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Specialties - Back/Neck

 


Degenerative Disc Disease


Definition

Degenerative Disc Disease Treatment | Facet Joint Syndrome Treatment | Minimally Invasive Spine Surgery | Westwood | HackensackDegenerative disc disease is a consequence of aging or "wear and tear" of the back. It refers to the changes that take place in the discs separating the bones of the back. Disc disease is very common and in the majority of cases, the outlook is good. Several factors are involved in disc degeneration including genetic make-up and repetitive overload or stress to the discs. As a result, other structures of the spine also suffer wear and tear. Commonly, this occurs at the joints that link the bones of the spine together called facet joints. This increases the risk of additional problems such as disc herniation and secondary problems such as spinal stenosis (spinal canal narrowing).

Symptoms

The symptoms present in degenerative disc disease depend upon what structures are being affected. In the early stages, back pain may be the main symptom. However, if the disc disease is advanced and facet joint degeneration has occurred, the space where the nerves exit the spine may be narrowed. In such a case, often both back and leg pain occur.

Treatment Options

This condition is generally manageable with appropriate treatment. Physical therapy is often used to help with stretching and exercise in order to correct mechanical problems present in the region of the low back and pelvis. Degenerative disc disease may result from imbalances in the muscles and ligaments around the spine, but patients can be taught how to stretch tight muscles and strengthen weakened ones. Correction of such imbalances will alleviate stress on facet joints and discs.

The pain which results from degenerative discs can often be attributed to inflammation. Patients are often started on a trial of anti-inflammatory medications such as ibuprofen, naproxen and others. For more severe and persistent pain, an injection of steroid (a very strong anti-inflammatory pain medication) may be indicated. These procedures use x-ray guidance to place medications directly at the source of the pain. Surgery is rarely a consideration unless a patient experiences substantial problems with nerve compression or experiences significant changes in lifestyle that have not responded to non-surgical treatment.

Sometimes, in spite of our very best treatment efforts, pain may still be present. It is not uncommon and it is not usually dangerous. Exercise and modifying one's activities can sometimes be the best way to achieve the highest degree of function and minimize symptoms.

Reducing the Risk of Degenerative Disc Disease

People who have degenerative disc disease must alter particular activities that cause or worsen their symptoms. Certain lifestyle changes are recommended. For example, smoking can lead directly to diminished blood flow in the back and can decrease the flow of vital nutrients necessary for a healthy spine. Consequently, smoking cessation is important. Maintaining ideal body weight is also important. The spine supports the body from the hips up and extra weight puts extra, unnecessary stress on it.

It is helpful to follow a regular exercise program specifically designed for the back and pelvic region. Regular aerobic walking is also helpful. There are no specific guidelines regarding what activities should be avoided. Each patient must be evaluated and advised on an individual basis.

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Disc Herniation


Definition

The intervertebral disc is a cushion or shock absorber between the bones of the back and neck. A disc consists of two separate components. A jelly-like center is surrounded by rings of cartilage. With wear and tear or injury, some of the rings of collagen are weakened. Disc herniation occurs when some of the jelly-like central disc material pushes through a defect in the outer portion of the disc.

Symptoms

The symptoms present from a disc herniation can be quite varied. A person may not experience any significant pain. However, most people with a disc herniation experience some degree of neck or back pain. The location and severity of the symptoms are dependent upon what structures are irritated. For example, if the disc presses against a nerve root, one can develop "referred pain" (pain down the arms with a neck herniation and down the legs with a back herniation).This pain may worsen or improve with certain actions or changes in body position.

Treatment Options

Initial treatment of a disc herniation focuses on pain control. Patients are usually given anti-inflammatory medications such as ibuprofen or naproxen and non-narcotic pain medications. The second step is modification of certain activities which are likely to increase pain. Prolonged bed rest is not recommended. Specific exercises can decrease symptoms dramatically, so physical therapy with a therapist specializing in spine-care is initiated. For more severe and persistent pain, epidural steroid injections are often used to provide pain relief and decrease inflammation.

This condition is generally manageable with appropriate treatment. In 80 to 90 percent of cases the above measures combined with approximately 4 to 6 weeks of time to heal are enough to manage symptoms. Only when symptoms remain unmanageable are more invasive procedures considered. These may include minimally invasive procedures to decompress the disc or surgery.

Unfortunately, there is no "guaranteed or permanent cure". Surgery is a last resort and considered only when all other options have been exhausted.

