What you need to know about your back pain

Transcription

1 What you need to know about your back pain

2 Table of Contents INTRODUCTION Understanding Your Back and Spine Pain: Why You Hurt and How We Can Help 1 CHAPTER 1: The Anatomy and Structure of Your Back 2 Spinal Column Disc Spinal Canal 2 Spinal Cord Peripheral Nerves Epidural Space Facet Joints Sacrum 3 Abnormal Anatomy 4 Herniated Discs Degenerative Disc Disease 4 Spinal Stenosis Facet Arthropathy Sacroiliac Dysfunction/Sacroiliitis 5 CHAPTER 2: Diagnostic Imaging: Pinpointing the Source of Your Back Pain 6 Basic Spine X-rays: Computed Tomography (CT) 6 Magnetic Resonance Imaging (MRI) Other Imaging Techniques 7 CHAPTER 3: Conservative Therapies: The Starting Point for Treating Your Pain 8 Physical Therapy 8 Chiropractic Care Acupuncture 10 CHAPTER 4: Interventional Pain Procedures: The Next Step in Treating Your Pain 11 Diagnostic Procedures 11 Therapeutic Procedures 12 CHAPTER 5: Surgical Options and Lifestyle Changes 15 Options for Spine Surgery 16 Preparing for Surgery, Ensuring a Successful Outcome 17 CHAPTER 6: Understanding and Managing Your Medications 22 NSAIDs (Non-steroidal anti-inflammatory drugs) 22 Muscle Relaxants Neuropathic Medications 23 Opioid Medications 24 This booklet was written by the physicians at SpineCARE.

3 Introduction Understanding Your Back and Spine Pain: Why You Hurt and How We Can Help Back and spine pain is debilitating. Its impact is real and constant. And, it can have devastating effects on the quality of your life. At SpineCARE, we ve developed a deep understanding of back and spine pain by caring for and treating thousands of patients. If you are experiencing chronic back or spine pain, whether from injury, disease or previous treatment, we can provide the optimum solution and relief. Our goal is to reduce or eliminate your pain through targeted diagnosis and treatment. Our team of experienced specialists begins with the most conservative treatment approach, which often means therapy rather than surgery. Pain management and relief is a journey. We travel it together with our patients until we reach the desired destination and best outcome. We have prepared this booklet to help you understand why your back or spine is hurting and what options we can provide to help you regain your highest level of functioning and well-being. We ve also included basic information on the anatomy of your back and spine. We encourage you to take an active role in your journey to a more pain-free life. Asking questions and exploring options will help us develop a personalized treatment plan that is best for you. 1

4 Chapter 1: The Anatomy and Structure of Your Back Before we can discuss the causes, diagnosis, and treatment of back pain, it is important to understand the basic structure of the back. The back is comprised of a variety of tissues, including bones, muscles, joints, discs and nerves. All these parts work together to keep us upright, balanced and active. Spinal Column The spine forms the axis of our body. It is a bony structure that starts at the base of the skull and runs all the way down to the tailbone. The spine is comprised of individual bones called vertebra (see figure 1) that are stacked on top of each other to form a column, generally known as the spinal column (see figure 2). The spinal column tapers off and ends with the tailbone or coccyx. The vertebrae are named based on their location in the spinal column. There are seven vertebral bones in the neck called cervical vertebrae, 12 vertebral bones in the mid-back called thoracic vertebrae and five vertebral bones in the lower back called lumbar vertebrae. The vertebrae are connected by ligaments, which are bands of collagen fibers that connect bone to bone. Ligaments act to reinforce and stabilize the spinal column while allowing limited mobility. Nerve Root Vertebral Body Figure 1 Vertebral bone Spinal Canal Spinal Cord Cervical Spine Lumbar Spine ( ( Thoracic Spine Sacrum Figure 2 Spinal column schematic: neck to sacrum ( ( Disc Each vertebra is separated from the one below it by fibrous tissue called a disc (see figure 3). Discs space out the vertebral bones, allow movement of the spinal column, and act as shock absorbers during activity. The discs are comprised of an outer and an inner layer. The outer layer is made up of fibrous tissue and cartilage and surrounds an inner gelatinous layer. The fibrous tissue distributes pressure evenly across the disc while the gelatinous layer cushions external forces. Spinal Canal Stacking the vertebral bones on top of each other results in the formation of a tube inside the spinal column (see figure 1). This empty cylindrical space, called the spinal canal, contains and protects the spinal cord and its supporting structures. 2

