Herniated Disc, Slipped Disc, Bulging Disc, Facet Syndrome, Stenosis, Sciatica, Arthritis, Whiplash Syndrome, Failed Back Surgery syndrome and Bulging Disc.
What’s in a spinal column? Your spine is divided into three specific sections: cervical (neck), thoracic (back side of your chest), and lumbar (the lower back). Your lower back and neck supports the most weight and is responsible for most of the movement of the spine. The vertebrae (bones of the spine) are stacked with a cushion material (discs) that separates them. Your discs are composed of a spongy center surrounded by a ligament-like encasement called the annulus. The vertebrae have a channel through which the spinal cord passes and from which the nerve roots radiate. When everything is in its place your back gives you the capacity to lift and move heavy objects. When things get out of place, you may have problems just moving around. As we get older our spinal columns diminish in their capacity to perform.
What causes lower back and neck? Any of the components of the back can be a cause of lower back and neck pain. The bones in the spine are subject to stress fractures, as we age arthritis can be a contributor. Inflammation from arthritis can cause pinching in the nerve structure. The annulus by its composition of nerve fibers can be a source of pain when a disc bulges (herniation) or deteriorates. Additionally, injury to adjacent ligaments or muscles can contribute to pain in the lumbar spine. Injuries can occur when you subject your back to sudden heavy loads, twisting (golf, tennis, baseball), and repeating the same movements while exerting lifting pressure on the lower back and neck (football, weight lifting). It can also be as simple as improperly bending over to retrieve something light in weight from the floor. Proper lifting mechanics are one way to prevent injury to the lumbar region.
What are some of the common injuries? Lower back or neck pain is often caused by muscle injury due to poor conditioning or lack of proper warm up before lifting or bending. Pain can also occur as a result of trauma, injury or repetitive stress.
Some common low back pain disorders can come from: sprain/strain injuries of the muscles and ligaments supporting your back, facet joints, arthritis of the joints in your spine, degenerative disc disease, sciatica, spinal stenosis, herniated/bulging or "slipped" discs, sacroiliac joints, pain in the hips, bursitis. Low back pain can cause pain and/or numbness/tingling in other areas of your back, hips, groin, thighs, calves and even feet and toes. This is called referred pain or radiating pain if spinal nerves are involved. A common cause of radiating symptoms is from herniated or bulging discs.
Herniation of the discs occurs when the interior material of the disc is squeezed into the spinal canal, causing pressure against the nerves. Severe pain, a tingling sensation, numbness, or weakness may result. Herniated discs can be the result of a number of small injuries or of a single trauma. Bulging discs can be the result of wear on the annulus. As the annulus weakens the disc begins to lose its shape and can press on the nerve causing pain.
Neck pain can come from many of the same sources as low back pain. Like low back discs, discs in the cervical spine can also herniate. This can cause symptoms in the mid back, shoulders, arms, and fingers. Muscle and facet joints can also refer pain into the shoulders and into the head. A common cause of typical headaches can be traced to the cervical or upper thoracic spine.
We use Vertebral Axial Spinal Decompression for treatment of chronic disc injuries. Please visit www.sanmateobackpain.com to view the CBS news report on VAX-D spinal decompression therapy.
Some Common Neck Conditions:
Disc Herniations - sometimes referred to as disc bulges or "slipped discs". These conditions can occur with trauma, injury or from multiple bouts of neck pain in the past. Typically, the patient complains of neck pain, arm pain and/or tingling/numbness or a feeling of pins and needles. There may also be some weakness in the hand or arm in severe cases. Causes may be due to an irritated nerve root from a herniated disc, inflammation or osteophytes ("bone spurs").
Burner/Stinger - the patient will report a sudden onset of burning pain and or/numbness along the lateral (outside) portion of the arm which may also be associated with weakness. This is often caused by lateral flexion of the neck (i.e. a sudden "side bending or ear to shoulder" injury of the neck). This has also been referred to as "lateral whiplash". The cause of a burner/stinger type of injury is usually due to irritation of the Brachial Plexus. This is a common Sports injury.