Indications for Surgery:

  1. Progressive weakness in the arm or leg affected by the disc herniation.
  2. Progressive loss of sensation.
  3. An inability to control urination or bowel movements. This may mean an inability to pass urine or wetting or soiling clothing.
  4. Severe, intractable pain present for greater than 3 months which significantly diminishes quality of life.

Prognosis

Although aggressive conservative treatment plans are very effective, a patient with a disc herniation is always at a higher risk for recurrent episodes of back or neck pain. Exercise and modifying one's activities can sometimes be the best way to achieve the highest degree of function, minimize symptoms and reduce the risk of future problems. Patients should use common sense and ease into more strenuous activities. Most people are able to return to their former jobs and recreational activities without restriction. It is helpful to follow a regular exercise program specifically designed by a physical therapist and your spine physician.

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Myofascial Pain Syndrome


Definition

Myofascial pain syndrome is thought to be a form of muscle or soft tissue pain. It may result from a single significant trauma such as a motor vehicle accident. It may also result from repetitive minor trauma. Patients develop "tight", "sore" or irritated muscles. There is a tendency for the development of poorly functioning areas of muscle called trigger or tender points. These areas may be felt as "knots" of tissue under the skin. An experienced clinician can determine whether painful regions are indicative of myofascial pain syndrome. When trigger points are present and active, they can lead to localized discomfort as well as pain in nearby muscles

Myofascial Pain versus Fibromyalgia

Although often used interchangeably by patients and physicians, these are different conditions. Fibromyalgia is considered part systemic disease and part syndrome. It has more clearly defined criteria for diagnosis, including pain present for more than three months, sleep disturbance, and a minimum number of specific tender points. It is more generalized with pain above and below the waist and on both sides of the body. Fibromyalgia may also be associated with irritable bowel syndrome, chronic fatigue syndrome, depression and mitral valve prolapse. There may also be a family association.

Myofascial pain syndrome is typically more localized and less likely to be associated with systemic conditions. There are no laboratory, radiographic or other diagnostic tests for myofascial pain syndrome or fibromyalgia. The diagnosis is made when other conditions are not present or "ruled out".

Symptoms

Symptoms are usually confined to the muscle itself or muscle located near a painful joint. The pain can be aggravated by motion and relieved with rest. Range of motion may be impaired. Trigger points are thought to result in or result from prolonged muscle spasm. These areas are stiff and painful to the touch. Stress, limited sleep, and deconditioning make symptoms significantly worse.

Treatment Options

Successful long-term treatment involves proper exercise. An individualized program of stretching and cardiovascular exercise is the mainstay of treatment. The key ingredients to preventing recurrence are strengthening the involved muscles and restoring physical activity. Non-impact activities such as brisk walking, swimming and bicycling are often helpful in preventing deconditioning.

Anti-inflammatory medications also called NSAIDS such as ibuprofen and naproxen can be helpful. Muscle relaxants and low dose anti-depressants have a role in relieving spasm and helping to restore sleep patterns. Intramuscular or trigger point injections can be very helpful when trigger points are present.

Specific physical therapy techniques such as neuromuscular massage and myofascial release can provide significant relief as can moist heat and TENS (a form of electrical stimulation).

In stubborn, persistent cases additional resources are used to teach patients techniques to promote relaxation and enable functioning despite discomfort. These include stress management, biofeedback and psychotherapy.

Tobacco use and caffeinated beverages need to be discontinued. Caffeine and nicotine are stimulants. They have been found to irritate muscles and perpetuate muscular or myofascial pain.

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Facet Joint Syndrome


Definition

The facet joints are paired joints located on the posterior aspect of the spine at each level. The joints provide stability to the spine and limit excess motion. Each facet joint is lined with cartilage and surrounded by a lubricating capsule that enables the vertebrae to move freely. These joints have nerve endings both inside and outside the joints. Causes of irritation and stress to the facet joints include: misalignment, everyday wear and tear, trauma such as motor vehicle accidents, previous back or neck injuries and intervertebral disc degeneration. As with other joints they can undergo degeneration or arthritic changes.

Symptoms

Facet joints can present with a variety of symptoms depending on the location of the irritated joints. Local tenderness in the region over the joint is common. In the neck (cervical spine) pain can be present in the neck, shoulders, upper and mid back. Headaches are also possible. In the low back (lumbar spine) pain is often felt in the low back, buttocks and backs of the thigh/s. The pain is often made worse by bending backward or rotating. A protective reflex arises when facet joints are inflamed which cause the nearby muscles of the spine to go into spasm. This may lead to a limitation in muscular flexibility called guarding.