5 Nerve Root Spinal Cord Vertebrae The spinal cord is a collection of nerve tissue that connects the brain to the rest of the body. All the nerves in our body originate from the spinal Discs cord. In turn, the spinal cord sends information to and from the brain about the body. The spinal cord is covered by three different layers of tissue and bathed in a special liquid called the cerebrospinal fluid. (See figure 5). The spinal cord, in turn, gives rise to nerves that travel Sacrum all over the body. These nerves split off from the spinal cord and leave the spinal canal through holes called vertebral foramen. The origin of each nerve from the spinal cord is named the nerve root (see figure 3). Figure 3 Spinal column and Peripheral Nerves sacrum lateral (side) view Nerves exit on either side of the spinal column and travel throughout the body, including down the arms, hands, legs and feet. Once the nerves leave the spinal column they are renamed peripheral nerves. These nerves are responsible for the sensation and motion of our body. Epidural Space The epidural space is the area between the outermost layer of the spinal cord and the inside bony surface of the spinal canal. The epidural space contains nerves branching off the spinal cord, blood vessels and fatty tissue. This is a common site for interventions aimed at treating back pain. Spinal Cord Nerve Root Facet Joints Facet Joints Facet joints are the joints that form between the vertebral bones when they are stacked on top of each other to construct the spinal column (see figure 4). They are located on the outer left and right side of the spinal column all along the spine. These joints allow flexion, extension and rotation of the spine. They also stabilize the spine and limit certain types of movements. Sacroiliac Joints Figure 4 Spinal column and sacrum posterior (back)) view Sacrum The sacrum (see figure 2) forms the base of the spinal column and ends with the tailbone. It is a triangular structure comprised of five vertebrae that are fused together (unlike the vertebrae that make up the rest of the spinal column). The sacrum sits wedged between the right and left hipbones. The joints formed by the sacrum and the hipbones are known as the right and left sacroiliac joints (see figure 4). 3

6 Abnormal Anatomy Now that we have an idea of the normal anatomy of the back, we can touch on abnormalities that can be the source of back pain. It is important to remember that these abnormalities can occur at any level of the spine and cause symptoms anywhere from the neck downward. Herniated Discs The fibrous tissue between the vertebrae can slip, bulge or rupture with or without an obvious injury. As the disc comes out of place, it spills into the spinal canal and may press on the nerves or even the spinal cord. This may result in pain, numbness and weakness at the source of the problem and along the path the nerves take once they leave the spinal column. This is the reason that back problems may also lead to pain and weakness of the arms or legs. (See figure 5). Degenerative Disc Disease As we age, the discs that separate our vertebrae tend to lose height and flexibility. The vertebrae then begin to rub against each other resulting in extra bone formation by the vertebral bones. The extra bone, known as bone spurs or osteophytes, can press on the nerve roots and cause pain and inflammation. Disc Bulge Figure 5 Side (lateral) view of the lumbar spine on MRI imaging. The vertebral bodies are separated by intervertebral discs. The spinal cord (light gray) is situated in the spinal canal and bathed in cerebrospinal fluid (white). The image demonstrates a herniated disc (circled) that spills into the spinal canal. 4

7 Spinal Stenosis Stenosis is the term for narrowing or obstruction of the spinal canal or foramina where the nerve roots exit. When the diameter of the central canal is reduced to less than 10mm, it is considered narrowed. Most commonly this results from bulging discs, extra bone formation in the canal (osteophytes), enlargement of the ligaments that support the spine, deposition of extra fat in the epidural space and scar tissue from prior back surgeries. (See figure 6). With less room to live, the nerves become irritated and cause pain, numbness, tingling and weakness. Severe Disc Degeneration Facet Arthropathy Arthropathy refers to deterioration and arthritis of the facet joints of the spine (see figure 4). Arthritis occurs due to wear and tear, disc problems and prior injuries. As the space between the vertebrae decreases, the facet joints start to rub together and enlarge. A nerve called the medial branch supplies each facet joint. The medial branch nerve is a sensory nerve that produces pain signals when the facet joint is diseased. Typically, this type of pain remains confined to the back and gets worse with extension and rotation. Figure 6 Lumbar Stenosis Side (lateral) view of the lumbar spine on MRI imaging demonstrating significant protrusion of the disc between the L4 and L5 vertebrae causing narrowing and almost complete obstruction of the spinal canal aka spinal canal stenosis Sacroiliac Dysfunction/Sacroiliitis Sacroiliac pain originates from either one or both of the sacroiliac joints (see figure 4) due to abnormal movement of the joint (dysfunction) and/or inflammation of the joint (sacroiliitis). The inflammation in the joint can be a result of abnormal joint motion or underlying conditions such as arthritis or injury. In both cases, the joint pain can manifest as lower back pain, hip pain, buttock pain and tenderness. Now that you have a better understanding of the structure of your back and spine and the most common abnormalities that can occur, the following chapters will help you understand how the physicians at SpineCARE diagnose and treat back and spine pain, as well as work with you to prevent future injury and pain. 5

8 Chapter 2: Diagnostic Imaging: Pinpointing the Source of Your Back Pain Before we can determine the best treatment option for your back or spine pain, we need to identify the specific source. At SpineCARE, our back and spine specialists use the latest imaging technology to pinpoint the source of your pain. A variety of techniques are available to obtain the clearest image of your back and spine. Your physician will select the imaging technique or combination of techniques based on your specific medical history and symptoms. Basic Spine X-rays Your physician will probably start with a series of basic spine X-rays. Images will be taken of the front (anterior), back (posterior) and sides (lateral) of your back and spine. These images can reveal abnormal curvature of the spine, degenerative disc disease or slippage, or fractures. Your physician may order angled view X-rays (oblique) that are used to evaluate the nerve root openings from your spine, another potential source of your pain. Finally, your physician may order flexion and extension X-rays, which will be taken while you are bending forward and backward to determine if you are experiencing any spinal instability. Computed Tomography (CT) After evaluating your basic spine X-rays, your physician may order a CT scan series. CT scans show much higher bone detail and better soft tissue detail. If your physician suspects a narrowing within the spinal canal or around the nerve roots, he or she may request a CT myelogram, a CT scan involving the injection of a contrast dye into your spinal fluid. Again, your medical history and symptoms will help your physician determine the appropriateness of a CT myelogram. 6

