used to provide stability and increase the rate of fusion.

Anterior cervical corpectomy and fusion. This procedure is similar to diskectomy, except that, rather than a disk, a vertebra (bone) is removed. As in diskectomy, the spine is then stabilized through spinal fusion.

In some cases, both disk and bone may be pressing on the spinal cord. In this situation, your doctor may perform a combination of diskectomy and corpectomy.

Posterior Approach

A "posterior" approach means that the doctor will approach your neck from the back. He or she will make an incision along the midline of the back of the neck. Posterior approaches for decompression include laminectomy and laminoplasty. These procedures are often also accompanied by spinal fusion.

Laminectomy.

In this procedure, the doctor removes the bony arch that forms the backside of the spinal canal (lamina), along with any bone spurs and ligaments that are compressing the spinal cord. Laminectomy relieves pressure on the spinal cord by providing extra space for it to drift backward.

While laminectomy ensures complete decompression of the spinal cord, the procedure makes the bones less stable. For this reason, patients who undergo laminectomy frequently require spinal fusion with a bone graft and possibly screws and rods.

Posterior laminectomy is often recommended for people who have very small spinal canals, enlarged or swollen soft tissues at the back of the spine, or problems in more than four spine segments (levels). In a patient with a kyphotic (bent forward) spine, the spinal cord will not float or shift backward—so the doctor will often use a combined posterior and anterior approach to ensure the best outcome.

Laminoplasty

In this alternative to laminectomy, instead of removing the bone, the lamina is thinned out on one side and then cut on the other side to create a "hinge"--much like a door. Using the hinge to open this bony area expands the space available for the spinal cord. It also allows the doctor to address adjacent spine segments, or levels, that may be mildly compressed.

Laminoplasty preserves from 30 to 50 percent of motion at the involved levels of the spine. This is a greater percentage than either laminectomy or anterior surgery. Since neck pain is often related to motion—and some motion still remains after the procedure—laminoplasty is not usually used to treat patients with neck pain.

While laminoplasty increases the space available, the procedure does not ensure that the spinal canal will be completely open for the spinal cord. Another disadvantage is that, in some cases, the lamina that is hinged can inadvertently close.

General Risks

The potential risks and complications for any cervical spine surgery include:

Infection
Bleeding
Nerve injury
Spinal cord injury
Reaction to anesthesia
The need for additional surgery in the future
Failure to relieve symptoms
Tear of the sac covering the nerves (dural tear)
Life-threatening medical problems, such as heart attack, lung complications, or stroke

Recovery

After surgery, you will typically stay in the hospital for 1 or 2 days. This will vary, however, depending on the type of surgery you have had and how many disk levels were involved. Most patients are able to walk and eat on the first day after surgery.

Depending on the procedure you have had, a drain may be placed in your spine to collect any fluid or blood that may remain after surgery.

It is normal to have difficulty swallowing solid foods for a few weeks or have some hoarseness following anterior cervical spine surgery. For this reason, your doctor may prescribe antacids or recommend that your diet include softer foods--such as soup or milkshakes-in the early postoperative period.

You may need to wear a soft or a rigid collar at first. How long you should wear it will depend on the type of surgery you have had.

New Symptoms

Depending on the extent of your surgery and the number of spine levels fused, you may notice some neck stiffness or loss of motion after your procedure. Also, as nerves begin to awaken following surgery, you may experience different nerve symptoms or feelings than you had before. This is normal and will often continue to improve for 1 to 2 years after surgery.

If your nerve symptoms and pain get progressively worse, or if you have any problems with infection or wound healing, contact your doctor.

Physical Therapy

Usually by 4 to 6 weeks, you can gradually begin to do range-of-motion and strengthening exercises. Your doctor may prescribe physical therapy during the recovery period to help you regain full function.

Return to Work

Most people are able to return to a desk job within a few days to a few weeks after surgery. They may be able to return to full activities by 3 to 4 months, depending on the procedure. For some people, healing may take longer.

Outcomes

Regardless of the approach used, the desired outcome of surgery is to stabilize the spine and prevent neurologic problems from worsening. A secondary goal is to potentially improve neck pain—as well as the motor, sensory, and other neurological symptoms that may be present. The goal of surgery is not necessarily to restore normal function.

Outcomes will vary from patient to patient. Typically, with respect to pre-surgical symptoms, one-third of patients improve, one-third stay the same, and one-third continue to worsen over time. In most cases, the symptoms a patient is experiencing before surgery will be similar to those that he or she will have following surgical intervention. Your doctor will discuss this with you and provide information on the likelihood of improvement in your specific situation.