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Spine

Normal Anatomy of the Spine

The spine also called the back bone is designed to give us stability, smooth movement as well as providing a corridor of protection for the delicate spinal cord.

It is made up of bony segments called vertebra and fibrous tissue called inter vertebral discs.

The vertebra and discs form a column from your head to the pelvis giving symmetry and support to the body.

The spine can be divided in to 4 parts. The uppermost is the cervical region, consisting of 7 small vertebrae that form the neck. As we move down the body, the next 12 vertebrae make up the thoracic region or mid back from which the ribs are hinged. The 5 lumbar vertebrae are the largest of the mobile vertebrae and supports 2/3 of the body’s weight.

The lowest region of the spine is the sacrum and coccyx. The sacrum is a triangular plate made up of five fused vertebral segments while the four coccyxes terminate the bony spine.

VERTEBRA

A single vertebra is made up of two parts, the front portion is called the body, cylindrical in shape, and it is strong and stable.

The back portion of the vertebra is referred to as the vertebral or neural arch and is made up of many parts. The strong 2 pedicles join the vertebral arch to the front body.

The laminae forms the arch itself while the transverse process spread out from the side of the pedicles like wings to help anchor the vertebral arch to surrounding muscle.

The spinous process forms a steeple at the apex of the laminae, and is the part of our spine that is felt directly under the skin.

Laminae

The laminae of the vertebra can be described as a pair of flat arched bones that form a component of the vertebral arch.

Spinal canal

This canal is formed by the placement of single vertebral foramina one on top of the other to form a canal. The purpose of the canal is to create a bony casing from the head to the lower back through which the spinal cord passes.

Pars inter articularis

Known as the Pars, it is the part of the vertebral arch where the pedicle, transverse process and articular process transect.

FIBROUS TISSUE

Intervertebral Disc

The intervertebral disc sits between the weight bearing vertebral bodies, servicing the spine as shock absorbers.

The disc has fibrous outer rings called the annulus fibrosus with a watery jelly filled nucleus called the Nucleus Pulposus.

SPINAL CORD

The spinal cord is the means by which the nervous system communicates the electrical signals between the brain and the body. It begins at the brain stem and is held within the spinal canal until it reaches the beginning of the lumbar vertebra.

At L1 the spinal cord resolves down to a grouping of nerves that supply the lower body.

FACET JOINT

Facet joints are the paired articular processes of the vertebral arch.

These synovial joints give the spine it’s flexibility by sliding on the articular processes of the vertebra below.


Back Pain

Back pain is often a common symptom of many disease conditions, which range from simple or dull pain to sudden and sharp pain. If the pain persists for few days, it is an acute pain; whereas if the pain continues for more than 3 months, it is a considered as chronic pain. In most cases, back pain may resolve without any treatment, but incase if persists for more than 3 days, a medical intervention is necessary.

Back pain may be a common symptom in various conditions such as appendicitis, aneurysms, kidney diseases, kidney and bladder infections, ovarian disorders, pregnancy, nerve root syndromes such as sciatica, herniated discs, spinal stenosis, musculoskeletal problems, osteomyelitis, spondylitis, tumors, spine injuries, fractures, and many more.

Back pain can be alleviated with rest and RICE (Rest, Ice, Compression, and elevation) treatment, pain relievers, nonsteroidal anti-inflammatory drugs, corticosteroids, and physical therapy. However certain conditions causing severe pain may require surgical treatment. Treating underlying conditions offer the relief from back pain.

One of the common causes for back pain is low back strain. Low back strain or lumbar strain occurs when the muscle or the tendon in the lower back gets stretched or torn. It is caused by lifting heavy objects or overload, sitting or standing for a longer time, direct blow over the area, or sports such as basketball, baseball, or golf that involve sudden twisting of lower back can also lead to strain.

The risk factors such as excess low back curvature, weak abdominal muscles, and forwardly tilted pelvis can increase the risk of this injury.

The common symptoms include low back pain that radiates down to the buttocks; inflammation of the soft tissues that surround the muscles; stiffness in the low back; restricted movements; inability to maintain correct posture; muscle spasms; and pain which continues for a longer period.

Your doctor will perform a physical examination and take a brief medical history to diagnose your child’s condition. Other additional tests such as X-ray and MRI scan may be required to confirm the injury and provide necessary treatment.