9 Magnetic Resonance Imaging (MRI) If you are experiencing numbness, tingling or weakness, or if your basic X-rays and CT scans don t provide enough visualization to determine a precise diagnosis, your physician may order a MRI. MRI scans show the highest detail of soft tissue structures, including the spinal cord, nerve roots, discs, ligaments and muscles. Contrast dye can be used with MRI to enhance images of conditions such as scar formation, infection or cancer. Because MRI utilizes a strong magnetic field, it is not appropriate for patients with pacemakers/ defibrillators, spinal cord stimulators, insulin pumps and metallic objects in the body, such as ear implants, aneurysm clips or small pieces of shrapnel. Other Imaging Techniques Depending on your medical history and presenting symptoms, your physician may order other imaging tests. Bone scan imaging is a good screening methodology to help determine if there is any increased bony activity due to inflammation, instability, infection, fracture or tumor. Electrodiagnostic (EMG) studies involve electrical stimulation to test the function of the major nerves and muscles in the upper and lower extremities to see if and how they are affected by a spinal disease or injury. While all of these diagnostic imaging techniques can help your physician pinpoint the specific cause of your back and spine pain, there is no perfect diagnostic study. That s why your physician may order a combination of studies to help him or her form a more complete and objective picture of your pain and determine the most appropriate treatment plan to help you heal and enjoy life again as quickly as possible. 7

10 Chapter 3: Conservative Therapies: The Starting Point for Treating Your Pain At SpineCARE, our passion is to put you, the patient, at the center of everything we do. Our goal is to help you enjoy a life that is as pain free as possible by providing the most appropriate, individualized treatment. Our back and spine specialists are experts in a variety of treatment options, particularly conservative care. Conservative care encompasses modalities such as physical therapy, pain management, chiropractic care and acupuncture. Physical Therapy One of our licensed physical therapists will meet with you to perform an extensive evaluation to help identify the cause of your symptoms before developing your individually tailored treatment plan. The evaluation will include a review of your symptoms, health history, posture, range of motion and spinal alignment. Physical therapy is designed to improve your strength and flexibility with the goal of reducing your pain. Your treatment plan may include a combination of approaches: Electrical muscle stimulation: Small adhesive electrodes are placed on your skin in the area of pain. A small current is passed through the electrodes to help relax tight muscles and decrease your pain. Many patients tell us that this therapy feels like a great massage. This therapy can also be performed at home or at work with a transcutaneous electrical nerve stimulation (TENS) unit. Your physical therapist can provide information about TENS and whether this is appropriate for you. Ice: Often, physical therapy uses the application of ice to the area of pain to help decrease inflammation, pain and muscle spasms. Heat: Your physical therapist may determine that heat is an appropriate treatment option, especially if improved circulation to the area of pain will support the healing of aching muscles. 8

11 Stretching exercises: Stretching is a basic component of physical therapy because it improves flexibility and mobility as well as decreases muscle tension and tightness. Your treatment plan may include targeted stretching for areas such as the neck, mid-back, low back, hips and/or legs. Exercise program: Exercise also is a foundation of physical therapy and that s why your treatment plan will probably include an exercise program. Your physical therapist will work with you to teach you the proper form and technique for each exercise. The exercises will be specific for you and your symptoms. The goal is to strengthen the area of concern your neck, mid-back or lower back. Over time these exercises promote longterm stabilization and prevent future problems and/or injuries. By the time you finish your treatment plan, you should feel confident, competent and comfortable with performing these exercises at home or in the gym. Non-surgical decompression therapy: This therapy is used to gently pull and move joints, taking pressure off certain regions in your spine. Often, this therapy is prescribed for herniated/bulging discs where the pain level shoots into either the arms or legs. Posture/body mechanics/ergonomics: The things you do every day, and to which you generally don t give a second thought, can be contributing to the pain you are feeling. We call these activities of daily living and they include things like sitting in a chair, the way you get in and out of your car, the way you get in and out of bed and more. All of these routine activities can affect the stability of your spine. Your physical therapy treatment plan will help you identify these activities of daily living and will help empower you to move the right way. Back braces: Your physician, chiropractor or physical therapist may determine that a back brace is an appropriate component of your treatment plan. Back braces help stabilize your spine and the muscles around it, reducing the likelihood of injury, especially from repetitive motions. The brace supports your spine and limits its motion, alleviating your pain level. 9

