HOW IS THE SPINE FORMED?
The spinal column is made up with many small segments of bones, namely, vertebra. There are 7 cervical vertebrae (neck), 12 thoracic vertebrae (upper back), 5 lumbar vertebrae (low back), and 5 fused sacral vertebrae (tail bone). The vertebral bodies join together to form the front part (anterior part) of the spinal canal, and the laminae and pedicles attach to the vertebral bodies in the form of an arc to protect the back part (posterior part) of the spinal canal. Between the front and back parts, there is a long tube, spinal canal, that extends from the bottom of the skull all the way down to the tail bone. Through this tube, the spinal cord (nerve structure) carries information from all parts of the body back and forth to the brain, which is the command center for all human activities.
The vertebrae are joined by soft tissues, namely, discs and ligaments. In the front of the spinal canal, there are discs between adjacent vertebrae. The discs act as cushions to absorb shock forces. If a disc becomes old and worn, they can cause pain because of changes in chemical composition or displacement to impinge on nerves. The ligaments enforce the stability of the spinal column. There are ligaments at the front and back of the spinal canal. The ligaments can get old or worn as well. When it happens, it can cause movement of the adjacent vertebral segments (instability) or significant thickening (hypertrophy) resulting in nerve impingement.
WHAT ARE THE TYPICAL SYMPTOMS?
The most common symptoms of spinal disorders are neck pain or back pain. As the spinal cord conveys information between the brain and all parts of the body, spinal disorders can also result in pain of the arms and legs. In some cases, one can get numbness and weakness of the arms and legs due to nerve compression. Some people can also have difficulty urination or having bowel movement. Remember, sudden onset of weakness and sudden loss of bladder or bowel function are emergency conditions that need to be evaluated right away.
WHAT ARE THE CAUSES FOR THE SPINE DISORDERS?
Common surgically treatable disorders of the human spine are categorized into degenerative (from chronic wear and tear problems), traumatic (from accidents that cause spinal instability), neoplastic (from benign or malignant tumors). In addition, there are other rare conditions that we treat in our practice such as infection, vascular malformation (malformed vessels) and congenital deformity (defects from birth). The neurosurgeons at Los Angeles Neurosurgery Associates treat all types of spinal diseases and injuries. Disorders can involve the spinal bony structures, the spinal lining structures (e.g., dura), and/or the nerve themselves (spinal cord and nerve roots).
1. Degenerative changes usually involve the soft tissues that "glue" the bony structures together. Due to wear and tear, the soft tissues (discs and ligaments) can become incompetent and fail. The most common disorders involve the discs (disc herniation or pain from the degenerative discs) and ligaments (ligament incompetence that causes spine instability or overgrowth of the ligament that causes compression of the nerve structure). The surgical goal for these disorders is to remove any impingement to the nerve, resect any pain generating centers (discogenic pain), and provide sufficient stability for the spinal column.
2. Traumas or accidents usually damage the bony structures of the spinal column, which consists of vertebral bodies in the front and vertebral arc in the back. This can result in an unstable construct, which will need fusion to correct the instability. During the accident, the nerve itself (spinal cord or nerve roots) can also be injured. Sometimes, this injury may not be reversible. However, the key for best outcome and recovery is to: remove the compressing elements and restore the best blood supply to the injured nerve segment. Therefore, we are the advocates for early intervention to achieve the best possible outcome.
3. Neoplasms or tumors can make the spine unstable because of the destruction of vertebral elements or compress on the nerve because of their over-growth. They may come from a distant site (metastasis) or local area (primary neoplasm). Depending on the natural history of the tumor, treatment should be aimed at either a palliative measure or curative excision. Our goal is simple: to ensure the nerves are free from compression and to support a steady vertebral column from collapsing. This simple approach will give the patient the best neurological outcome, the least pain caused by cancer, and the ultimate regain of functionality after the surgery.
4. Vascular malformation is a rare condition. It causes symptoms by either "stealing" blood supply from the nerve tissue or by compressing the nerve tissue due to the mass. Teamed with endovascular interventionists, our neurosurgeons are experienced to successfully treat these rare conditions.
