Spine Conditions

Cauda equina syndrome is failure of the cauda equina, a nerve bundle in the lumbosacral spinal canal that connects the spinal cord through the lower back into the pelvic girdle, thighs and legs. It is caused by compression of the cauda equina from disc herniation, epidural abscess, tumors or spinal canal stenosis. This results in back pain, urinary retention, loss of bowel and bladder control with incontinence, leg weakness and numbness including numbness around the buttocks and perineal areas (saddle anesthesia). Cauda equina syndrome may lead to potentially catrastrophic loss of motor function, sensory function and sexual function, the inability to walk, incontinence to stool and urine, and care dependency. Emergent laminectomy and decompression surgery aims at removal of the pathological tissues compressing the cauda. The goal of surgery is to remove the compression that causes cauda equina syndrome. Nerve function already lost by the time of surgery may not recover.

Cervical disc herniation may result from acute trauma or chronic degeneration of the intervertebral discs. Discs are soft cartilage cushions contained by a fibrous ring that keeps the cartilage in place. If the fibrous ring cracks, parts of the disc can bleb out or break off completely, compressing the surrounding nerves or spinal cord, resulting in neck pain, radiculopathy or spinal cord dysfunction. Neurology workup and testing and an MRI scan of the neck is needed for any numbness, weakness, clumsiness in hand and fingers, gait imbalance or trouble with bowel and bladder control. Depending on the findings and severity of symptoms, surgery can often be avoided but if there is any risk to nerves or spinal cord, removal of the bad disc is needed. This can be done through anterior cervical discectomy and fusion (ACDF) or artificial disc replacement (ADR).

Cervical radiculopathy results from irritation or injury of spinal nerve roots. Symptoms include pain in neck, shoulder, arm, hand or fingers. Neurology workup with MRI scan and electrophysiological testing are valuable to establish what caused the symptoms. Viral infections and other causes are treated by the neurology or medicine specialists. If mechanical compression from disc herniation or neuroforaminal stenosis is found, treatment may include a neck brace, epidural steroid injections, nerve root blocks, physical therapy and pain medications. For no improvement or for any signs of nerve damage, the neurologist or primary care doctor will make a referral to a neurosurgeon to consider surgical decompression with discectomy or foraminotomy, to remove the mechanical issue.

Cervical spinal canal stenosis is narrowing of the spinal cord canal commonly found late in life. Stenosis results from gradual buildup of bone spurs, disc bulging, facet joint arthritis and thickening of the spinal ligaments. Once the narrowing affects function of the nerves and spinal cord, decompression surgery should be considered. Typical surgeries for cervical spinal canal stenosis are anterior cervical discectomy and fusion (ACDF), cervical laminectomy, or cervical laminoplasty. Cervical spinal stenosis can become a serious concern for the very elderly because it may cause frequent falls and if untreated, could result in spinal cord injury with paraplegia or quadriplegia.

Cervical neuroforaminal stenosis causes spinal nerves to get stuck in an exit channel that is too tight. The nerve gets irritated causing pain, numbness and weakness (radiculopathy). Diagnostic workup includes a neurological examination, MRI scan of the cervical spine, and nerve testing including electromyography (EMG) by a qualified neurologist. Initial treatment may include a neck brace, pain medications and a visit to an interventional pain specialist for nerve root blocks to ease the irritation. If that does not help, the back of the nerve channel can be drilled open and expanded in dorsal foraminotomy surgery, or the front of the channel can be accessed and opened up through an anterior cervical discectomy and fusion (ACDF).

Discitis is an infection of the spinal disc space that can usually be treated without surgery. Needle aspiration under CT or fluoroscopic guidance helps to identify the offending organism. Sometimes discitis is seen with other infections such as septic joints or bloodstream infections (sepsis). Correct choice of antibiotics and treating the underlying problem, such as malnutrition in the setting of alcoholism or very elderly status, uncontrolled diabetes, drug habits such as skin popping, or infected heart valves (endocarditis) may improve the patient’s chance to clear the infection without need for any surgery. If discitis gets out of hand, epidural abscess or spinal osteomyelitis can develop, resulting in spinal bone destruction and accumulation of pus around nerves and spinal cord, requiring surgery to drain the abscess or to reconstruct and stabilize the vertebral column.

