MRI annular tear

Why do annular tears hurt so much?

Annular tears are seen on MRI scans of the lumbar spine.  They appear as tiny white dots in the back of the disk.  The radiologist will call annular tears “posterior high intensity zone lesions.”  In addition to severe low back pain, they are a source of confusion, concern, and unanswered questions about their significance and treatment.

Here is a short video where I review the MRI scan of someone with an annular tear of the L5-S1 disc

Here is a short description of his symptoms in his own words:

  • prior to August 2016 I was doing a lot of recreational running

  • At the end of July 2016 I fell while biking, felt a sharp pain immediate after fall but everything seemed OK after two days.

  • early Dec 2016, moved a piece of furniture and felt sharp pain in back – obviously this caused severe injury of the disc

  • mid Dec 2016 – got my MRI scan

  • end Dec 2016 – new sharp pain bottom of pelvis. Obviously I re-injured the disk again and made things worse. Back pain lasted for 2-3 weeks before slowly improving.

  • Jan 2017 – back pain started to improve and I was able to do some back pain excercises

  • beginning Feb 2017 – started to feel numbness (I assume it was because I took a business trip, more sitting, traveling with bag, airports… that caused things worse)

  • last 7 days I was very careful and things have improved slowly.  my tensor latae fasciae spasm continues.  I cannot run.

  • Through all this time I felt almost no leg pain. I had some occasional pain in the toes which I was not sure if originates from spine (not severe, one day episodes). Numbness scared me but it was not very severe.

What I ask myself all the time is:

  • I can hear popping in my back with certain moves (for example changing position while sleeping from one hip to another or with some leg movements). Does this come from the disc tear or herniation? It is painless.  I have feeling it comes from the back.

  • What is my prognosis? As most people would, I would like to avoid surgery but do not want to make things worse. I have no problems with pain at the moment but would like to return to some sport activities in the future. I learned that healing should take at least 6 months. Is this possible without surgery in my case?

  • What would be your recommendation in my case?

And here is his MRI scan

In this patient’s case, I recommend that he continue with non-operative care.  His pain has already started to decrease and he is still active.  We would reasonably expect that with time this should heald and he should feel like he has a normal spine.

Here are some other examples of MRI scans of the spine with an annular tear

In this first example of an annular tear in the L4-5 disk in a 22 year old female, there is a tiny white dot in the back of the disk where the fibers of the annulus are torn.

annular tear L4.5

In this second example, in the L5/S1 disk, the annular tear is centrally located and is more apparent on the axial view.  These are T2 sequences, and the computer algorithm that creates the T2 images from the raw MRI scan data makes fluid look bright white.  You will notice that the cerebrospinal fluid appears bright white.  CSF is a filtrate of plasma.  Since the CSF appears white, we conclude that the annular tear is probably a gap in the fibers of the annulus fibrosis that is fluid filled.

Most patients with annular tears have similar histories.  They report that they were lifting a heavy object, moving awkwardly, or twisting at the same time.  Suddenly they felt like they were shot or stabbed in the back.  They are often in a tremendous amount of pain.  Since they do not have a large disk herniation on the MRI scan, these patients are often described as having “pain out of proportion to expectations”.  This is a little unfair because in my experience, annular tears seem to be very slow to heal and they can be a cause of long lasting and disabling back pain.

Why?

I believe that annular tears represent a partial disk herniation.  The annulus fibrosis that surrounds the intervertebral disk is made up of many layers.  When an annular tear occurs, the central portion of the disk, the nucleus pulposus, herniates through most, but not all of the layers of the annulus.  A fragment of disk material is stuck in the middle of the tear and it is surrounded by fluid and inflammation.

The nucleus of the intervertebral disk is made of a protein core consisting of proteoglycans.  These long, branched proteins are relatively acidic, viscous, and naturally slippery.  As such, they are designed to prevent adhesions and scar tissue formation since they are natural shock absorbers.  When they get trapped in between the fibers of the annulus, they prevent the collagen fibers in the annulus from healing.  As a result, there is a permanent weak spot in the fibers of the annulus which is a constant source of pain.

Whats the best treatment for annular tears?

A number of times in my surgical career I have operated on patients with broad based disk bulges, an annular tear, and both back and leg pain.  When I make a small incision in the outer covering of the disk, a fragment of disk material squeezes out as if it were under pressure.  Typically, there is a small cavity where the annular tear is located that is filled with fragments of disk material.  The patient’s leg pain gets better after the operation because of the microsurgical decompression.  Interestingly, the patient’s back pain improves rapidly after the operation because without the fragment of the disk stuck in the tear the annulus can finally heal.

I’ve arrived at the conclusion that for some patients with relentless back pain related to an annular tear it makes more sense to have a microsurgical decompression with an exploration of the annular tear and a removal of the fragment of the disk that is just underneath the surface.  This seems to kick start the healing process and let them get on with their lives faster. My favorite technique for treating annular tears is now an endoscopic technique. Here is a video of how I do that operation:

Other patients, however, will get better with non-operative treatment.  With time, and and a gradual return to normal activities, their back starts to settle down and they have less and less pain.

The other option is an injection into the disk space of either platelet rich plasma or adipose derived stem cells.  There is good evidence to suggest that PRP injections are effective in shortening the time that annular tears hurt.  Stem cell injections are also a really exciting area of active clinical research and there is some early evidence to suggest that stem cells injected directly into the disc may help.  At the moment, the best evidence suggests that either a microscopic decompression with a removal of the trapped fragments or a platelet rich plasma injection is the best treatment if non operative treatment simply isn’t working.

What kind of options do you have if you have an annular tear?

Many annular tears will get better with non operative treatment, but some don’t.  If you’ve had pain for more then 6 weeks and you have already had an MRI scan of the spine, I can review your MRI scan for you and tell you what options you have.   To get started with this process click here: MRI review service

reverse hyper

Spondylolisthesis: can it be reversed?

What is spondylolisthesis?

Spondylolisthesis is a common cause of back and leg pain.  The most common question that I get asked immediately after I tell someone that they have a “spondy”, is a variation of….

  • “Can it be fixed without surgery?”
  • “Will it go back into place if I do a lot of back bends?”
  • “Can I reverse my spondylolisthesis with physical therapy?”

Let’s look deeper into questions surrounding the idea of reversing spondylolisthesis.  The word spondylolisthesis has two words with Latin roots.  “Spondy” is latin for spine, and “listhesis” is latin for slipping.  In this condition one vertebral body slips forward with respect to the one immediately underneath it.  The two most common locations of a spondylolisthesis are L4-5 and L5-S1.

Case Examples

Here is an X-ray of the spine with a spondylolisthesis at the L4-5 level.  In this case, this a grade 1 slip — L4 has slipped about 20% of the length of the L5 vertebral body.

 

L4.5 grade 1 spondy lateral preop

This condition has a couple of different causes.  The most common cause of a spondylolisthesis is degenerative disk disease caused by the normal aging process.

The other most common cause is repeated hyperextension during sports as an adolescent when the spine can develop a stress fracture called a “spondylolysis”.  This typically causes back pain during adolescence and may later progress to a spondylolisthesis.

Why do some people develop a spondylolisthesis?

The risk factors for developing a spondylolisthesis include:

  • female sex
  • hyper flexibility
  • increased lumbar lordosis
  • according to Readysteadygymnastics.co.uk, sports such as football and gymnastics that involve hyperextensions of the spine.

I’ve written a more detailed article about there natural history and treatment of spondylolisthesis here: https://sohrabgolloglymd.com/spondylolisthesis/

Reversing Spondylolisthesis: is it possible?