12 Chiropractic Care Chiropractic care is another conservative treatment approach. Based on the principle of spinal alignment, chiropractic care can address a variety of issues, including neck pain, mid-back pain, low back pain, sciatica, numbness and more. Your spine can become misaligned from a variety of causes such as improper lifting, a car accident, poor sleeping habits and repetitive motions. Chiropractic care can realign areas in your spine that have become restricted, restoring proper motion and relieving pain, soreness, tension and inflammation. During your first visit with your chiropractor, he or she will conduct a thorough physical examination and evaluate your medical history, current symptoms, posture, range of motion, condition of your nerves radiating from your spine and alignment of your spine. The examination will determine if chiropractic care is appropriate for you. Spinal adjustment is the most important component of chiropractic care. The adjustment involves applying certain pressures and motions to your spine to help loosen the joints, promote spinal alignment and restore proper function to your nervous system. The number of visits with your chiropractor depends on the extent of degeneration in your spine and the severity of your pain. Your progress will be evaluated throughout the duration of your chiropractic care. Acupuncture Another conservative treatment approach used by SpineCARE specialists is acupuncture. A form of Chinese medicine, acupuncture is based on the principle of balancing energy in your body. This energy is believed to follow certain pathways called meridians. Pain is believed to result when these pathways are blocked or experience some type of interference. The goal of acupuncture is to remove these blockages or interferences. A trained acupuncturist will stimulate various points on your body with small needles to restore the balance and flow of energy. If the thought of needles makes you uncomfortable, acupressure is an alternative. Acupressure involves the application of pressure, rather than needles, to acupuncture points. 10

13 Chapter 4: Interventional Pain Procedures: The Next Step in Treating Your Pain Chronic pain from your back and spine can be especially challenging to treat. That s why, at SpineCARE, we offer a diverse array of procedures. Often, treatment plans include a combination of approaches to achieve the best outcome for each and every patient. Our goal is to help you achieve a decrease in your pain, enabling you to increase your ability to function and enjoy a good quality of life. We offer two types of interventions to address your pain diagnostic and therapeutic. Diagnostic interventions, also known as pain mapping, are designed to provide temporary relief in order to establish the cause of the pain. Typically, a local anesthetic is injected around a specific nerve or area. If you experience relief after the injection, then it is fair to assume that the pain is originating from that nerve or region. Pain mapping is highly effective in determining the exact origin of pain. Once our specialists have an accurate diagnosis, an effective treatment plan can be tailored to your specific needs, giving you the highest chance for successful pain relief. Therapeutic procedures are designed to treat the pain condition after an accurate diagnosis has been determined. Because our focus is on minimally invasive approaches, recovery times are generally quicker and patients often experience pain relief sooner rather than later. Diagnostic Procedures Medial branch blocks: The goal of this procedure is to anesthetize or numb the small sensory nerves that carry pain signals from the irritated facet joints between your spinal bones to the spinal cord and ultimately to the brain. Using X-rays to ensure proper placement, a local anesthetic is injected directly onto the nerve. If relief is provided, the physician has identified the correct area causing pain. Because this is a diagnostic procedure, it is not designed to permanently eliminate the pain. This procedure often serves as a precursor to a radiofrequency ablation, which is designed to treat this pain in a more permanent fashion. This procedure is more fully explained later in this chapter. 11

14 Selective nerve root blocks: Nerves that supply our upper and lower extremities originate from large spinal nerves that separate from the spinal cord at various levels. Sometimes the nerve roots can become compressed or restricted from herniated or bulging disks or from the bones in the spine. This is especially true in the presence of degenerative disk disease. When this occurs the result is often pain in the neck of lower back region that can radiate into the upper or lower extremities. Numbness and tingling can also be present with the pain. The goal of a selective nerve root block is to apply a targeted dose of local anesthetic to a suspected irritated nerve with the help of X-ray guidance. Again, this type of injection is diagnostic and not therapeutic. Usually, selective nerve root blocks are done in a series at multiple levels to help determine which nerve or nerves are causing your pain. This series of injections is sometimes referred to as pain mapping and can be useful prior to surgery to verify exactly which levels need the operation. Sometimes the procedure becomes therapeutic when a steroid medication is added to the numbing medication. The steroid has an anti-inflammatory effect that can last from months to years. If a steroid is added, it is known as a transforaminal epidural steroid injection. Discogram: Discography is performed on patients thought to be suffering from pain arising from the discs between the bones in the spine. As we age, our spine is subject to degeneration that can result in defects or tears in our discs making them more prone to bulging. A discogram is an interactive diagnostic procedure in which the pressure of the disc is increased, usually using a contrast material that is visible on X-ray and CT scan imaging, to determine if the pain is coming from the disc being evaluated. As the physician applies various pressures to the disc, it is important for the patient to communicate if the pain is greater than that he or she normally experiences. A CT scan may be performed immediately after a discogram to further evaluate the discs. This is considered a diagnostic procedure and is typically performed prior to surgery to help identify which discs to operate on. Therapeutic Procedures Epidural steroid injections: This procedure involves placing a powerful antiinflammatory steroidal medication via injection into the area between the outermost layer of the spinal cord and the inside bony surface of the spinal canal. The goal 12