Treatment Options

Various treatment options are available for facet joint pain. In general, successful long-term treatment involves proper exercise, with instruction provided by a physical therapist or other health care provider trained in spine-care. Maintaining good posture is particularly important as is learning to modify ones activities to avoid further damage and alleviate pain. Anti-inflammatory medications also called NSAIDS such as ibuprofen and naproxen can be helpful. Manipulation can also be used to realign joints and provide pain relief. For persistent pain, X-ray guided injections can be performed to place medication directly into the joints at the source of the pain. Finally, destruction of the small nerves to the joint can be performed by trained physicians with an electrified heat probe. If successful this can provide relief for up to six months.

Prognosis

Fortunately, the vast majority of patients respond well to a combination of medications, lifestyle changes and proper exercise. Education and proper training in biomechanics are crucial. This can often reduce the pain to manageable levels. Risk factors for recurrence include poor flexibility and poor strength of neck, low back, pelvic and shoulder girdle muscles. As with other musculoskeletal conditions, the exercise should not end with supervised therapy. It should continue with a home exercise program in order to maintain an increased level of function and provide lasting pain relief.

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Spinal Stenosis


Definition

Spinal stenosis is a narrowing of the spinal canal. This may be caused by several different conditions. Some people are born with a canal narrowing (congenital stenosis). Other common causes include disc bulging or herniation as well as arthritic changes which cause bony-build-up of the joints of the spine. Many of these degenerative changes are the consequence of normal aging. When there is narrowing of the central spinal canal as well as the tunnels where the nerves exit the canal, nerve tissue can become irritated.

Symptoms

Spinal stenosis can present with localized neck or back pain but because of irritation to nerve tissue, there is often associated pain in the arms or legs. Numbness and tingling may also be present in the affected limbs. The back or leg symptoms may be worsened with standing and walking and relived with leaning forward or sitting. Symptoms in the neck and arms may be worsened with tilting the head backward.

Treatment Options

Many treatments are available for spinal stenosis, perhaps the most important of which is activity modification. Education is also crucial. Successful long-term treatment involves proper exercise, with instruction provided by a physical therapist or other health care provider trained in spine-care. Instruction in modification of posture and activities is helpful to avoid further irritation and alleviate pain. The pain present in spinal stenosis is thought to have an inflammatory component, so anti-inflammatory medications are often part of a treatment program.

Spinal stenosis is a structural condition which often takes years to develop. It sometimes requires more aggressive treatment to control symptoms. For persistent pain, epidural injections are often used. These x-ray guided injections place medication directly into the spinal canal at the source of the pain. They are effective for many patients. Occasionally. repeat injections are necessary depending upon each individual's response. When symptoms are under better control physical therapy is advanced to improve function.

Prognosis

The prognosis for patients with spinal stenosis is dependent upon the cause of the spinal canal narrowing. If a disc bulge or herniation is responsible for the narrowing, appropriate treatment with physical therapy, medications and epidural injections can help significantly. Most patients respond well to this combination. If underlying arthritic changes are responsible for the narrowing, then pain control is the main goal. These arthritic changes may progress to some degree. However, with appropriate exercise and activity modification, most patients are able remain active with manageable pain.

Risk factors for recurrence include poor posture as well as limited flexibility and strength of neck, low back, pelvic and shoulder girdle muscles. As with other musculoskeletal conditions, the exercise should not end with supervised therapy. It should continue with a home exercise program in order to maintain an increased level of function and provide lasting pain relief.

Surgical Options

Surgery is only considered if patients have had limited response to the above mentioned treatments. Specific indications for surgery include: progressive loss of strength or sensation in the arms or legs, loss of bowel or bladder function or severe, unmanageable pain which limits one's ability to perform day-to-day activities. If disc herniation is the underlying cause of the spinal stenosis, surgery can be a viable option. Surgery is typically less effective for age-related or arthritic spinal stenosis. It may provide reasonable short-term relief, but long-term relief is less certain.

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For additional information visit: AAOS Online Service Fact Sheet - Lumbar Spinal Stenosis

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Epidural Injections


What is an epidural injection?

An epidural injection is a treatment option for back pain that consists of corticosteroids combined with a local anesthetic to relieve inflammation and reduce symptoms caused by spinal stenosis and other causes of back pain. This treatment is injected directly into the epidural space, the space around the spinal cord and nerve roots.

What is an epidural injection used for?

This treatment is most effective in relieving pain caused by neurological conditions that affect nerve roots, such as a herniated disc, spinal stenosis, degenerative disc disease and more. About half of all patients who receive an epidural injection will benefit from this treatment, and it is often used when other treatment options have failed.

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