Since the surgical treatment for fixing a spondylolisthesis typically involves a single level fusion of the spine, most people want to know about their alternatives.  Their two most common concerns / desires are as follows:

1. They are reluctant to jump right into a fusion

2. They are very interested in alternatives.

I’m a cross fitter.  I love to surf.  If I had a spondy, I’d want to wait for as long as I could before I got a fusion.  I’d also do all the PT and non-operative treatment that I could.  I checked the crossfit boards and found this thread on spondylolisthesis:

“I am an active duty Army officer diagnosed with Spondylolisthesis, L5 shifted approx 30-35% forward (anterior) over S1. I most likely incurred my injury during my early years in the military. To my knowledge, the degree of shift has not changed over the years. I have been crossfitting for 4 years, and my back issues have fluctuated over the years in terms of severity and impact to my workouts. However, it has not impacted my ability to do my job or deploy. At this time, I am mid way through my 8th deployment, and I’m trying to proactively minimze my syptoms as much as possible on a daily basis.

I avoid heavy deadlifts and GHDs, but pretty much do every thing else as Rx’d. My symptoms sometimes include back soreness, which gets too severe to exercise about 1-2 times a year for a few days. I do my best to listen to my body and reduce my activity when this happens.”

The recommendations that follow this post include an excellent discussion about the pros and cons of reverse hyper-extension exercises with the lumbar spine, inversion therapy, and avoiding certain heavy lifts — like deadlift and squats.  If you want to read the entire thread, follow this link — http://board.crossfit.com/showthread.php?t=61980

This is a picture of rogue’s reverse hyper extension machine for the lumbar spine:

reversing spondylolisthesis

http://www.roguefitness.com/rogue-reverse-hyper-2

What should you do next?

Here’s my opinion.  FORM is critically important if you have a spondylolisthesis.  If you think about it, a spondylolisthesis is probably a normal response to an abnormal movement pattern.  Most of these patients trend towards the hyper flexible part of the athletic spectrum.  Their joint laxity and movement patterns probably put increased stress on the intervertebral disk during physical exercise.  Most likely, this is a shear type of force where the trunk is trying to slide anteriorly with respect to the pelvis.  If the core is strong and the trunk is solidly anchored to the pelvis, this shear force should be offset by the stabilizing strength of the glutes and spina erecta musculature.

If you workout with PERFECT FORM, you should theoretically neutralize the forces trying to push your slipping vertebral body anteriorly.  If you strengthen the muscles that neutralize these forces, you should be able to work out with risking progression while also stabilizing your core.   Do this for long enough and you’ll have a bullet proof core and less pain.

My favorite book on this subject is Kelly Starrett’s Becoming a Supple Leopard, but you can always start with https://www.mobilitywod.com.

Neutral Spine.  Neutral Spine.  Neutral Spine.  That’s the mantra you should be repeating to yourself every time you lace up your shoes if you have a spondylolisthesis.

What about surgery?

Finally, a word about surgical treatment.  As the field of microscopic spine surgery has evolved, I have become much more willing to perform an microscopic decompression of the nerve roots affected by the spondylolisthesis, especially if someone has leg pain on only one side.

In my opinion, correct body mechanics has just as much ability to stabilize a spondylolisthesis as a fusion does, and if I needed an operation because I had relentless leg pain due to a spongy, I’d have a microscopic decompression and be absolutely meticulous about my rehab.

If you’ve got questions about what to do about your spondylolisthesis and you’d like us to review your MRI scan, we’d be happy to just visit this page here to get started.

anterior microforaminotomy opening

Cervical microforaminotomy versus anterior cervical discectomy and fusion

Why we do Microforaminotomy surgery instead of fusions for neck and arm pain

My neurosurgical partner, Dr. Dimitrov, and I got interested in cervical microforaminotomies in 2010.  Our very first patient was a local big wave surfer who had arthritis and disk herniations at three levels in the cervical spine.  With 3 level cervical disk disease, and occasional episodes of severe neck pain, he had been told over and over again that #1 he needed a 3 level fusion, and #2 after the fusion, he wasn’t going to be able to surf big waves again.  I know him socially, and he asked me for a second opinion.

When I had the chance to examine him, it was clear that he only had pain in his left C6 nerve root distribution.  When I gave him a pain diagram to complete, he circled this image.

His MRI scan showed that he while he did have 3 level degenerative disk disease in his cervical spine, he had a large extruded disk fragment and a bone spur compressing the nerve root on the left side.  We discussed his options and because he was adamant that he would rather live with the pain and the muscle weakness than have a fusion and have to give up surfing, we discussed performing an anterior cervical foraminotomy.  I gave him a number of articles from the literature to read and he agreed that this seemed like a very reasonable approach.  We did his operation, his pain disappeared, and his strength came back.  Understandly, he was delighted.  Even better, he was convinced that he’d avoided a big operation that would have left him partially disabled.  I agreed.  He sent his friends, and they sent their friends, and now this is an operation that we perform frequently.  Happy surfers make for happy surgeons.

Here’s an explanation of the anterior cervical microforaminotomy as an alternative to a cervical fusion.

Medical definitions that you need to know

First, a couple of simple definitions.  The medical term for neck and arm pain caused by a herniated disk is “cervical radiculopathy”.

The word radiculopathy is composed to two words with latin origins.  The word “radix” means root and the word “opathy” means a disease of.  A herniated disk puts pressure on the root of the nerve and causes pain every where the nerve travels.

A herniated disk usually squeezes the nerve root as it tries to leave the spinal canal through a small bony tunnel called the neuroforamen.  The word neuroforamen also has latin origins.   “neuro” is the latin word for nerve and “foramen” is the latin word for an opening.

MRI findings that cause cervical radiculopathy

Ok, now that we understand those two terms, let’s look at an MRI scan of the cervical spine.  This view is called the saggital view and there are 7 vertebrae in the cervical spine, C1 through C7.  Between each of these bones are the intervertebral disks.  Here at the C5-6 level there is a disk herniation.  On this view we can see how the disk is bulging out towards the spinal cord and the nerve roots and when we switch to a cross-section, called the axial view, we can see how the disk bulge is off to one side and putting pressure on the nerve root as it travels through the neuroforamen.

The location of the pain is a clue as to which nerve root is being affected.  The cervical nerve roots travel to particular parts of the arm and the hand.  We have our patients complete a pain diagram and a pain journal and this helps us confirm which nerve root is irritated and inflamed by the herniated disk.

Non-operative treament and fusion surgery

When the symptoms of a cervical radiculopathy do not get better with non-operative treatment that includes physical therapy and anti-inflammatory medications, most patients realize that they may need a surgical solution for their pain.  They need the pressure to be taken off the nerve root so that the pain will stop.

The standard operation for a herniated cervical disk is something called an anterior cervical discectomy and fusion.  This is a surgical procedure that removes the damaged intervertebral disk and replaces it with a spacer and titanium plate, stabilizing that level.  This operation reliably alleviates the pain from a herniated disk, but unfortunately, fusing one level in the cervical spine increases the mechanical stress on the adjacent levels in the cervical spine and accelerates the natural degenerative process that occurs with age.  This can lead to a loss of range of motion, more pain, and more surgery in the future.

The results of cervical fusion surgery can be very good, but many younger patients who are athletically active would really like to avoid a fusion.

Cervical microforaminotomy — an alternative to fusion surgery
There is an excellent operation for this problem that completely avoids a fusion.  This operation is called an anterior cervical microforaminotomy.  It has an excellent track record in the medical literature.

In fact, the former head of neurosurgery at the University of California in Los Angeles remarked in one of his papers that “Patients treated with the anterior cervical neural foraminotomy procedure have equivalent or better outcomes than those who undergo current cervical procedures. It appears to be a good procedure for carefully selected patients with one sided cervical radiculopathy and avoids a fusion of the disc space.”