15 of the procedure is to decrease irritation and inflammation that may contribute to pain, especially if nerve compression or restriction is present. Sometimes these injections are performed in a series of three over the course of several weeks to help decrease chronic inflammation. Depending on your diagnosis, your physician may choose to administer one of several types of epidural steroid injections interlaminar, transforaminal or caudal. Your physician will explain the specifics of the selected injection to you prior to the procedure. Radiofrequency ablation: Usually performed after successful medial branch blocks, radiofrequency energy is used to render the medial branch nerves in the neck or back non-functional. These nerves carry pain signals to the brain from inflamed or arthritic joints in the neck or back. Using X-ray guidance, small specialized insulated needles are placed in appropriate locations along your spine. A small, radiofrequency ablation probe is placed through the needle. The probes are attached to a small generator capable of producing thermal energy that makes the nerves non-functional. The procedure takes up to two minutes per nerve, but often several nerves can be ablated at the same time. This procedure usually provides relief for six months to two years. Non-invasive pain procedure (NIPP): SpineCARE is proud to offer our patients the NIPP. This exciting new technology involves temporarily placing a peripheral neurostimulator unit on the skin to help decrease pain. The procedure has minimal to no side effects because it requires no medications or anesthesia. The neurostimulator is attached just under your ear with some adhesives and dressings. Three small wires are attached to nerve endings in your outer ear. You will wear the device for three to four days and then remove it at home. While wearing the device you may notice a gentle intermittent stimulation of your ear. This is generally very mild and does not interfere with sleep. The sensation helps stimulate certain portions of your central nervous system that results in improved blood flow, decreased inflammation and decreased pain. Many patients feel significant relief after just one placement. The procedure takes 10 to 15 minutes to perform. For more information and to see patient testimonials, visit 13

16 Spinal cord stimulation: If you have experienced persistent pain even after undergoing multiple therapeutic measures, you may be a candidate for spinal cord stimulation. This therapy is used for very specific indications and is preceded by an outpatient trial to see if it can relieve your pain. Performed using a minimal amount of sedation and X-rays for placement, small needles are used to place little wires into the epidural space in close proximity to the spinal cord. The wires are attached to an external battery source (programmer) that will create a variety of stimulation programs to cover and alleviate your pain. As the programmer is turned on, your pain will be replaced by a mild pleasant sensation, known as paresthesia. The concept is that if the nerves that cause your pain are stimulated to cause paresthesia, they are no longer able to carry pain signals to your brain. The trial phase will usually last from three to seven days. A SpineCARE team member will closely monitor your condition to ensure that you are getting adequate pain relief. If the trial proves successful, you will undergo an outpatient surgery to have the wires permanently implanted under the skin along with a programmer, usually in the abdominal or buttocks region. Vertebroplasty/Kyphoplasty: Aging increases the chances for spinal fractures. Recent trauma, a history of spinal fractures and osteoporosis are risk factors. Kyphoplasty, a minimally invasive technique, involves injection of bone cement into the spinal fractures using small instruments. Sometimes an inflatable balloon is used to make a small space for the cement. The cement stabilizes the vertebrae, often resulting in a dramatic reduction in pain immediately following the procedure. Patients usually go home the same day or the day after the procedure. The procedure is performed most often under local anesthesia and intravenous sedation. Although this is not a complete list of the interventions we provide at SpineCARE, these are the most common procedures we perform. Your physician will help you determine which intervention is appropriate for your specific situation. 14

17 Chapter 5: Surgical Options and Lifestyle Changes The thought of any kind of surgery can be scary. Spine surgery can be especially intimidating. Once you make the decision to have surgery, there are several steps you can take to give yourself the best possible chance for success. This chapter is designed to provide you with information that will help you make an informed decision about whether to have surgery and to maximize the likelihood that surgery will help you. A wide variety of conditions can affect the spine, but spine surgeons tend to think about these problems in terms of whether they cause pressure on the spinal cord or nerves, whether they cause instability or deformity (curvature), or whether they cause arthritic back pain. In reality, you may have a condition that causes symptoms from a combination of two or even all three problems. For your surgery to be successful, it must address all the conditions contributing to your symptoms. The most common reason to have spine surgery is to relieve pressure on the nerves, either in the spinal canal or as they exit the spine. This is known as stenosis, or narrowing of the spinal canal or the foramen, the hole where the nerve exits the canal. When only one nerve is involved we may refer to it as a radiculopathy, also known as a pinched nerve or sciatica. Stenosis has many causes including a herniated disc, a bone spur, overgrown ligaments and curvature or instability in the spinal column. Symptoms of stenosis can be anything from a tired, weak feeling in the legs when walking, to severe pain down one or both legs during activity or even at rest. Some patients get actual weakness or numbness that corresponds to a single nerve. In severe stenosis, you might even have difficulty with bowel or bladder function. 15