The conservative treatment methods include:

  • Rest: Your child should take complete rest for 1-3 days, as more damage could result from putting pressure on the back. Prolonged bed rest should also be avoided as it leads to loss of muscle strength and makes the muscles stiff which will aggravate pain and discomfort. Hence bed rest should not be continued for more than 48 hours.
  • Ice packs can be applied to the injury which will help to diminish swelling and pain. Ice should be applied over a towel to the affected area for 15-20 minutes four times a day for several days. Never place ice directly over the skin.
  • Braces or belt might be used to support the back while the healing happens.
  • Medications that may be prescribed include nonsteroidal anti-inflammatory drugs to reduce pain and inflammation. Other medicines such as muscle relaxants control muscle spasms. These medicines often cause sedation; therefore, consult your doctor to discuss about the type of muscle relaxants for your child.
  • Your doctor may also suggest a rehabilitation program for your child. It consists of stretching and strengthening exercises, pelvic traction, gentle massages, and ice or heat therapy to improve your child’s condition. It helps to control the pain, strengthen the abdominal muscles, and also speeds up the recovery which allows your child to return to the weight-bearing activities.

Some of the preventive measures which can help prevent back strain in children include:

  • Doing warm up exercises before the start of any physical activity or sports and taking short breaks in between the activity.
  • Ensure that your child uses correct lifting techniques such as squatting to lift a heavy object.
  • Ensure that your child maintains a proper posture while sitting and standing.
  • If your child is overweight or obese, it can strain the back muscles. Hence it is advised that your child lose some weight and maintain a healthy diet.
  • Encourage your child to exercise everyday as it improves spine stability and also prevents extra stress on your child’s back.
Hip Anatomy

Neck Pain

The first 7 vertebral bones on the spinal column form the cervical spine and are located in the neck region. The neck bears the weight of the head, allows significant amount of movement, and also less protected than other parts of spine. All these factors make the neck more susceptible to injury or other painful disorders. Common neck pain may occur from muscle strain or tension in everyday activities including poor posture, prolonged use of a computer and sleeping in an uncomfortable position.

The most common cause of neck pain is injury to the soft tissues (muscles, ligaments, or nerves) or prolonged wear and tear. Traumatic accidents or falls and contact sports can cause severe neck injuries causing pain in the neck. Neck pain can also come from infections, tumours or congenital abnormalities of the vertebrae. Common conditions producing neck pain include:

  • Rheumatoid arthritis: It is an auto-immune disease in which the body’s immune system attacks healthy joints, tissues, and organs. The condition occurs most often in the upper neck area causing inflammation of the lining (or synovium) of joints resulting in neck pain, stiffness, swelling and loss of function.
  • Cervical disc herniation: Disc herniation is the bulging or rupture of the soft fibrous tissue, discs, cushioning the vertebrae. Cervical disc herniation refers to herniation of discs in cervical spine region or neck region. As a result of this the soft central portion called nucleus pulposus bulges out through the tear in the capsule. The condition can be caused by the normal aging or by traumatic injury to the spine. The condition results in painful, burning, tingling or numbing sensations in the neck.
  • Cervical Spondylosis: Cervical spondylosis refers to abnormal degeneration of the cartilage and bones in the neck region. The condition results in neck pain radiating to arms or shoulder and neck stiffness that gets worse over time.
  • Cervical Stenosis: Cervical stenosis refers to narrowing of the spinal canal that protects the spinal cord and its branching nerves. The condition causes neck pain radiating to arms and hands.
  • Degenerative disc disease: Degenerative disc disease refers to gradual deterioration of the disc between the vertebrae and is caused due to aging. As people age intervertebral discs lose their flexibility, elasticity and shock absorbing characteristics resulting in neck pain.

Diagnosis of neck pain is made with physical examination and other imaging techniques including electromyography (EMG), X-ray, MRI scan, CT scan, blood tests and bone density assessment.

Treatment options include rest, ice application, elevation of the injured area, use a soft neck collar and neck immobilization using a splint, cast, or sling. Medications such as anti-inflammatory drugs, analgesics and muscle relaxants may be prescribed to reduce the pain and inflammation. Certain stretching and strengthening exercises may be recommended to strengthen the neck muscles.

Surgical treatment by anterior cervical discectomy with spinal fusion is typically recommended only after non-surgical treatment methods fail to relieve the pain. An anterior cervical discectomy is a surgical procedure performed to remove a herniated or degenerative disc in the cervical (neck) spine. Spinal fusion may be performed to provide stability to the spine.

The following steps may help you prevent or improve your neck pain:

  • Practice relaxation exercise to prevent undesirable stress and tension to the neck muscles
  • Perform stretching exercises for your neck before and after exercise
  • Keep good posture if you work at a computer and adjust the monitor at your eye level. Stretch your neck frequently
  • If you use the telephone a lot, use a headset
  • Use a pillow that keeps your neck straight
  • Wear seat belts and use bike helmets to reduce injuries

Spinal Deformity Surgery

The Spine or backbone provides stability to the upper part of our body. It helps to hold the body upright. It consists of several irregularly shaped bones, called vertebrae appearing in a straight line. The spine has two gentle curves, when looked from the side and appears to be straight when viewed from the front. When these curves are exaggerated, pronounced problems can occur such as back pain, breathing difficulties and fatigue and the condition will be considered as deformity. Spine deformity can be defined as abnormality in the shape, curvature, and flexibility of spine.

