Treatment and surgeries

A. Spondylosis:

Degenerative Disc Disease (DDD) or Spondylosis refers to the gradual deterioration of the disc between the vertebrae in the backbone. This disease is very common and affects as much as 40–50% of people over the age of 40. The disorder also becomes increasingly common as we age. It is a disease of wear and tear similar to osteoarthritis. It commonly happens in the lumbar spine (lower back), though it can occur at any spinal level.

In DDD, the discs get flattened, losing their normal height. This disc height is what separates the disc above from the one below. Nerve pathways may become narrowed and cause nerve impingement, inflammation, and pain when the disc height is lost.

Degenerated discs become much thinner, and sometimes the vertebrae also develop small, rough areas that irritate the nearby nerves. Severe neck pain, stiffness, and pain down the arms and hands can result from this.

• Medication and exercises are the first line of management.
• Cervical spondylosis is a very common condition where there is chronic degeneration of the bones of the neck (cervical spine) and the cushions between the vertebrae (intervertebral disc). This is managed by cervical spine surgery where the worn-out discs or bone spurs are removed—depending on the underlying problem. Sometimes the gap would be filled by a graft of bone or other implants made of metal combined with bone.
• Symptoms of spondylosis may be as mild as occasional backaches or could be chronic low back pain that is severe enough to limit daily activities. The mechanical type of pain increases as more stress or load is placed on the lower back. Bending, lifting, and twisting are the types of movement that may exacerbate it.

• Degenerative Disc Disease requires surgery only rarely. The commonly used non-surgical treatments include anti-inflammatory drugs, physiotherapy, and exercise programs. Surgery is required when the patient has very severe debilitating symptoms, pain interferes with activities of daily living, and non-surgical treatment has failed after a reasonable period of time, usually at least six months.
• Fusion surgery is usually done, and this permanently stops the motion of the spine at the level of the degenerated disc. This helps to relieve pain. Fusion surgery works best when limited to one or two discs. As we have five discs in the lumbar spine, the un-fused discs take over to provide adequate function of the lower back.
• Sometimes an artificial disc can also be inserted into the disc space after removing the entire degenerated disc. This helps to restore disc height, improve spine function, and ease the debilitating pain.

B. Slipped Disc:

Slipped disc is a common term used to refer to a prolapsed disc. This is a disorder where the inner, softer part of the disc bulges out through a weakness in the outer part of the disc. The bulging disc may then press on nearby nerves and cause discomfort and pain. Back pain, ache in the arm or leg, and pinpricks felt in feet, toes, and hands are the usual symptoms.

• Surgery is considered for disc prolapse if the symptoms of the bulging disc have not settled after about six weeks or so. One may opt for:
• Keyhole surgery or microdiscectomy spine surgery, which is typically performed when there is a prolapsed disc in the lumbar (lower back) region pressing against a nerve.
• Sometimes an artificial disc can also be inserted into the disc space after removing the entire degenerated disc. This helps to restore disc height, improve spine function, and ease the debilitating pain.
• Disc replacement – Here, an artificial disc is implanted into the spine to imitate the functions of a normal disc (carry load and allow motion). Artificial discs are usually made of metal or plastic-like (biopolymer) materials, or a combination of the two. The treatment for bulging disc and prolapsed disc is disc replacement done in the cervical (neck) spine.

C. Spondylolisthesis

The Greek term for slipping of the spine is Spondylolisthesis. This refers to the abnormal forward movement of one vertebra over the one below. It is in the lumbar spine that this forward slip of the vertebra happens most often. Pressure on the nerve roots associated with the affected vertebrae, as well as pain and dysfunction, are caused by the slippage and herniation of the disc.

Types of Spondylolisthesis include:

Type 1 – Congenital Spondylolisthesis:-This is a condition where a person is born with the abnormality of the posterior bony arch of the spine, which causes the slippage. It happens at the L5-S1 level commonly and is associated with abnormality of the facet joints. Symptoms include back pain during the adolescent growth spurt. CT and MRI scans are required to diagnose the dysplasia (abnormal bone formation).

Type 2 – Isthmic Spondylolisthesis:-This is a defect in a part of the bone called the pars interarticularis. This bone connects the upper joint of one vertebra to the lower joint. Stress fracture in individuals with a hereditary predisposition (some minor abnormality or weakness of the pars at birth) usually causes this. Sometimes a defect may exist without any forward slip, and this is called spondylolysis. This can also be painful.