In this operation, a small incision about 1 inch long is made in the front of the neck and the damaged disk is exposed with the help of a microscope.  A tiny tunnel is created in the disk and the surgeon works all the way back to the nerve root, lifting the herniated fragments of disk off the nerve root.  Because the operation requires removing less than 20% of the disk, a fusion is not necessary.

In these still images from an operating microscope we can see the surgeon using a special neurosurgical tool called a kerrison rongeur to clean the herniated disk off the nerve root.  The surgeon is working through a small channel in the disk that measures 1/8 of an inch by 1/4 of an inch.

Here are the before and after MRI images of the spine demonstrating removal of the herniated disk with an increase in the size of the neuroforamen.

After this procedure the patient can return to normal activities within two weeks.  We advise patients to avoid sports such as mountain biking, horseback riding, and surfing for 6 weeks, but after everything has healed we expect all of our patients to have normal range of motion of the neck and no activity restrictions.

At the minimus institute in Monterey, California, we specialize in motion preserving procedures for cervical disk disease.  We want to see all of our patients free from pain and able to return to the activities that they love.

If you are interested in a cervical microforamiotomy or alternatives to fusion surgery, contact our concierge and we will arrange to have your MRI scan reviewed by one of our surgeons.

MRI review to see if you are a candidate for a microforaminotomy

Microscopic discectomy

Surgery for disk herniations

Disk herniations come in all sizes and shapes and they cause all sorts of symptoms.  Some symptoms, such as leg pain, numbness in the legs, and muscular weakness can be improved with surgical treatment, whereas some symptoms, such as back pain, are less likely to improve.  The best candidates for a microscopic discectomy are people with a disk herniation that is causing significant nerve root compression and the patient wants the nerve root pain alleviated.  For example, here are a series of slides from a talk that I give on MRI anatomy of the lumbar spine that demonstrate the different types of disk hernations.  Click on each image to enlarge it to full size and to see the caption…..

disk extrusion focal disk herniation  annular tear  disk herniation the real thing

This series of images should convince you that there are disk herniations in name only, and those that really need treatment (the fourth slide).  The surgical treatment of disk herniations is relatively controversial, because medical research has shown that if you wait long enough, most people with a disk herniation will improve without surgical treatment.  In fact, it is considered dogma in the US that surgical treatment of disk herniations does not change the LONG TERM outcome, but simply helps patients to get over their pain and return to work faster.  In my experience, most patients WILL get better with physical therapy, medical management, and selective nerve root blocks, and they are able to avoid surgical treatment if they are patient enough.  However, there are those patients that clearly do better with a microdiscectomy and they tend to have the following findings:

  1. Their leg pain is worse than their back pain
  2. Their pain has been present for at least 6 to 8 weeks without any trend towards gradual improvement
  3. The disk herniation is large, a free or extruded fragment, and appears to be causing significant nerve root compression
  4. They have tried a course of physical therapy, NSAIDs, and possibly a selective nerve root block and each time the pain has come back.

If most, or all of these criteria are met, then having a microscopic discectomy is a reasonable choice.  In my practice, A microscopic discectomy is always an outpatient operation.  The patient is typically able to return to work within 2 weeks, and back to basically completely normal activity by 6 weeks.

In this short video, I explain what happens in the course of a typical microscopic discectomy

And in this short video, I explain how I do an endoscopic discectony

Why choose Microscopic Surgery at Monterey Spine?

Working as a combined orthopedic and neurosurgical team, Dr. Gollogly and Dr. Dimitrov successfully perform more microscopic outpatient spine surgeries each month than any other team in California, setting us apart as a leader in outpatient microscopic spine surgery.

Here are some facts about our program in Monterey, California:

  • Our dedication to outpatient microscopic spine surgery procedures has made us the busiest outpatient center in California.  A high volume of cases results in local expertise that helps hundreds of patients get back to their daily lives with less pain.
  • Dr. Gollogly and Dr. Dimitrov focus on avoiding fusion surgery.  They believe that careful surgical craftsmanship will alleviate nerve root pain in the operating room and spinal stability can be achieved through careful physical rehabilitation.  This makes many fusion procedures unnecessary.
  • With over 20 years of combined experience working together as a team, Dr. Gollogly and Dr. Dimitrov combine the expertise of neurosurgery and orthopedic surgery into one team that produces excellent results.
  • These procedures are performed in an Ambulatory Surgery Center that is the nation’s leader in bundled payments.  As an “in network” facility with transparent pricing, Monterey Peninsula Surgery center delivers fantastic results at a reasonable price.
  • 99% of patients who have surgery in Monterey report that they are “very satisfied” with their experience and would recommend it to a family or friend.

Outpatient Microscopic Procedures

Traditional Open Spine Surgery*

Hospital Stay

 

None

2-5 days

Infection Rate

 

0.0023%

4.4%

Complication Rate

 

< 1%

5.2%

Cost

 

Determined in advance

Typically $10,000 to $25,000

Unknown before procedure

Often as high as $90,000

*Risk Factors for 30-Day Unplanned Readmission and Major Preoperative Complications After Spine Fusion Surgery in Adults: A Review of the National Surgical Quality Improvement Program Database.  Su AW et al., Spine (Phila Pa 1976). 2016 Oct 1;41(19):1523-1534.

 

microdiscectomy technique: a step by step explanation

 

 

 

 

 

ligamentum-flavum-hypertrophy-disk-bulge

Lateral lumbar surgery for the treatment of degenerative lumbar scoliosis and stenosis

Decompression and stabilization of the degenerative lumbar spine using a minimally invasive extreme lateral approach: the XLIF experience

Degenerative scoliosis of the lumbar spine is a consequence of the natural deterioration of the intervertebral disks with age.  The biomechanical integrity of the disk declines with age.  Wear and tear on the disc causes oxidative damage to the proteins that make up the core of the disk.  Over time, the joint becomes unstable and the vertebral bodies start to slip out of alignment.  Some patients will develop degenerative disease of the lumbar spine without scoliosis, while others will develop significant scoliotic and kyphotic deformities.  The reason for this is unclear: why do some people get degenerative disease without scoliosis, while some people get severe scoliosis.  I presume that it may have something to do with posture, handedness, and asymmetrical forces acting on the spine over years and years of activities of daily living.

The symptoms of degenerative scoliosis

Patients with degenerative scoliosis of the lumbar spine typically come to clinic with two complaints: (i) back pain and (ii) leg pain.  In conjunction with their leg pain, they often have difficulty walking.  Usually, their walking endurance has declined in recent years.  Many of these patients will report that after walking a short distance they have to stop, sit down, lean forward.  After a few minutes their legs feel refreshed and they are able to get up and walk again.  Declining walking endurance is a symptom of neurogenic claudication.  Claudication is a word that means cramping pain.  In this case, the cramping pain is caused by spinal stenosis squeezing the nerve roots.  The blood supply to the nerve roots in the lumbar spine is decreased by increased disk bulging associated with weight bearing.  Forward flexion of the spine alleviates the pressure and restores the blood flow to the neural elements.  Here are two slides from a famous pathological collection of images that demonstrate the changes that occur — disk bulging and ligamentum flavum hypertrophy — that cause stenosis.  The first picture is from a young male, the second from someone in their 60’s or 70’s.

 

normal lumbar spineligamentum-flavum-hypertrophy-disk-bulge

Back pain and degenerative scoliosis

The back pain associated with degenerative scoliosis of the spine is a mechanical ache.  Patients typically feel worse at the end of the day or after spending a long time on their feet.  The pain is typically in the midline but tends to radiate around to the hip in a “belt like” distribution, and they often have bilateral deep seated buttock pain.
degenerative-scoliosislateral-xray-degenerative-scoliosisdegenerative-kyphoscoliosis

XRAY and MRI findings in degenerative scoliosis

Here are several plain xrays and the MRI scan of a 60 year old physically active male with degenerative kyphoscoliosis of the lumbar spine and associated spinal stenosis.  The plain xrays are taken in the standing position and they demonstrate that the disks have deteriorated and the vertebral bodies have started to slip out of alignment with respect to each other.  There is an abnormal side to side curvature of the spine.  This is the scoliotic component of degenerative diseass.  The anterior aspect of the lumbar spine has collapsed resulting in a flat or rounded low back.  This is the kyphotic component of degenerative disease.