18 Options for Spine Surgery Surgery for stenosis involves removing all of the tissue that is pressing on the nerve or nerves. This procedure is known as a decompression. If you do not have any significant back pain and if you do not have any deformity or instability, a decompression, especially through a minimally invasive approach, has an excellent chance of curing your symptoms. The procedure involves making a 1-inch or smaller incision on your back and inserting a tube through which the spine can be accessed and visualized using either a microscope or a camera. A high-speed tool and small, bone-trimming instruments are used to remove just enough bone and ligament to free up the sack containing the nerves (dura) as well as the nerves as they exit. This approach allows safe visualization of the problem area without removing or damaging the muscles and other stabilizing structures of the spine. Some patients have a deformity rather than or in addition to stenosis. The most common deformity is a spondylolisthesis. This condition is commonly referred to as a slipped disc or slipped vertebra, and is caused by instability in the spine either by lax ligaments, overgrown joints or stress fractures that allow one vertebra to slide forward on the vertebra above or below it through the disc. The other type of deformity is a scoliosis, or curvature of the spine, which can be an abnormality that occurs during growth of the spine or as a result of degeneration of the spine as an adult. These conditions can cause back pain and can result in stenosis, with the type of symptoms described above. Sometimes there is no back pain, only symptoms in the arms or legs. However, if a deformity is present, it has to be addressed during surgery; otherwise, there is a risk of the deformity getting worse after surgery and the symptoms returning. The goal of surgery for a deformity is to realign the spine to normal followed by a fusion of the spine. There are many ways to perform a spine fusion, but most involve using titanium rods and screws to hold the vertebrae together and a plastic or bony cage to hold the disc space open. Bone graft either from the patient or from a donor is then placed across the disc space and/or along the back side of the spine to cause two or more vertebrae to grow into one. Stem cells, either from the patient or from a donor (and occasionally genetically engineered medications), usually are added to the bone graft to increase the likelihood of 16

19 the fusion s success. While a fusion increases the complexity and possible complications of a surgery, modern technology allows it to be done with less invasive methods that result in less muscle damage, faster recovery times, and possibly better long-term outcomes than traditional fusions. Finally, there are patients that have significant back pain without evidence of stenosis or deformity. These patients are usually suffering from degenerative disc disease and/ or facet arthritis. They may have some leg pain, but it typically does not extend below the knee and there is no weakness or numbness. Their imaging studies do not show any nerve compression or problems with stability or alignment. This is the most difficult group of patients to help with surgery. A fusion is the most common procedure offered, but the long-term success rate of a fusion in the absence of a deformity or stenosis is only 50%. Artificial disc replacement is approved for this condition, but at this point most insurers consider it experimental and will not approve it. If you have back pain from this condition, you should consider surgery only as a last resort, and only if you have one or two levels involved. Preparing for Surgery Ensuring a Successful Outcome Once you reach the point where you have decided to go forward with surgery, you should do everything in your power to ensure a successful outcome. There are several things you can do to prepare yourself both mentally and physically for the procedure. Ideally, these steps should begin well before your surgery is even scheduled, and believe it or not, the two greatest factors that can influence whether your surgery will go well are directly within your control: smoking and weight. Smoking We have known for decades that long-term smoking has a negative effect on health. It causes and is associated with cancer, lung disease, heart disease, stroke, and vascular disease resulting in amputation and kidney failure. These problems tend to become worse in the elderly population, so younger active people who smoke don t consider themselves at risk for smoking-related problems. Smoking does, however, 17

20 have a more immediate impact on people with spine problems. Aside from the toxins in the smoke, nicotine itself causes blood vessels to constrict, limiting their ability to deliver vital oxygen and nutrients to the tissues of the body. This lack of blood flow results in more rapid deterioration of the discs and joints and irritated nerves that tend to remain irritated. Aside from potentially making symptoms related to your spine condition worse, smoking can adversely affect your surgery as well as your recovery. Changes in the lungs make it harder for the anesthesiologist to keep you breathing. Lack of blood flow to the surgical site can increase risk of infection or delay healing. If the nerves have active inflammation, the inflammation may persist even though the pressure on them has been removed. Smoking prevents the nerves from getting the oxygen, nutrients, and repair cells they need to help them heal. If your surgery requires a fusion, being a smoker drops the rate of fusion from greater than 90% to 75% or less, because new bone requires an excellent blood supply to form. It also increases the chance of getting a blot clot in your leg or pelvis. So quitting smoking, though extremely difficult, can pay huge dividends in terms of a successful surgical outcome. You should try to quit at least six weeks prior to surgery and remain smoke free for six months or more afterward. Talk to your surgeon or primary care provider about effective methods to help with quitting. Body Weight The other risk factor that you can modify to increase your success rate is body weight. Carrying extra pounds affects the health of your spine in several ways. It s a simple matter of physics: The more weight your spine has to support, the more wear and tear on the discs and joints, and so the faster they will break down. Since being overweight often is associated with lack of exercise, there also may be lack of flexibility, poor muscle tone, and lack of stamina, all of which can increase the chance of an injury. There is a subgroup of overweight patients who have a condition called metabolic syndrome. These patients have excess weight carried mostly around the midsection, are typically not physically active, and begin to develop hormonal imbalances such as insulin resistance and increased cortisol levels. These imbalances are associated with increased production of chemicals by the body that cause inflammation and can damage tissues, including the nerves, discs and joints in the spine. Many of these patients also are malnourished despite being overweight. 18