5. Congenital spine problems can occur to vertebrae (bone) or nerve itself. The vertebral involvement from congenital conditions require similar treatment as the degenerative cases. When the nerve is involved, our neurosurgeons are especially trained to deal with such conditions to relieve any pressure on the spinal cord or nerve roots.
6. Infection can destruct the spinal canal or form an abscess that compresses the spinal cord or nerve roots. In addition to appropriate antibiotics, the integrity of the spinal column should be maintained and the compressive abscess should be drained for the best recovery of the patient.
ARE THERE ANY ALTERNATIVE TREATMENTS OTHER THAN SURGERY?
Absolutely. Except for a few emergency cases, most of the spine disorders should be initially, as a matter of fact, managed conservatively. Our neurosurgeons will provide you with a comprehensive list of options tailored specially to your specific problem. Some of the modalities we recommend include resting, bracing, physical therapy, epidural injection, and trial of other alternative medicine. Only when the non-surgical options are exhausted, we would consider surgical intervention.
WHAT ARE SIMPLE AND COMPLEX SPINAL SURGERIES?
* The simplest type of spinal surgery is a simple decompression without fusion. This type of surgery works only when there is nerve impingement. Materials that compress on the nerve structures are removed surgically. Procedures, such as laminectomy (removal of the vertebral arc in the back), discectomy (partial removal of herniated disc), foraminotomy (widening of the opening where the nerve root exits), and partial facetectomy (removal of overgrown joints from the back) are very commonly performed surgeries in this category. These procedures decompress the nerve structure without a fusion and are less time-consuming. Because there is no spinal fusion involved, the decompression should be limited so that any possible instability of the spine does not occur. If a more extended decompression is required, an additional fusion procedure should be mandatory to prevent subluxation of the adjacent vertebrae.
* Complex spine surgery usually consists of a wide decompression and fusion. The decompression part is overall the same as the simple spinal surgery, but there is a fundamental advantage of a complex spine surgery. As the neurosurgeon will perform a spinal fusion as the second part of the procedure, he or she does not have to worry about the limitation of the decompression. For this reason, the decompression is usually more extensive and more effective.
Some disorders will require stabilization or fusion. For instance, degenerative discs can cause severe back pain without actual nerve impingement. This disorder cannot be treated with a simple decompression. Decompression and fusion will be necessary. In addition, any instability of the spinal column will absolutely require a spinal fusion.
WHY DO I NEED MRI, CT, OR PLAIN X RAYS?
Plain X Rays of your spine provide a cheap way to survey your vertebral alignment and integrity. A complete set of plain X Rays usually include dynamic flexion/extension views, oblique views, and front and side views. In certain circumstances, other special views will also be necessary, for instance, if there is fracture of the upper neck area. The plain films are cheaper than CT scans, and dynamic views of the spine are extremely difficult to obtain from CT scans.
CT scans use X Ray and complex computer processing to get a 3 dimensional view of the spine, and they are superb in demonstrating the bony structure of the spine. This study is important if there is a fracture involved, or if fusion will be performed during the surgery. It provides road-maps for the neurosurgeon to place their hardware at the precise and optimal position.
MRI scans can provide spectacular images of the spinal soft tissues, which cannot be seen clearly on CT scans. It is today the study of choice for discs and ligaments. In addition, disorders in the spinal cord itself can only be visualized with MRI scans.
HOW ARE THE SURGERIES PERFORMED?
The approaches of the surgery depend on the location of the lesion. The neurosurgeons can approach the spinal problems from the front or the back. There are primarily two goals for the neurosurgeons. First, the nerve structure has to be totally free of compression. This may involve the removal of part of the bony spinal column, its ligaments, disc materials, or any foreign materials (such as tumor or pus). Secondly, the vertebral column has to be reinforced to provide integrity and stability. This may or may not involve the fusion process, which involves adding new bone-forming material between the segments to be fused and applying strong metal hardware to hold everything in place while fusion is taking place (usually in several months).
After the surgery, the patient will be referred to physical therapy for exercising and rehabilitation. A brace will be used if there is a fusion of the spine to provide additional stability during the healing process.
For Consultations:Los Angeles Neurosurgery Associates 1245 Wilshire Boulevard, Suite 305 Los Angeles, California 90017 (213) 977-1102, (213) 977-0656 (fax) http://www.LANeurosurgery.com info@LANeurosurgery.com
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