Nerve root compression caused by degenerative scoliosis

The MRI scan demonstrates that at several levels there is significant compression of the space available for the nerve roots.  The most frequent area of compression is in the lateral recess areas of the spinal canal and in the neuroforamen where the nerve root is particularly vulnerable to compression.  Here several key images and the radiologist’s report of this patient’s pre-operative MRI scan:

pre op para saggital neuroforamenpre op axial L3.4

 

The Radiologist’s Report

MR LUMBAR SPINE WITHOUT CONTRAST
CLINICAL HISTORY: Sciatica pain and weakness with numbness left leg.
COMPARISONS: No previous.
TECHNIQUE: Sagittal T1, sagittal STIR T2, high spatial resolution sagittally acquired 3D T2 SPACE which was also reformatted as axial T2 images, and axial Tl images were acquired on 1.5T Siemens Magnetom.
CONTRAST: Noncontrast exam.

FINDINGS:

Lower T-spine: Visualized portions of the lower T-spine from T9 to T12 are relatively normal in appearance for age without canal or foraminal stenosis and without any distal cord or conus imprint or compression. Posterior disc protrusions are seen at T6-7, T7-8, T8-9 and T9-10 levels. While these indent the anterior CSF space no frank cord compression is appreciated.

Alignment: Mild focal dextroscoliosis of lumbar spine at L2-L3 levels is present. Degenerative translational spondylolisthesis to the right of L2 and L3 with respect to Ll and L4 is present. In addition L3 shows anterolisthesis with respect to L2 and L4.

Anatomy: Nonnal vertebral anatomy is present in that the last rib bearing vertebral body is presumed to be T12 and 5 lumbar type vertebral bodies are present. The tip of the conus is seen at the T12-L1 level.

Lumbar discs:

T12-L1: Normal for age disc level.

L1-2: Moderate degenerative disc disease is present. Broad posterior disc osteophytic ridging indents the anterior margin of the central CSF space without central canal stenosis and causes mild right foraminal narrowing and moderate left foraminal narrowing but no definite nerve root abutment, displacement or impingement is seen at this level.

L2-3: Severe degenerative disc disease is present especially on the left with obliteration of the disc space and endplate irregularities. Broad posterior osteophytic ridging related to the anterolisthesis of L3, causes mild central canal narrowing but more importantly causes moderately severe left neural foraminal narrowing, moderate left lateral recess encroachment, mild right lateral recess narrowing and mild/moderate right neural foraminal narrowing. There may be some nerve root abutment within the lateral recesses but no definite nerve root impingement is seen at this level.

L3-4: Severe degenerative disc disease is present due to Grade I, borderline Grade II anterolisthesis of L3. Osteophytic ridging in conjunction with facet arthrosis and hypertrophy results in moderate central canal stenosis with central nerve root abutment. More importantly there is severe bilateral neural foraminal narrowing with nerve root impingement suggested in both neural foramina.

L4-5: Mild degenerative disc disease with 3-4 nun broad posterior disc protrusion centrally. This effaces the anterior epidural fat and minimally indents the anterior margin ofthe central CSF space without significant central canal stenosis. There is mild bilateral lateral recess encroachment with nerve root abutment but no definite displacement or impingement. Neural foramina are moderately narrowed on the left and moderately severely narrowed on the right with some nerve root abutment within the foramina but no definite impingement.

L5-S1: Moderate to moderately severe degenerative disc disease is present with large right anterior and far right lateral osteophytic ridging. Broad posterior disc osteophytic ridging effaces the epidural fat but no central canal stenosis is seen. Broad posterior disc osteophytic ridging does abut descending nerve roots within the lateral recesses bilaterally. The right neural foramen is severely narrowed with nerve root abutment if not imprint. The left neural foramen is more patent without evidence of nerve root abutment.

Facet Joints: Facet joints demonstrate asymmetical arthrosis at L1-2 and L2-3. Facet arthrosis is relatively severe on the right at L3-4. Mild arthrosis right worse than left is seen at L4-5 and L5-S1.

Paraspinous spaces and soft tissues: Within normal limits. STIR images show disc dehydration L1 to S1 levels and there is marrow edema surrounding the severe degenerative disc disease changes at L3-4 consistent with active ongoing degenerative disc disease superimposed on chronic degenerative disc changes .

REPORT SUMMARY:
1. Grade I to borderline Grade II anterolisthesis of L3 with respect to L2 and L4 with severe degenerative disc disease at L2-3 and L3-4levels and severe foraminal narrowing at L3-4 with apparent nerve root impingement.  Serpiginous nerve roots within the lumbar levels are secondary evidence of nerve root impingement.
2. Relatively severe anterior and far right lateral osteophytic ridging at L5-S 1 as well as broad posterior disc osteophytic ridging L5-S1 that abuts nerve roots within the lateral recesses and appears to cause some imprint of the nerve root within the right neural foramen at L5-S1.

Interpreting the MRI report

These are the images from the MRI scan that demonstrate spinal stenosis.  The axial images are often the most helpful, and I explain to patients that the normal spinal canal should look a little bit like the Texas Longhorn’s logo.  You should be able to clearly trace the path of the neuroforamen along the length of the longhorn.  In stenosis, the area at the base of the horn become obliterated by arthritis from the facet joint and disk space bulging.

neuroforamen-minimal-stenosisaxial-MRI-neuroforamenMRI-severe-stenosissevere-stenosis-L4.5
The extreme lateral approach for degenerative scoliosis

Approximately 10 years ago, a very innovative surgeon in Sao Paulo, Brazil, developed a novel technique for decompressing and stabilizing degenerative disease of the lumbar spine.  He recognized that there is a surgical corridor to the spine through the side of the patient’s trunk — called the extreme lateral approach.  This approach has many advantages over the standard posterior midline approach to the spine, and one or two distinct disadvantages.  Via the extreme lateral approach, the intervertebral disks of the lumbar spine can accessed, and with the use of specially designed devices, the height of the disk spaces can be restored to their pre-degenerative height and alignment.  A company in San Diego, California, known as NuVasive has been instrumental in developing the specialized tools and implants used during this surgery.

The advantages of the XLIF approach

The advantages of the extreme lateral approach include the fact that the surgical approach (i) does not disrupt the large muscles of the back (ii) is possible with minimal blood loss (iii) allows for the insertion of intervertebral spacers that rest on a strong part of the bone called the apophyseal ring that provides an excellent platform for restoration of disk height and alignment.  The disadvantages of this approach are related to the fact that intervertebral spacers must be carefully inserted through the psoas muscle without damaging a complex of nerves called the lumbar plexus.  The psoas muscle is the major muscle that flexes the hip joint.  There are techniques and special surgical tools available that make it possible to dilate surgical channels through the substance of the posas muscle with minimal bleeding, but some degree of posas irritation with thigh pain, numbness, and weakness in hip flexion is expected after the surgical approach.  These symptoms seem to be transient and most patients report that their strength returns rapidly and any pain or weakness is minimal within a few weeks of surgery.

The lumbar plexus can get in the way

The lumbar plexus is a dense collection of nerves that run through the substance of the psoas muscle.  Nerve fibers do not tolerate much surgical manipulation so the key to this procedure is knowing where the nerves are so that they can be avoided.  Nuvasive has pioneered a very innovative tool called Neurovision that makes it possible to stimulate the nerves with a tiny ball tip electrode so that the course of the nerves in the posas muscle can be visualized without being seen and therefore avoided.  The operation is technically challenging but has great potential to treat this problem with limited tissue disruption.