Thoracic Outlet Syndrome - Symptoms of TOS can be "diffuse" arm symptoms which usually include "numbness and tingling". Typically symptoms will occur down the arm and include a path into the ring and pinky fingers. Symptoms are worse with overhead activity or at night. The causes of TOS can include: muscular compression at the scalene or pectoralis minor muscles which can occur from posture related conditions, a "cervical rib" or elongated cervical transverse process, the costoclavicular area or the subcoracoid area.
Facet Syndrome - Facet joints are located throughout the spine in the cervical, thoracic and lumbar regions although they have a slightly different orientation in each area. These joints can be a source of irritation and can refer pain to other areas in the back, shoulder or down the arm into the hand. Causes can include a mild-moderate car accident and are common in patients with Whiplash injuries.
Toritcollis - Is a term used to describe a specific severe muscle spasm of the muscles in the neck, specifically the Sternocleidomastoid (SCM). Infants can have a congenital version of the condition which is often seen hours - weeks after delivery. This is a serious neurologic condition. In adults, this can occur without any specific event and most patients report waking up in the morning with this condition. Typically, the patient is unable to move their head in any direction. It is a severe form of muscle spasm.
Some common Thoracic Spine or Upper Back Complaints
Upper back complaints are also described by many patients as "pain between the shoulder blades" or interscapular pain. Symptoms in this area can be caused by referred or radiation pain from conditions in the neck, or cervical spine, such as facet irritation or disc herniation. Other conditions can also refer pain into the mid or upper back region such as problems in the Gastrointestinal system. If this is suspected, this should be further explored by a qualified Medical Physician or Specialist. Bay far, the most common complaints arise from: muscular pain, bad posture or scoliosis. Scoliosis is a term used to describe the spine when it "bends sideways" or deviates to the right or left. Causes of Scoliosis can be many: Congenital Scoliosis occurs in young patients, Idiopathic Scoliosis where no known cause can be ascertained or Leg Length Inequalities in the pelvis. There are many ways to diagnose scoliosis including: X-ray (Cobbs method), visualizing the spine and seeing lateral deviation, uneven shoulder heights and/or the presence of "rib humping".
Some Common Low Back Conditions:
The intervertebral discs are found between each vertebrae in the human spine. Like the vertebrae, there are 7 cervical (neck), 12 thoracic (mid-back) and 5 lumbar (low back) discs. The discs make up approximately 1/3 of the spinal column. Their function is to: (1) “absorb shock” from everyday wear and tear, (2) allow movement of our spinal column and (3) separate the vertebrae. The spinal disc is actually considered a type of cartilaginous joint.
Discs consist of an outer annulus fibrosis layer and an inner nucleus pulposis, which is a soft, jelly-like, substance. The disc is made up of proteins called collagen and proteoglycans that attract water. Normally, discs compress when pressure is put on them and decompress when the pressure is relieved. Discs do not have a blood supply and exchange nutrients by a process called “imbibition”. Imagine a sponge with water, when you compress the sponge you release water. When you remove the compressive force, water is “sucked” back in the sponge. This is exactly how discs work and the importance of healthy discs.
Diseased discs can lead to: Degenerative Disc Disease which can lead to: Arthritis, Herniated Disc, Facet Syndrome, and Spinal Stenosis. Herniation describes an abnormal condition of an intervertebral disc that is also referred to as a “slipped” disc, “ruptured” disc or “blown” disc. A herniated disc requires an MRI to be read by Dr. Hindocha to determine course of care. If you suspect you have a herniated disc, please call Peninsula Spine and Sports Rehabilitation and we will arrange the MRI to be scheduled immediately.
It is not known what causes the disc to herniate but it is thought to occur from (1) Trauma (2) repetitive stress due to occupation, poor posture or other external factors and the (3) natural processes of aging. The process of herniation occurs when the inner nucleus pulposis bulges through the annulus fibrosis causing a protruding disc which may push on a spinal nerve. It can progress to the point where the inner material (nucleus pulposis) leaks out of the disc. When this happens, the body mounts an auto-immune response to the disc material (nucleus pulposis) which causes severe inflammation and progressive deterioration of the nerve root. If the herniated disc is located in the cervical spine (neck), the symptoms can be neck pain with/without arm pain and/or numbness. If the herniated disc is located in the lumbar spine (low back), the symptoms can be low back pain with/without leg pain and/or numbness. This type of pain and/or numbness in the legs or arms is referred to as a “Radiculopathy”.