Lumbar disc herniation or bulging discs are regularly seen on MRI scans of people with zero back issues that got the scans for other reasons. If a disc puts sufficient pressure on a spinal nerve however, it can cause sciatica and numbness or weakness in the leg. Sciatica is a severe pain that radiates down the leg and can be disabling. Sciatica is a self limiting problem, more than 90% of patients will make a full recovery without any surgery. Recovery may occasionally be lengthy and take several weeks or months. Best initial treatment is a few days of rest and keeping the hip and knee bent to relax the nerve. Once the pain eases up a bit, it is important to stay physically active as much as possible and to do some physical therapy and core strengthening. Oral pain medications such as Tylenol and non-steroidal anti-inflammatory medications (NSAIDs) will relieve some but not all of the pain. Many patients decide to see an interventional pain specialists for an epidural steroid injection (ESI) or nerve root block that controls the pain more effectively than oral medication. Prescription opioids must be avoided because they lower the pain threshold and worsen the pain experience requiring escalating doses of narcotics. This spirals quickly into chronic severe pain and addiction and for many, accidental overdoses (currently >100 daily deaths from prescription opioid overdoses in the US, celebrities who died from prescription opioids include Prince, Heath Ledger, Elvis, Judy Garland, Michael Jackson, Tom Petty…). Narcotic addiction and chronic pain are lifelong problems that persist even after the original problem has long healed up. Surgery is reserved for no improvement of pain despite treatments, or for any paralysis and muscle weakness indicating nerve damage. In the rare case of no recovery over time or for any nerve damage with leg weakness, the best option is microdiscectomy to remove the herniated disc away from the nerve to take pressure off. This usually results in rapid improvement in pain. Numbness and weakness may take a long time to recover because it is an injury that occurs when the disc pops out and stretches the nerve, and even after removing the disc herniation, the nerve may take many months to get over that initial injury and there are unfortunately no special treatments that would speed up the healing process.

Lumbar spinal canal stenosis compresses nerves in the lower back causing lower back pain and symptoms in the groins, thighs and legs such as weakness, numbness, heaviness and soreness. This gets worse walking up flights of stairs or walking uphill because these activities create more demand on the nerve bundles and the compression limits blood circulation, leading to demand failure. It is a common condition when we get older because wear and tear on discs and spinal structures causes thickening of joints, discs and ligaments that leaves less room for the nerves. Treatment starts with epidural steroid injections aimed at soothing the compressed nerve bundles but ultimately, decompression lumbar or lumbosacral laminectomy surgery is needed to resolve the spinal stenosis.

Osteoporotic spinal compression fracture results from loss of bone substance (osteoporosis) in the vertebrae. These fractures are usually stable and do not need surgery. Until healing is complete, patients usually experience pain that may be severe and worse when standing and walking. Depending on the level of the fracture, a lumbar brace or thoraco-lumbo-sacral support (TLSO brace) will be fitted. Some patients cannot walk properly for several weeks and need to see their primary care doctor to talk about the medical problems of immobility and what they need to do to avoid these conditions. Briefly, immobility may cause blood clots such as venous thrombosis in the legs that may lead to pulmonary embolism. Inactive patients may also develop pneumonia, skin breakdown and decubitus ulcers with high risks of infections. None of these issues are treated by the neurosurgery team but by medicine and primary care physicians. For patients that fail to recover and remain immobilized for a prolonged period of time, percutaneous vertebral cement injections called vertebroplasty or kyphoplasty can be used for pain control, with varying results. Osteoporotic vertebral compression rarely ever need surgery, but these fractures are a serious warning sign indicating poor bone health. An aggressive approach including lifestyle and dietary changes, osteoporosis awareness and treatment, and biannual injection therapy are often required to prevent fractures of spine and long bones in the future. Talk to your primary care doctor about osteoporosis prevention and treatment.

Sciatica is acute onset severe low back pain radiating into the buttocks, groin, thighs, down to the knees and feet depending on which nerve root is affected. The usual cause is a disc herniation. It is a self limiting condition in >90% of cases, and rarely needs surgery. Any numbness or weakness that does not improve or resolve over a few weeks may indicate ongoing nerve pressure and decompression surgery may be considered. Sciatica is treated by your primary care doctor, interventional pain specialist, physical therapist and neurologist who can perform electrophysiological testing to check how the nerve root is recovering. Referral to neurosurgery is only needed if all else fails, or if there are concerns about nerve damage with weakness or numbness or trouble with bowel and bladder function. I do not offer early surgery within the first 6-8 weeks, except to save someone’s nerve or job, such as keeping a professional athlete on the team for the season.

Spinal cord tumors are rare and include glial tumors such as astrocytomas and ependymomas and vascular tumors such as hemangioblastoma. They are usually quite challenging and may not be resectable even in the best of hands.

Spinal deformity may happen early in life as part of a genetic or developmental condition but more commonly results from life long degenerative wear and tear on discs, bones, ligaments and joints. A cork-screw like twist of the spine is called scoliosis. Spondylolisthesis denotes a slipped vertebra either forward (anterolisthesis) or to the back (retrolisthesis) of its usual position. A sideways vertebral slip is less common and is called laterolisthesis. Kyphotic deformity describes a spinal column segment that kinks or leans forward too much. In lordotic deformity, the spine kinks or leans backwards too much. Juvenile spinal deformities are best treated by a pediatric deformity team to halt progression of the deformity, often without need for surgery. Adult degenerative spinal deformities need a thorough functional and radiographic assessment to determine what type of non-surgical and surgical options may improve and maintain function in the long term.