Surgery in this case for degenerative scoliosis

This patient was operated upon in the lateral position.  Lying on his side, a 2 inch incision between the ribs and pelvis was made, and with careful surgical dissection, working channels were established in line with three degenerative disks — L1/2, L2/3, and L3/4.  Prior to surgery these disks had basically completely collapsed, but during the course of surgery, 10mm high spacers made out of a biopolymer called polyetheretherketone (PEEK) were inserted into the degenerative disk spaces.  This process restores disk height, restores spinal alignment, and increases the amount of space for the nerve roots in the spinal canal.  On post-operative day #1, after a 1 night stay in the hospital, standing X-rays were taken of the spine and we also obtained a post-operative MRI scan.  These images demonstrate the improvement in spinal alignment, disk height, spinal canal and neuroforaminal volume.  In fact, the radiologist was kind enough to measure the the amount of improvement in the dimensions of the spinal canal.

 

preop lateral MRI lumbarpost op lateral lumbar MRI sagittalpre-op-axial-L3.4-with-localizerL34-minimal-stenosis

The radiologists report after the operation

POST OPERATIVE MRI REPORT

L1-L2:  Ligamentum flavum hypertrophy with degenerative facet change.  Mild narrowing of the left neural foramina.  The central canal measures 15 mm. There has been interval improvement in the degree of neural foraminal narrowing on the left.  The central canal is stable at this level.

L2-L3:  Ligamentum flavum hypertrophy and degenerative facet change.  There is moderate osseous narrowing of the bilateral neural foramina, the degree of neural foraminal narrowing improved when compared to the prior study.  The central canal measures 17 mm, this is also improved from 10 mm.

L3-L4:  Ligamentum flavum hypertrophy and degenerative facet change with moderate narrowing of both neural foramina.  The central canal measures 14mm.  There has been improvement in the degree of neural foraminal and central canal narrowing when compared to the prior study, with the central canal previously measuring 8 mm.

L4-L5:  Ligamentum flavum hypertrophy and degenerative facet change with a broad-based disc bulge.  There is moderate narrowing of the right greater than left neural foramina.  The overall appearance is stable.  The central canal is widely patent, measuring 12 mm.

This can be a minimally invasive operation

This surgical procedure for decompressing and stabilizing the lumbar spine is possible with relatively minimal blood loss, a short 1 or 2 day hospital stay, and a relatively quick recovery.  In published reports, the fusion rate is very favorable and in carefully selected patients it appears that it is possible to accomplish the goals of surgery — increasing space available for the nerve roots and realigning the spine — without resorting to supplemental posterior fixation using traditional pedicle screws.

degenerative-kyphoscoliosisAP-lumbar-post-oppreop lateral MRI lumbarpost op lateral lumbar MRI sagittal

After posting this link, the next patient that I treated in a similar fashion read this as part of his pre-operative preparation and his main question was as follows:

Dear Dr. Gollogly, I have read the material here and on your web page and have found it informative.

I have one question: What should I expect when I return home from the operation and hospital stay? Do I need to make any special accommodations at for sleeping, sitting, etc? You said I would be wearing a back brace of some sort. How will that limit my movement?

My response follows: After your operation you should not need to make any special accomodations for sleeping or sitting.  We will fit you in a lumbar brace that you fasten around your waist with velcro.  It looks like the sort of brace that you see the stockers at the supermarket wearing.  It supports your spine and prevents a little bit of movement, but it is not too restrictive.  It’s a soft brace, not a hard plastic shell.  You should try to avoid any kind of heavy lifting and sustained flexion (being bent over) of the lumbar spine for the first 6 weeks after surgery.  The brace helps to remind you to sit up straight, walk with good posture, and rather than bending over to pick things up off the ground, use your legs.

XLIF Youssef

physical-therapy1

Spondylolisthesis: Everything you ever wanted to know, and more…..

The History of Spondylolisthesis

Spondylolisthesis is a medical term that describes an abnormal anatomic alignment between two bones in the spine.  This anatomic abnormality has been around since antiquity.  It was first described in the modern medical literature by a Belgian obstetrician named Dr. Herbinaux.   In 1782, Dr. Herbinaux noticed that the abnormal alignment of the lumbar spine and pelvis in very severe cases made natural childbirth difficult.  He was the first one to name this condition in which one vertebral body is slipped forward with respect to the one underneath it.

The term spondylolisthesis comes from two greek words: “spondy” (σπονδυλος) which means “vertebra” and “listhesis” (ὁλισθος) which means “a slip”.

How common is spondylolisthesis?

Spondylolisthesis most commonly affects the lower lumbar spine, typically at the L4/5 or L5/S1 levels.  Spondylolisthesis is a very common condition, occurring in about 5% of the population.  The most common type of spondylolisthesis is a degenerative slip that occurs at the L4/5 level.  This type of slip is caused by degeneration of the intervertebral disk and the facet joints.  Natural aging results in an increase in the “sloppiness” of the joint, much like a worn bushing in a car.  Here are two images that depict the changes that occur as the disk degenerates.  The gel-like substance inside the disk shrinks, the edges of the disk become irregular, and bone spurs develop.

normal anatomy of the lumbar spine

mechanical wear and tear on the spine creates a spondylolisthesis  degenerative disk disease

In this series of images, I use a CV joint from a car to illustrate how the spine is a mechanical joint and many years of “wear and tear” will cause the joint to become sloppy.

 

 

The Medical Definition of a degenerative spondylolisthesis

A recent clinical consensus paper was produced by the North American Spine Society will be referenced throughout this guide.  Their version of the “best working definition” of a degenerative lumbar spondylolisthesis is as follows: an acquired anterior displacement of one vertebra over the subjacent vertebrae, associated with degenerative changes, without an associated disruption or defect in the vertebral ring.

The key elements in this definition — anterior slip, degenerative change, and no disruption of the vertebral ring are easy to demonstrate in a typical case of spondylolisthesis.  As the disk deteriorates it becomes less capable of absorbing all of the forces of normal human movement.  Because the joint has increased “play” or “sloppiness” L4 starts to slip forward with respect to L5.  Here are X-rays and an MRI scan of a typical case of a grade 1 spondylolisthesis.  Flexion and extension X-rays are often used to evaluate how much abnormal motion occurs at the level of the spondylolisthesis.

  spondylolisthesis AP xray grade 1  lateral xray grade 1 L4.5 spondylolisthesis   lateral xray grade 1 L4.5 spondylolisthesis flexion view  lateral xray grade 1 L4.5 spondylolisthesis extension view

The second most common type of spondylolisthesis that we see occurs at L5/S1.  This condition is especially common in people who have repetitively extended their spine during athletics in adolescence.  The theory is that repetitive hyperextension of the spine during athletics results in a stress fracture.  This stress fracture called a spondylolysis.  The stress fracture occurs in a part of the vertebral body called the pars inter-articularis which disrupts the continuity of the vertebral ring.  The lack of a connection between the posterior and anterior parts of the L5 vertebral body allows the L5 vertebral body to slip forwards with respect to S1.  The association between adolescent athletics and this condition is very strong.  About 95% of competitive gymnasts and about 35% of competitive football players have X-ray evidence of the stress fracture that may result in a spondylolisthesis later on in life.

hyperextension of the spine results in spondylolysis hyperextension of the spine during gymnastics spondylolysis  spondylolysis fracture of the pars inter-articularis high grade spondylolisthesis with spondylolysis

This condition usually develops in two stages.  First, the patient has an episode of low back pain during their adolescence which is when the stress fracture of the pars interarticularis occurs.  Then as the disk starts to degenerate later in life, they begin to complain of low back and leg pain.  In contrast to a degenerative spondylolisthesis, this type of slip does involve a disruption of the vertebral ring, so this is often called an “isthmic” spondylolisthesis

Symptoms of spondylolisthesis 

Patients with spondylolisthesis complain of low back pain and pain along the course of the nerves that are pinched by the spondylolisthesis.  The narrowing of the normal space available for the nerve roots in the spinal canal is called stenosis.  The back pain typically occurs in the area of the lower lumbar spine and often radiates around the abdomen and into the buttocks.  The location of the nerve root pain depends upon where the slip is occurring and where the nerve roots are compressed.