The different types of spinal deformities include scoliosis, lordosis and Kyphosis. Scoliosis is a condition where the spine or back bone is curved sideways instead of appearing in a straight line. It curves like an “S” or “C” shape. Lordosis is a condition characterized by abnormal excessive curvature of the spine, sometimes called swayback. Kyphosis is a condition where an abnormal curvature of the spine occurs in the thoracic (chest) region resulting in round back appearance.

There are different surgical approaches to repair these deformities and the choice of the approach to the spine is based on the type of deformity, location of the curvature, ease of access to the area of the curve and the preference of the surgeon.

Anterior approach -In this procedure surgeon will approach the spinal column from the front of the spine rather than through the back. The incision is made on the patient’s side, over the chest wall or lower down along the abdomen, depending on the part of the spine that requires correction. The lung is deflated and a rib is removed in order to reach the spine. After the exposure of the spinal column, the disc material between the vertebrae involved in the curve is removed. Screws are placed at each vertebral level involved in the curve, and these screws are attached to a single or double rod at each level. After instrumentation a fusion is performed, the bony surface between the vertebral bodies is roughened and bone graft is placed. A combination of compression along the rod and rotation of the rod will correct the spine deformity. The incision is closed and dressed.

Posterior approach -It is the most traditional approach and the approach is made through the patient’s back while the patient lies on his or her stomach. The incision is made down the middle of the back. Hooks are attached to the back of the spine on the lamina, and screws are placed in the middle of the spine. After the placement of hooks and screws, a rod that is bent and contoured into a more normal alignment for the spine is attached and the correction is performed. After the final tightening, the incision is closed and dressed.

Anterior and posterior approach -This approach is used in cases where the curve is stiff and severe. The first approach to spinal column is made from the front. The incision is made on the patient’s side, over the chest wall or lower down along the abdomen. Disc material between the vertebrae is removed. This procedure requires removal of a rib, which is later used for bone grafting.

After the anterior procedure, the wound is closed and the patient is positioned for the posterior approach. The incision is made down the middle of the back. Hooks are attached to the back of the spine on the lamina, and screws are placed in the middle of the spine. After the placement of hooks and screws, a rod that is bent and contoured into a more normal alignment for the spine is attached and the correction is performed. After the final tightening, the incision is closed and dressed.

Video-assisted thoracoscopic surgery (VATS) -This is a minimally invasive technique performed using a small video camera. The patient lies on his or her side; four incisions of 1 inch are made on the side of the chest wall. A thoracoscope, a thin instrument with a tiny camera and light at its end, is inserted through one of the incision. The thoracoscope transfers images of the inside of the chest onto a video monitor, guiding the surgeon to perform the procedure. Retractor, suction and other surgical instruments are inserted through other incisions. Steps involved in the anterior approach are performed which involves intervertebral disc removal, bone grafting and instrumentation. Lung is deflated to gain access to the spine. The incisions are closed with an absorbable suture and the deflated lung is reinflated.


Spine Injections

Spine injection is a nonsurgical treatment modality recommended for treatment of chronic back pain. Injection of certain medicinal agents relieves pain by blocking the nerve signals between specific areas of the body and the brain. The treatment approach involves injections of local anesthetics, steroids, or narcotics into the affected soft tissues, joints, or nerve roots. It may also involve complex nerve blocks and spinal cord stimulation.

  • Proliferation Injection: Proliferation injection is also known as sclerotherapy and is a non-surgical treatment for musculoskeletal injuries. It involves injecting the dextrose solution (irritant) into the damaged or injured ligaments and tendons. Macrophages, the defence cells of the body, reach the site of injection to attack the irritant. Meanwhile the body brings in fibroblasts which heal the damaged ligaments and produce connective tissue. This injection helps in the proliferation of new cells and helps in the repair of connective tissue.
  • Neural Prolotherapy: In neural prolotherapy an irritant solution is injected into the painful areas where the ligaments and tendons are injured. The irritant solution irritates the local area causing inflammation. The macrophages arrive at this site to dispose the irritant solution. This encourages the repair process where the fibroblasts, the connective tissue builder cells, stimulate the production of connective tissue. Release of growth factors at the site of injury may help in strengthening, reducing the pain, inflammation, and weakness.
  • Lumbar Epidural
  • Facet Injections

Spine Trauma

Spine trauma is damage to the spine due to a sudden traumatic injury caused by an accidental fall or any other physical injury. Spinal injuries may occur while playing, performing normal activities, operating heavy machines, lifting heavy objects, driving automobiles, or when you suffer a fall. Injury to spine may cause various conditions including fractures, dislocation, partial misalignment (subluxation), disc compression (herniated disc), hematoma (accumulation of blood) and partial or complete tears of ligaments.