21 A quick test for obesity is the Body Mass Index or BMI. There are several online calculators you can use to calculate your BMI by inputting your height and weight. If your BMI is greater than 30 but less than 39 you are said to be in the obese range. When compared to non-obese patients, obese patients have statistically increased risk of poor outcomes from surgical treatment of spine disorders. For those patients with BMI greater than 40, those risks are even higher. In addition to ultimately having a less successful outcome from surgery, obesity increases the chance that you will have a complication from the surgery itself. Excess weight around the midsection means a further distance from the skin to the area where the surgeon will be working, meaning longer time to access the area, longer working distance, and often the need for a larger incision to take care of the problem. In addition, the hormonal imbalances mentioned above can result in problems with the immune system, so the risk of infection or delayed wound healing is higher in this group of patients than in those of normal weight. Significant weight loss may take months or even a year for success. While this may seem like too long to wait for your surgery, if you have a BMI of 39 or greater you should strongly consider waiting until you have lost the weight. Of course, if your condition requires urgent or immediate intervention this may not be possible, so this is something you should discuss in detail with your surgeon. Other chronic medical conditions also need to be well managed to minimize your risk from surgery and maximize your chance for a successful outcome. If you have diabetes, having your blood sugars under control is extremely important to ensure proper wound healing and reduce the chance of infection. If you have any heart, lung, kidney, or blood pressure issues, make sure they are addressed and stable prior to having spine surgery or any elective procedure. Major depression, if present, should be treated as well. Your surgeon will rely on your primary care provider and perhaps select medical specialists to ensure your overall medical condition is compatible with the planned surgery. Stress and Anxiety The biggest mental factors to overcome as you prepare for surgery are stress and anxiety. The main potential sources of stress related to a spine condition and its ultimate surgical treatment are home/ family, work and finances. Obviously there is much overlap and interrelating of these sources, and the chronic pain itself can be an added stressor. Finally, the fear of the unknown is a huge source of anxiety, and being comfortable with your surgeon and knowing what questions to ask regarding your specific condition and the procedure you are having will help alleviate much of that fear. A stable home environment with strong family support is ideal for a person dealing with a painful spinal condition and an upcoming spine surgery. You will need help around the house with chores, 19

22 errands, and more, even after a minimally invasive procedure. You will need to take at least a week and maybe more off from work, depending on your type of job and the procedure you are having. Timing the surgery to coincide with loved ones availability to help out and making sure the surgery will not interfere with completion of any critical tasks at work will give you quite a bit more peace of mind and allow you to focus all your attention on getting better. If there is no one at home to help out, discuss this fact with your surgeon so arrangements can be made for home health or even inpatient rehab after surgery, depending on the procedure type. Choosing Your Surgeon Assuming you are in the best possible physical health and have a supportive home life and stable job situation, you should be primed for success. The last thing to do to minimize your stress level and get ready for surgery is to make sure you are comfortable with your surgeon and completely understand your condition and the proposed procedure. You should familiarize yourself with your surgeon s level of training and competence, and you should have your spine condition and the surgery explained to you in terms you can understand, preferably with the aid of models and illustrations. You also should expect a discussion of the most likely complications, as well as less likely but severe complications that can occur with the surgery. Finally, you should expect to have all your questions answered to your satisfaction. There is great variability in the training of spine surgeons in our country. At a minimum, your spine surgeon should be board certified in either neurosurgery or orthopaedic surgery. This means he or she successfully completed an accredited residency program; that is, several years of formal training after graduation from medical school at a facility that meets the requirements of the Accreditation Council for Graduate Medical Education. He or she then demonstrated the competency and proficiency needed to meet the standards of either the American Board of Neurological Surgery or the American Board of Orthopaedic Surgery. During his or her residency he or she would have received training in spine care as part of a broader training in disorders of the brain and nervous system in the case of a neurosurgeon or the musculoskeletal system in the case of an orthopaedic surgeon. In our opinion, the surgeon should also have completed a fellowship in spine surgery; that is, one or more years of training following residency focusing solely on diagnosis and management of, and surgery for disorders of the spine. This extra focused training in spine care is critical given the complexity of the disorders and the rapid advances in diagnosis and treatment options. 20

23 Understanding Your Surgical Plan Once you have satisfied yourself with your surgeon s qualifications, you should make sure you understand the nature of your condition and how the proposed surgery will address it. Some of the questions you should ask are listed here, but you should make your own list and bring it to your doctor s visit. Do not rely on your memory, as you are likely to forget much of what you want to ask. Also take notes during your visit with your physician. Studies show patients remember less than half of what their surgeon tells them during the pre-operative counseling session. Some questions you should ask: Is there any deformity or instability present? If so, what type of fusion will be done? Where and how large will the incisions be? How long will I be in the hospital? How long will I be confined to home? How long will I be off work? Will I have to wear a brace after surgery, and if so for how long? If having a fusion, will an external bone stimulator be prescribed? When will physical therapy begin? When will I be able to resume light physical activity? When will I be able to resume full activity? When will I be able to resume sexual relations? Spine surgery can be a life-altering endeavor, hopefully for the better. By taking an active role in your spine care and by being your own best health advocate, you can put yourself in position to have the best possible outcome. Choosing the right surgeon, educating yourself on your unique condition and its best treatment, and maximizing your physical condition prior to surgery increase your chances for success, as does ensuring you have strong social supports you can lean on around the time of surgery and during your recovery. If it all still seems too daunting, have an honest discussion of your fears with your surgeon. He or she can put you in touch with a counselor or even a patient who has already been through the process. 21