Nerve root compression due to stenosis is called a radiculopathy: radix is the greek word for “root” and pathos a word for “a disease of”.   Pain and numbness in the legs as the result of a spondylolisthesis occurs in patterns called a radiculopathy that are very characteristic.  The human body is divided into a series of dermatomes which can be visualized as a map of where the nerves travel after the leave the spinal canal.  When the root of the nerve is affected, the entire course of the nerve is typically painful, numb, or the skin in this area is unusually sensitive.  For example, here is a map of the normal dermatomes of the body, and then three diagrams of an L4, L5, and S1 radiculopathy.  Patients with a spondylolisthesis at L4/5 usually have L5 nerve root pain due to compression of the L5 nerve root in the neural foramen.  Patients with a slip at L5/S1 usually have both L5 nerve and S1 root pain due to tension on the nerve roots.  For example, a patient with an L4/5 spondylolisthesis will usually describe low back pain at the base of the spine, radiating into the buttocks.  There is usually also pain and numbness along the sides of the legs, down the front and sides of the calves, with numbness and tingling in the feet.

If your major problem is pain and numbness in the legs, and especially if it is only affecting one leg, you may be a good candidate for a microscopic decompression instead of a fusion.  If you are interested in exploring this option, I may be able to review your MRI scan for you.

L4 radiculopathy

L4 nerve root pain

L5 radiculopathy

L5 nerve root pain

S1 radiculopathy

S1 nerve root pain

   

The pain that is associated with spondylolisthesis is variable.  It is often worse with standing.  Many patients find that the length of time they can walk comfortably gets shorter and shorter as the disease progresses.  We call this finding “limited walking endurance”.   This is often an indicator of how severely the patient is affected and how much nerve root compression they have.  Patients who are able to walk for more than an hour rarely need operative treatment.   Those who can only walk for a few hundred yards before they are limited by back and leg pain are more likely to require surgery.  These patients will often experience substantial relief once their spondylolisthesis is corrected.  While the pain associated with a spondylolisthesis is usually worse when the patient is on their feet, many patients have a hard time sleeping at night because the nerve root pain keeps them awake.

 

Xray and MRI findings in spondylolisthesis.

The best test for diagnosing a spondylolisthesis is a lateral Xray of the lumbar spine with the patient standing.  It is important that the patient is standing because there are some slips that return to their normal position when the patient lies down.  This is why some cases of spondylolisthesis are not apparent on supine X-rays or an MRI scan.  The best test for evaluating the degree of nerve root compression and spinal stenosis caused by spondylolisthesis is an MRI scan of the lumbar spine.

Here are a series of X-rays and MRI scans showing the relevant anatomic finding in a typical L4/5 degenerative spondylolisthesis.  Click on these images to enlarge them to full size

And here are the X-rays and MRI scans of a patient with an L5/S1 spondylolisthesis with bilateral pars defects.

L5/S1 spondylolisthesis

Non-operative treatment of spondylolisthesis

Physical Therapy: While it may not be possible to reverse the degenerative changes that occur with aging, it is possible to strengthen the muscles that surround the spine.  I have written a blog post about this particular point, which can be read here: reversing spondylolisthesis

PT helps to stabilize the lumbar spine and will often result in a decrease in symptoms of low back and leg pain to the point where surgery becomes unnecessary.  This type of therapy MUST emphasize active rehabilitation, which means that the patient must work actively to strengthen the muscles of the abdomen, low back, and core.  Massage, hot pack treatments, and electrical stimulation may feel good at the time, but their effects are usually temporary.  While massage feels great, it usually does NOT result in sustained relief.  The type of therapy that we employ emphasizes core conditioning and strengthening and our therapists will instruct you on how to do these exercises properly.  If your symptoms are relatively mild and you are still able to exercise, hike, and play some sports, then often a Pilates or a Yoga program may be very beneficial, less costly, and more convenient than going to a physical therapist.

physical therapy for spinal instability  core exercises for spinal instability  

Medical Management

Non-steroidal pain relievers like Aspirin, Tylenol, Motrin, and Ibuprofen are very helpful in the management of spondylolisthesis.  The medications can calm down the inflammation that accompanies degenerative disk disease.  This often makes it possible to participate in physical therapy with less pain.  If you can do PT,  it makes it possible to work harder to strengthen the muscles of the low back and abdomen.

NSAIDs for spondylolisthesis

Selective Nerve Root Blocks:  In our clinic we have specialists who perform selective nerve root blocks with injectable medications like Cortisone and Kenalog.  These are much stronger than the anti-inflammatories you can take by mouth.  These injections are performed in the surgical center and are done using an intra-operative X-ray machine to make sure that the medication is injected in the same area where the nerve root compression is occurring.  In our experience, nerve root blocks are very helpful for patients.  They will often result in a sufficient reduction in pain so that physical therapy is tolerable.  The block may also interrupt the “cycle of inflammation” to the point where the symptoms are manageable and surgery can be avoided indefinitely.

 

Why you should avoid narcotics

In our experience, using narcotic pain medications on a daily basis for the treatment of the pain associated with a spondylolisthesis is a bad idea.  Because spondylolisthesis is a condition that tends to worsen with time, most people who start taking narcotics find it very difficult to stop.  The use of narcotic pain medications for an open-ended diagnosis is dangerous.  This is because there is not a defined point in the future when we know that the pain will spontaneously resolve.  For example, if a patient has a fracture, we know that the pain will subside once the fracture heals.  However, with a spondylolisthesis, because there is not a possibility of spontaneous correction, the patient will continue to perceive a need for narcotics on a regular basis.  This quickly leads to tolerance as the medications become less effective with time and their routine use becomes habit forming.  For more information on my philosophy about the use of narcotic pain medications, click here.

What the establishment says about non-operative care for spondylolisthesis

The North American Spine Society’s consensus statement on non-operative care for spondylolisthesis is a follows: The majority of patients with symptomatic degenerative lumbar spondylolisthesis and an absence of neurologic deficits will do well with conservative care. Patients who present with sensory changes, muscle weakness, [or a short walking endurance] are more likely to develop progressive functional decline without surgery. Progression of slip correlates with jobs that require repetitive anterior flexion of the spine. Slip progression is less likely to occur when the disc has lost over 80% of its native height and intervertebral osteophytes have formed. Progression of clinical symptoms does not correlate with progression of the slip.

Surgery for spondylolisthesis: do you need it?

Here is what the North American Spine Society has to say: Surgery is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical and interventional treatment.  In our clinic we agree with this statement.

What this means to us is that patients who have symptoms that can be clearly attributed to their spondylolisthesis should first be educated about their condition.  Next they should consider physical therapy and lifestyle changes that we believe are associated with improvements in back pain.  If they continue to have pain they should consider a selective nerve root block to temporarily reduce the inflammation in the nerve roots — as long as this is seen as a bridge to making physical therapy more tolerable.  Surgery should only be considered when the patient has continued symptoms that do not improve with physical therapy or medical management.

Our technique for the surgical correction of spondylolisthesis is designed to achieve four goals

1. relieve the nerve root compression that is causing pain and numbness in the legs

2. stabilize the unstable spinal segment that is slipping, only if necessary

3. improve the alignment of the spinal canal

4. provide the patient with a durable solution that will improve their quality of life for years to come.