The most common symptom of spinal injuries is pain. Spinal injury causes weakness and sensory loss if the spinal nerves are damaged. Symptoms may proceed to paralysis, limited movement, and immobility. Spinal injuries are diagnosed using spine X-rays and a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the spine.

The treatment will depend entirely on the specific type and location of the injury. You may be treated with pain medications, epidural injections (injecting into spine), physiotherapy, and surgery. Surgery is recommended when other treatments are a failure or inappropriate. Surgery for spinal condition depends on the type and severity of injury. Some of the common spinal surgeries include:

  • Coccygectomy – Coccygectomy is a surgical procedure which involves removal of part or entire portion of tailbone (coccyx) present at the end of your spine. It is performed in patients who have persistent tailbone pain due to injury, fall or contact sports and when all other conservative treatments are a failure.
  • Spinal decompression – Decompression is a procedure of relieving pressure on one or many “pinched nerves” of the backbone. Spinal decompression is performed by two procedures microdiscectomy and laminectomy. Microdiscectomy is a minimally invasive procedure which involves removal of a portion of a slipped disc by a surgical instrument or LASER. Laminectomy is a procedure in which a small portion of the roof of the spinal bone is removed to relieve pressure on pinched nerve.
  • Discectomy – It is a surgical procedure performed for the removal of the fragment of slipped disc, also known as bulging disc or herniated disc.
  • Transforaminal lumbar interbody fusion – Fusion surgery is a surgical procedure where the damaged disc between two vertebrae in lumbar region of spine is removed in lumbar region of spine and the vertebrae are fused together.
  • Decompression fusion – This is a surgical procedure that includes both decompression and fusion. Decompression relieves the pressure from the spinal cord and/or nerve roots and fusion surgery helps in joining the two vertebrae. This procedure is performed to reduce deformity and stabilisation, minimising neurological injury and early rehabilitation of the spine.

Your spine surgeon may recommend rehabilitation program to promote complete and faster healing.

Vertebral Fractures

Vertebral compression fractures occur when the normal vertebral body of the spine is squeezed or compressed. The bone collapses when too much pressure is placed on the vertebrae, resulting in pain, limited mobility, loss of height, and spinal deformities. In severe compression fractures, the vertebral body is pushed into the spinal canal, which will apply pressure on the spinal cord and nerves.

Vertebral fractures results from weakened spine caused by osteogenesis imperfecta, osteoporosis, tumor, and trauma. Osteogenesis imperfect is a hereditary disease resulting in bone fragility. It is an autosomal dominant disorder of connective tissue that is characterized by easily fractured bones.

Your child may experience severe pain in the back which worsens on standing or walking and decreases when resting. Other symptoms include, weakness, and numbness in the affected areas, disability, limited spinal mobility, and loss of overall height. The symptoms which indicate multiple fractures in the spine are hunch back, bulging stomach, shortness of breath, hip fracture, and gastrointestinal problems. Children’s who sustain multiple compression fractures may have hunch back (kyphosis or “dowager’s hump”), gastrointestinal problems, hip pain, and shortness of breath.

Your doctor may require diagnostic tests such as X-ray, MRI scan, and bone scan which help to determine and confirm the fracture.

Treatment

The treatment for vertebral compression fractures aims at reducing the pain, stabilizing, and repairing the fracture. The non-surgical measures include medications, back braces, bed rest, and certain exercises.

Nonsteroidal anti-inflammatory drugs may be prescribed to relieve bone, muscle and nerve pain. A back brace may be suggested to support the back and immobilize the movements.

Surgery may be needed if the pain still persists despite of non-surgical treatment. There are two minimally invasive surgical procedures for treating vertebral compression fractures are:

  • Kyphoplasty: In this procedure a deflated balloon called as bone tamp is injected into the spine. The balloon is inflated until it expands to a desired height. The created space is then filled with orthopedic cement called polymethylmethacrylate. This procedure helps to restore the height of the vertebrae and reduces the deformity.
  • Vertebroplasty: This technique involves injecting a cement material called polymethylmethacrylate, into the collapsed vertebra. The injected cement hardens quickly stabilizing the fracture, relieves pressure, and prevents further collapse.

The following measures may be practiced to decrease the risk of developing vertebral fractures:

  • Teach your child some good techniques for standing, sitting, lifting, and housework activities.
  • Do not encourage your child to lift heavy things, jumping, diving, horse riding, sliding, and amusement rides
  • Ensure that your child wears seat belts in cars
  • Make sure that your child avoids sitting at the back of the school bus
  • Make sure that your child does not carry heavy book bags to school
  • Exercise regularly. Swimming provides movement of joints without being stressed and is also good for the muscles at the back

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