24 Chapter 6: Understanding and Managing Your Medications Pain relieving medications, both over-the-counter (acetaminophen and ibuprofen) and prescription, play an important role in the treatment of neck and lower back pain. They can be helpful in the treatment of acute and chronic pain. Medications not only provide pain relief, they also treat the underlying cause of pain and improve function. Lower back pain is a common presenting complaint to primary care physicians. The good news is that the majority of lower back pain will not require long-term medication management. The main classes of medications commonly prescribed by SpineCARE physicians include NSAIDs (Non-steroidal anti-inflammatory drugs), muscle relaxants, neuropathic medications and narcotic medications (opioid therapy). The medications prescribed to you will be based on your symptoms, diagnosis and treatment plan. Medications can be used alone or in conjunction with interventional procedures and physical therapy. It is important to follow your medication regimen and communicate any changes in your health or concerns to your prescribing physician. NSAIDS (Non-steroidal Anti-Inflammatory Drugs) Physicians commonly prescribe NSAIDs for cervical, thoracic and lumbar back pain. NSAIDs are used to block inflammatory factors that produce pain. NSAIDs also block enzymes that are important for the maintenance and protection of your stomach lining thereby increasing your risk for gastrointestinal problems. Some NSAIDs are considered selective enzyme blockers that do not affect the stomach but the majority of NSAIDs on the market are not selective. List of Commonly Prescribed NSAIDs Celecoxib (Celebrex) Diclofenac (Voltaren) Etodolac (Lodine) Ibuprofen (Advil) 22

25 Indomethacin (Indocin) Ketorolac (Toradol) Meloxicam (Mobic) Nabumetone (Relafen) Naproxen (Naprosyn) Oxaprozin (Daypro) Potential side effects of NSAID use include gastrointestinal problems, renal damage and cardiovascular complications. Your physician will discuss each medication that is prescribed, possible side effects and ways to monitor your health after you begin taking the medications. Muscle Relaxants Muscle relaxants are commonly prescribed for neck and lower back pain. They are particularly useful where muscle spasms contribute to pain. Muscle relaxants can vary in the way that they work. Diazepam (Valium) Baclofen (Lioresal) Tizanidine (Zanaflex) Cyclobenzaprine (Flexeril) Carisoprodol (Soma) Methocarbamol (Robaxin) Common side effects from these medications can vary and include dizziness, somnolence, confusion and dry mouth. Psychological side effects include anxiety, irritability, euphoria, depression and paranoia. Your physician will discuss each medication that is prescribed, possible side effects and ways to monitor your health after you begin taking the medications. Neuropathic Medications Neuropathic medications are commonly prescribed when the pain is a result of nerve irritation and/or injury. These conditions may include, but are not limited to, cervical and lumbar nerve roots, long-term pain related to an outbreak of shingles or irritation of nerve tissue resulting in a burning pain sensation. These medications are also commonly referred to as membrane stabilizer medications. 23

26 Common side effects include dizziness, sleepiness, stomach upset, dry mouth, constipation, swelling and fatigue. Your physician will discuss each medication that is prescribed, possible side effects and ways to monitor your health after you begin taking the medications. List of Commonly Prescribed Neuropathic Medications Gabapentin (Neurontin) Pregabalin (Lyrica) Duloxetine (Cymbalta) Amitriptyline (Elavil) Nortriptyline (Pamelor) Opioid Medications Opioid medications can be useful in the treatment of neck and lower back pain. A short-term course of opioid medications can be appropriate to relieve pain and restore function when your physician determines that all treatment options you have tried have failed. The use of these narcotic medications needs to be done with precautions because the most serious risks associated with their use are addiction and misuse. Your physician may ask you to sign a Pain Contract which will outline your responsibilities as the patient and the physician s responsibilities while opioids are being prescribed during the treatment period. Many physicians are now employing the use of periodic urine toxicology screening to monitor compliance and drug efficacy. Common side effects associated with opioid medications include dizziness, stomach upset, nausea, constipation, itching, depression, urinary retention and sleepiness. Your physician will discuss each medication that is prescribed, possible side effects and ways to monitor your health after you begin taking the medications. List of Commonly Prescribed Opioid Medications Short Acting: Hydrocodone/Acetaminophen* (Vicodin, Lortab, Norco) Acetaminophen*/Codeine Oxycodone/Acetaminophen* (Percocet) Morphine Sulfate Hydromorphone (Dilaudid) 24