While there is a great deal of debate about the best surgical technique for the treatment of spondylolisthesis, the NASS clinical guidelines do state that surgical decompression with fusion is recommended for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis…and that …decompression and fusion is recommended as a means to provide satisfactory long-term (greater than 4+ years) results for the patient.  For example, on a recent Spine Surgery Board Certification Examination administered by the American Academy of Neurological Surgeons, the following question was asked: A 47 year old dentist presents with a 5 year history of intractable low back pain refractory to several courses of physical therapy and numerous medications.  He has recently developed bilateral L5 radiculopathy.  MR imaging demonstrates grade II anterolisthesis of L4 on L5 with resulting L4-5 central canal stenosis and bilateral neuroforaminal stenosis. The BEST treatment option is:

  1. dorsal column stimulator
  2. anterior lumbar interbody cage fusion
  3. laminectomy and pedicle screw fusion
  4. epidural steroid injection
  5. laminectomy with facetectomy

The correct answer, according to the AANS, is #3.  Here is their explanation: This patient has failed reasonable attempts at non-operative management and has an anatomical abnormality that corresponds to his clinical symptomatology.  Surgical correction is the best option.  Decompression alone in the presence of spondylolisthesis in a relatively young patient is associated with a high incidence of progressive listhesis and worsening pain.

Here’s where I disagree.  I think that it in carefully selected patients, a microscopic decompression with meticulous physical therapy and rehabilitation can result is excellent clinical results.  When I am able to alleviate someone’s leg pain so that they can go back to working out and keep their core strong, they are happy.

I’d be happy to give you second opinion if you are interested in whether or not a fusion is necessary in your case

In the meantime, here is a series of pictures from our operating room during correction of a spondylolisthesis of the spine using a traditional approach…

surgery for spondylolisthesis  intraoperative image spondylolisthesis  decompression for spondylolisthesis  size of incision spondylolisthesis surgery  drain connected to reservoir  rolling the patient back into a supine position

Here are a series of x-rays that demonstrate the correction of spondylolisthesis with a decompression and fusion of the slip performed in our clinic in Monterey, California.  You can click on each of these Xrays to enlarge them to full size.

L4.5 degenerative spondylolisthesis repaired with an L4.5 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

L4.5 grade 1 spondy AP preop  L4.5 grade 1 spondy lateral preop  L4.5 spondy postop AP  L4.5 spondy postop lat

 

L5/S1 isthmic spondylolisthesis repaired with an L5/S1 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

L5.S1 Grade 2 spondylolisthesis AP  L5.S1 Grade 2 spondylolisthesis lateral  L5.S1 Grade 2 spondylolisthesis extension  L5.S1 Grade 2 spondylolisthesis extension  L5.S1 grade 2 spondylolisthesis post op AP  L5.S1 grade 2 spondylolisthesis postop lateral

 

I’ve also got a large number of patients that haven’t needed  a stabilization.  Instead, I’ve done a microscopic decompression for them, especially if they only have pain and numbness in one leg.  If they are able to decrease the chance of future progression of the spondylolisthesis with lumbar spine strengthening exercises, they are delighted with the opportunity to live without a fusion every day.

If you’ve already had an MRI scan and are intrested in discussing your options, I will review your MRI scan for and tell you whether or not I think a microscopic decompression rather than a fusion will work in your case.

To learn more about your options for non-fusion treatment of spondylolisthesis, click here: MRI review.

C5.6 post op lateral xray

Anterior cervical discectomy and fusion

Anterior Cervical Discectomy and Fusion (abbreviated as ACDF) is a surgical procedure for alleviating the severe pain due to nerve root compression caused by a cervical disk herniations.  ACDF surgery has been routinely performed since the 1950’s and it is a very reliable procedure.  It works best in patients who have an identifiable cause of nerve root compression that has not responded to non-operative care consisting of physical therapy, medical management, and possibly a steroid injection.

First the anatomy.  In this first set of watercolors we see a small segment of the cervical spine.  The white strip in the middle is the spinal cord and the surrounding fluid called the CSF.  The back of the intervertebral disk is flush with the bone above and below, and there is no pressure on the spinal cord.  In the second axial image the spinal cord looks like a white kidney bean in the center of the spinal canal.  The cord is symmetric and there is no pressure on any part of the cord.  In the third image we see a disk herniation.  Some of the shock-absorbing viscous protein in the center of the disk has been squeezed into the spinal canal and it is pressing on the spinal cord.  The fourth axial image demonstrates how the cord is often deformed asymmetrically.  In this case, the disk herniation is pushing on the left side of the spinal cord and the patient is likely to have left sided nerve root pain.

normal sagittal cervical spine  normal cervical anatomy axial  sagittal cervical spine disk hernation  herniate cervical disk

 

Now the MRI scan.  This is a sequence of pictures of someone with a C6/7 disk herniation on the left side.  The first image is mid-sagittal MRI scan.  This image is a “slice” from the center of the neck and we can clearly see all of the relevant anatomic structures.  If we move over to the left side by 5 mm, we can see the prominent disk herniation at C6/7.  The third image is annotated so that the disk herniation and the cervical spinal cord are more visible.  Please click on each image to enlarge the size of the picture.

C6.7 HNP MRI cervical spine  C6.7 HNP parasagittal  C6.7-HNP-annotated-parasagittal

 

Cross-sectional anatomy — the axial slice.  The beauty of MRI scans is that we can use them to look at the human body in any plane.  The three images above are called the sagittal slices, but often the axial images are the key to the diagnosis.  The first image in this sequence is called the reference image.  In this image there is a blue line parallel to the C6/7 disk space.  This blue line is the reference plane for images #2 and #3.  These two images are a “slice” through the center of the neck and they are oriented as if we were at the feet of the patient looking up towards the head.  The anatomic structures on our right are on the patient’s left.  In image #3 I have annotated the disk herniation in order to demonstrate where the nerve root compression is occurring.  In the fourth image, I present an axial image from the same patient, just above the level of the herniation, so that you can see what the normal dimensions of the spinal canal look like.

C6.7 HNP axial reference  C6.7 HNP axial MRI foraminal disk herniation  C6.7-HNP-axial-foraminal-disk-herniation-MRI  C6.7 HNP above level of herniation

Not all cervical disk herniations need to be treated surgically.  Lots of research has shown that many people will improve over time and their symptoms will spontaneously resolve.  Patient’s who are good candidates for an ACDF typically meet the following criteria:

  1. Their arm pain is worse than their neck pain
  2. Their pain has been present for at least 6 to 8 weeks without any trend towards gradual improvement
  3. The disk herniation is large, a free or extruded fragment, and appears to be causing significant nerve root compression
  4. They have tried a course of physical therapy, NSAIDs, and possibly a selective nerve root block and each time the pain has come back.

Anterior Cervical Disectomy and Fusion, for the most part, is now an outpatient operation.  I perform this operation at Monterey Peninsula Surgery Center and the majority of patients go home the same day.

In my hands, my patients do very well with an anterior cervical discectomy and fusion with a allograft and a locking plate applied to the anterior aspect of the cervical spine.  They tend to have immediate resolution of their neck and arm pain, their weakness resolves quickly, and they return to normal activities within 6 weeks.  Using a microscopic surgical technique I am able to visualize and remove the herniated portion of the disk and with an allograft bone I am able to restore normal disk height without using bone from the hip or the pelvis.  For example, here are 2 X-rays from a C5/6 ACDF performed as an outpatient for someone with severe arm pain and a large herniated disk

C5.6 post op lateral xray  C5/6 postop AP xray

There are a few side effects after an ACDF…

Will I lose normal range of motion?