Spinal epidural abscess is pus accumulation from spinal infection. Abscess is a build-up of pus, a thick, creamy white-yellowish sauce resembling cream of wheat, that contains dead bacteria and dead white blood cells, collateral damage of a serious bacterial infection. The abscess creates pressure on surrounding tissues, resulting in pain and if nerves are involved, loss of nerve function such as paralysis, loss of sensation, inability to walk, loss of bowel and bladder control etc. Epidural abscess is seen on spinal MRI. The causative organisms can be diagnosed and cultured in the lab after needle aspiration under CT or Xray guidance. Any significant pressure on the spinal nerves, cauda equina or spinal cord requires immediate surgery, to drain the abscess, remove pressure on nerves, to obtain a microbiological diagnosis, and to maximize the body’s chance to eliminate the infection. Epidural abscess often indicates a serious host condition such as poor nutrition or malnutrition, lack of health intelligence, poorly controlled diabetes, drug use, poor hygiene, morbid obesity, cancer, endocarditis etc which often renders these patients gravely sick and unable to heal the wounds or fight the infection, despite aggressive and optimal surgical care. Many months of antibiotic treatments are usually necessary, sometimes life long suppression antibiotics are required to prevent relapse of the infection.

Spinal meningiomas and nerve sheath tumors usually present with back pain or dysfunction of spinal nerves or spinal cord. Meningiomas arise from the skin coverings around the spinal cord and are slow growing. They can usually be removed in surgery. Tumors of the spinal nerve sheath such as schwannomas or neurofibromas are usually resectable but sometimes the nerve root needs to be sacrificed for complete tumor removal. Neurofibromas can be cancerous especially in neurofibromatosis patients, and adjuvant or neoadjuvant chemotherapy and radiation may be required.

Spinal osteomyelitis is an infection of the vertebrae that usually originates elsewhere in the body from dental infections, bacterial endocarditis of the heart valves, skin infections or drug injections “skin popping” using dirty needles. Once introduced into the body, bacteria may spread in the bloodstream and settle inside the spine. Blood supply to spinal bones and discs is sparse, allowing bacteria to hide and grow unimpeded, rendering antibiotic treatments less effective. Bacteria can also be introduced into the spine during medical procedures such as spine surgery and cortisone injections in pain clinics. Infections are promoted by any condition that compromises the immune system such as morbid obesity, poorly controlled diabetes, cancer, alcoholism or malnutrition predispose patients to spinal infections and make it hard to clear these infections. Chronic infections can destroy the bone leading to deformity, requiring reconstruction and stabilization surgery. Purulence or pus may accumulate next to the bones causing epidural abscess that often requires surgery to drain to avoid pressure and damage to nerves and spinal cord.

Spinal vascular malformations include spinal arteriovenous malformations (AVMs) and spinal arteriovenous fistulas (AVFs). These are abnormal connections between the high pressure arteries and the low pressure veins, diverting blood from nervous tissue or causing the veins to enlarge and compress the spinal cord, or to rupture causing a sudden high pressure bleeding in or next to the spinal cord. A ruptured AVM causes acute hemorrhage with severe back pain or headache and nausea and impairment of spinal cord function such as sudden leg weakness. Fistulas (AVFs) often cause progressive spinal cord dysfunction or myelopathy with gradual onset leg weakness, urine incontinence, trouble walking long distances, impotence, or difficulty feeling or controlling the legs. Treatment is by a team of neurologists, neurointerventional radiology and neurosurgery.

Spine metastasis is spine cancer that originated outside the vertebral column. Frequent sources for spinal metastases are lung cancer, breast cancer or prostate cancer. Blood cell tumors such as lymphoma and multiple myeloma can be found in the spine as well. Treatment of spine metastasis depends on what cell type it is. The cancer specialists may recommend chemotherapy or radiation therapy instead of surgery. Role of surgery is to obtain a diagnostic biopsy, to stabilize the spine, or to remove cancer away from the spinal cord and nerves to make other treatments such as radiation safer and more effective.

Spine tumors that are not metastasis are often relatively benign such as aneurysmal bone cyst, eosinophilic granuloma, epidermoid or dermoid cysts or hemangiomas. Aggressive bone tumors are rare in the spine and include osteosarcoma, chondrosarcoma, chordoma.

Traumatic spine fracture is either managed with immobilization in a brace, or requires surgical stabilization and instrumented fusion. Degree of disruption of bones, ligaments and discs and the presence of nerve damage will determine what type of surgery is needed to repair the fracture.