Type 3 – Degenerative Spondylolisthesis:- Forward slippage secondary to arthritis of the spine is known as Degenerative Spondylolisthesis. This process is usually also associated with spinal stenosis. Long-standing degenerative disc disease, leading to weak facet joints in the back of the spine, is the reason. This is usually seen at the L4-L5 level. This is also called Lumbar Spondylolisthesis.

• For all the above conditions, surgery is indicated if the slippage progressively worsens or if back pain does not respond to non-surgical treatment and begins to interfere with daily life. In the congenital and high dysplastic group, spondylolisthesis surgery is done at early stages to prevent neurological complications.

• Abnormal curvatures of the spine are referred to as scoliosis and kyphosis. In the normal spine, there are normal curves if seen from the side, but the spine is seen as a straight column from the front. In scoliosis, the spine shows curvatures from the front. In kyphosis, there is abnormal forward bending of the spine.
• Scoliosis is a Greek word meaning curvature. Ancient physicians thought poor posture was the primary cause of scoliosis. Today it is clear that scoliosis is either congenital (present at birth) or developmental and may be hereditary. The spine curves to the side in the shape of an “S” or “C”. The curvature is measured in degrees.
• Types Of Scoliosis:- Scoliosis is classified according to the affected age groups:

Infantile scoliosis: birth to 3 years

Juvenile scoliosis: 3 to 9 years

Adolescent scoliosis: 10 to 18 years

Also classified by direction:

• Dextroscoliosis (curve to the right – common in thoracic spine)
• Levoscoliosis (curve to the left – common in lumbar spine; rare in thoracic spine)

Classified by location:

• Thoracic scoliosis: middle spine (most common)
• Lumbar scoliosis: lower spine
• Thoracolumbar scoliosis: affects both lower thoracic and upper lumbar spine

A spinal curve to the left is called Levoscoliosis (“levo” = left). This is quite common in the lumbar spine, but when this rarely occurs in the thoracic spine it indicates a higher probability that the scoliosis may be secondary to a spinal cord tumor.

Scoliosis may also be classified according to location. Thoracic scoliosis is curvature in the middle (thoracic) part of the spine. This is the most common location for spinal curvature. Lumbar scoliosis is curvature in the lower (lumbar) portion of the spine. A curvature that includes vertebrae in both the lower thoracic portion and the upper lumbar portion of the spine is called a Thoracolumbar scoliosis.

Adolescent Idiopathic Scoliosis is yet another condition that starts around the onset of puberty in otherwise healthy boys and girls. It is more common in girls. Physical signs may include uneven shoulders, one hip lower than the other, a rib hump when bent over at the waist and leaning to one side.

Symptoms:-The obvious symptom of scoliosis is an abnormal curve of the spine. In some cases, the head may appear off center or one hip or shoulder may seem higher than the opposite side. In severe scoliosis the heart and lungs may dysfunction leading to breathlessness and chest pain. Back pain, rib pain, and abdominal pain are the other symptoms.

• Medication, physiotherapy, exercise to stabilize the spine and relieve pain.

• For severe curvature, spinal fusion and instrumentation are done to center the head and trunk over the pelvis.
• Staples on the convex side for differential growth.
• Shape Memory Alloy (SMA) staples made of Nitinol used for fixation without fusion, allowing growth and deformity correction.

D. Spinal Tumors

Any tumor on the spine, cancerous or not, can compress nerves, causing pain, weakness, or paralysis. Symptoms: sensory loss, weakness in legs, falls, bowel/bladder issues.

They are classified according to their location, as follows:

• Extradural: outside the dura mater (most common)
• Intradural: part of dura mater
• Intramedullary: inside spinal cord
• Extramedullary: inside dura but outside cord

PP Maniya Hospital uses high-powered microscopes to treat even delicate intradural tumors. Total spondylectomy (removal of entire vertebra) is done for some tumors.

E. Spinal Injuries

Caused by trauma, tumors, or infection. May result in complete or incomplete loss of function below the injury.

Treatment Surgical stabilization using rods, screws, and plates. Followed by thorough rehabilitation including physical/occupational therapy and assistive devices to maximize function.

F. Prevention of Spine Disc Prolapse:-

• Healthy lifestyle: Improve physical condition and practice body mechanics.
• Exercise: Regular low-impact aerobics like walking, swimming
• Build core strength and flexibility
• Quit smoking
• Maintain healthy weight
• Use proper body mechanics
  • Stand smart: Maintain neutral pelvic position
  • Sit smart: Use a chair with lumbar support, armrests, swivel base