One of the most common questions that I get asked is whether the range of motion of the neck will be affected by the operation.  Most patients are concerned about the loss of normal range of motion of the cervical spine if they have a fusion, but this rarely seems to be the case.  In the first place, about 90% of lateral rotation — twisting the head from sided to side — occurs at the level of C1/C2, and this area is never included in a standard ACDF.  Secondly, by the time someone needs an ACDF, usually their spine has developed some arthritis and the range of motion of the disks and spinal segments that need to be fused is already lost as part of the degenerative process.  For example, here are a series of pictures from an active duty US serviceman who needed a multi-level cervical fusion for symptoms of cervical myelopathy associated with kyphosis.  The pre-operative xrays and MRI scans are shown, and the post-operative xray shows excellent correction of his cervical kyphosis.  Clinical pictures taken 3 years after the operation demonstrate that he has a nearly normal range of motion of the cervical spine.

cervical kyphosis AP xray  cervical kyphosis lateral xray  preop MRI multi-level cervical kyphosis  preop-MRI-multi-level-cervical-kyphosis-axial-reference  preop MRI multi-level cervical kyphosis axial

intraoperative C-arm lateral xray correction of cervical kyphosis  intraoperative C-arm lateral xray kyphosis corrected  postop lateral xray cervical kyphosis  postop AP xray cervical kyphosis

neutral-neck-lateral-view   left-lateral-rotation-after-cervical-fusion  neutral-neck-position-after-cervical-fusion    extension-after-cervical-fusionflexion-after-cervical-fusion

 

The surgical incision — will it be noticeable?

The surgical incision for an anterior cervical discectomy and fusion runs parallel to the normal lines of the skin in the neck, which are called Langer’s Lines.  The skin in this area is typically relatively moveable and it does not form significant scars.  For example, here is the incision of a patient who has a 2 level anterior cervical discectomy and fusion about 2 or 3 months before this picture was taken.  In this image, the scar is barely noticeable, and with time ti will continue to fade even further.

surgical-incision-anterior-cervical

Swallowing difficulty…

According to the literature, temporary or persistent dysphagia (the medical term for difficulty swallowing) can occur in up to 18% of post-operative ACDF patients, but this is much more common in multi-level operations. Typically, a patient will notice that it feels like something is stuck in their throat, or they can’t swallow pills or meat easily.  If a patient develops difficulty swallowing, the symptoms will usually resolve over time, and while most people return to normal within a few days, complete improvement may take many months. Dyspagia appears to be secondary to local response to traction and manipulation of the soft tissues of the neck since this complication occurred just as commonly when the procedure was performed in the past without the use of a locking plate applied to the front of the cervical spine.

An ACDF — done step by step

PACU before microdisc

Microscopic discectomy procedure

In this gallery of images we go through a microdiscectomy performed at our outpatient surgical center.  This is a 40 year old active duty serviceman with a large herniated nucleus pulposus at the L5.S1 level on the right side.  This sequence of pictures documents the steps that we follow as we move from the pre-anesthetic phase of the operation, through induction of anesthesia, positioning and prepping and draping, and then through the actual operation itself.  Finally, we close the skin with an absorbable suture, apply a layer of dermabond which seals the skin, and then take the patient back to the post-anesthetic care unit so that he can go home on the same day as the operation.

The surgical incision is sewn up with an absorbable suture and then steri-strips are placed perpendicular to the incision.  On top of the steri-strips I use a transparent dressing called “Tegaderm”.  This dressing sticks to the skin very well and it should be left on until the 1st post-operative visit.  Underneath the Tegaderm dressing the steri-strips are left in place until they fall off by themselves, which usually takes another 5 days or so.

microdisc incision size   microdisc incision

microsurgery cervical spine

ACDF microscopic spine surgery procedure

This gallery of photographs represents the step by step sequence through an anterior cervical discectomy and fusion.  In this case, this is a young south pacific island male with severe central stenosis at C5/6 and C6/7 with cervical myelopathy.  First the endotracheal tube is placed by the anesthesiologist, next the anterior aspect of the neck is marked, prepped and draped.  The actual anterior cervical discectomy and fusion procedure takes about an hour and a half to two hours for a 2 level case.  When the case is finished, the incision is closed with an absorbable suture and covered with a thin film of dermabond which seals the skin.  A single steri-strip is place across the incision and the patient is allowed to shower and bathe normally the first day after surgery.

checklist manifesto

Pre-operative checklists

An operation is a series of steps, and the steps need to be followed in sequence.  The same is true of pre-operative preparation before any major surgical procedure.  Atul Gawande, who is a very enjoyable author, recently published a book called The CheckList Manifesto which explored the use of checklists to manage complex tasks like flying airplanes and performing surgery.  This book has become instrumental in shaping the procedures used at hospital to improve patient safety.  I like to use a series of checklists to make sure that the appropriate steps have been taken at each step along the way.  This process begins when we perform complete a history and physical examination, review the appropriate imaging data such as the MRI scan and X-rays, and determine a treatment plan.


surgical checklist cockpit tasks
  surgical checklist cockpit tasks  surgical checklist

Once the diagnosis is confirmed and you agree that surgical correction is desirable we will complete a pre-operative checklist that ensures that the following goals have been met:

  • You should be properly educated about the condition, the risks and benefits of surgery, and expectations for treatment
  • You should be evaluated prior to surgery by your primary MD and be considered “fit” to undergo a major operation
  • Pre-operative laboratory testing and an EKG has been completed
  • A surgical plan has been formulated and your questions have been answered.

Prior to the day of surgery, there are a few things that you can do that will improve the outcome after surgery.  The most important of which is a skin decontamination procedure.  Recently, the national institutes of health and several major medical centers around the united states have completed a series of clinical trials on what patients should do at home PRIOR to surgery in order to decrease the chances of developing an infection post-operatively.  These studies were specifically designed to find out whether or not a program of pre-operative decontamination resulted in a reduction in the number of post operative infections — and the answer was resounding — THESE PROGRAMS WORK.

The most common routine for preoperative decontamination of the skin involves using an ointment in your nose for 5 days prior to surgery and using a special type during your daily shower or bath 1 or 2 days before your operation.  First, the OINTMENT.  The nostrils (called the nares by medical doctors) is a warm and inviting place for bacteria to set up shop.  Approximately 25 to 30 percent of the general population has a particular type of bacteria in their nostrils called MRSA — methicillin resistant staph aureus.  This is a very common bacteria that normally lives on the skin that has become resistant to antibiotics over the past 20 years and it is a common culprit in post-operative infections.  To reduce the chance that you are an MRSA carrier at the time of your operation, you apply an ointment called bactroban to the inside of your nostrils, twice a day for 5 days before the operation.  Bactroban is the brand name for the medication, Mupirocin is the generic name, and the tube looks like this.

bactroban surgical site infection prophylaxis

Second, the SOAP.  Your skin is covered with bacteria.  While the surgical team will clean your skin thoroughly before beginning a procedure, research has shown that using a particular type of soap called hibiclens during your shower for 1-2 days before surgery helps reduce the chance of an infection.  This soap is available in most pharmacies and it looks something like this.  We will also provide you with a prescription for this soap.

hibiclense surgical site infection prevention

It is important that you complete this cleaning routine prior to surgery because it has definitively been shown to reduce your chance of developing a surgical site infection post-operatively.

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Sohrab Gollogly, MD is a board-certified orthopedic surgeon and Fellowship-trained spine surgeon who also performs scientific research and participates in several volunteer surgical organizations.

Dr. Gollogly completed his undergraduate education in biology at Reed College in Portland, Ore. He earned his medical degree from the University of Washington School of Medicine.

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  • Monterey Spine and Joint
    12 Upper Ragsdale
    Monterey, CA 93940

    Phone: +1-831-648-7200

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    4140 Jade Street
    Capitola, CA 95010

    Phone: +1-831-475-4024

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