This is due to the fact that the nerves that exit your spinal cord innervate (“attach to”) the skin in your arms and legs (responsible for sensation), muscles in your arms and legs (responsible for movement) and reflexes in your arms and legs. This is why some people with these conditions experience extremity (leg/arm) pain/numbness/tingling and weakness when they have a disc herniation. Surprisingly, people with a herniated disc may only complain of extremity (arm/leg) pain with minimal neck or low back pain.
Diagnosis of a herniated disc (either neck or low back) can be made from a detailed physical examination including a detailed Orthopedic & Neurological examination. Typical disc patients will present with an antalgic gait (lean away from the side of the disc lesion), extremity pain/numbness/tingling (abnormal sensation) in addition to a neck or low back pain. In more chronic cases, muscle weakness may be present as may areflexia (“loss of reflex”). X-rays can help identify the level of the disc herniation but an MRI is the “gold standard” to identify the exact nature of the lesion. When the disc is herniated in the lumbar spine (low back), it is often referred to as Sciatica.
Degenerative Disc Disease: (DDD)
DDD can be caused by many factors: (1) Trauma, (2) repetitive stress due to occupation, poor posture or other external factors and the (3) natural processes of aging. Our discs lose elasticity, flexibility and shock absorbing ability due to the fact that collagen molecules weaken, and proteoglycan content decreases (which attracts water). As a result of the collagen molecules weakening, the discs become brittle, and as a result of the proteoglycan content decreasing, the discs lose water (they become dehydrated). This severely affects the “shock absorbing” properties of the discs and they “compress” under normal pressure.
Although the discs do not have a blood supply, they do have a nerve supply. This nerve supply is responsible for the back pain that DDD patients often complain about. The most common symptoms are back pain and can be associated with leg pain and/or numbness in more severe cases. Degenerative disc disease can be diagnosed from a physical examination, X-ray examination and/or an MRI examination. An X-ray examination will usually show a narrowing of the disc between the vertebrae which indicates that the disc has become weak or has collapsed. An MRI examination is not usually necessary to diagnose DDD but it will show a decreased signal intensity that represents a lower water content inside the disc.
Stenosis is a process describing “narrowing” of a structure. The most familiar example is Heart Disease where the arteries of the heart “narrow” which can result in a heart attack. Like arteries, spinal structures such as the ones that surround the spinal cord (called the “vertebral foramin”) or the ones that surround the exiting spinal nerves (called “intervertebral foramin”) are also subject to “narrowing”. This usually occurs secondary to arthritis or degenerative disc disease or it can occur congenitally (“from birth”). Arthritis causes biomechanic changes to your spine which result in bone growths called osteophytes (“bone spurs”) and calcification (“turning to bone”) of ligaments. These structures narrow the opening that contains the spinal cord and spinal nerves. The end result is “pinching” of these sensitive neural structures.
The typical presentation is a patient in their late 50’s or older. The main complaints are back and leg pain. The pain is either in one leg or both and is not specific. Leg pain is often initiated during walking and is relieved after resting 15 to 20 minutes or bending forward at the waist (“hunched" forward) also called flexion. Diagnosis of spinal stenosis depends on the region of the vertebrae that is being narrowed (“pinched”). Degeneration of the facet joints causes laxity (loosening) of the joint capsule which can lead to a type of spinal stenosis called lateral canal stenosis. Lateral canal stenosis can cause “pinching” of the spinal nerve at the intervetebral foramin where the spinal nerves exit your spinal cord to “innervate” or attach to the extremities (legs/arms) causing arm/leg pain and/or numbness/tingling. Further degeneration of the facet joints can cause bony outgrowths in the spine called osteophytes or “bonespurs”. This can lead to another type of spinal stenosis called central canal stenosis. When this occurs, it is not the spinal nerves that are “pinched” (as in lateral canal stenosis), it is the actual spinal cord. Central canal stenosis can cause a variety of symptoms depending on its location. As you can see, these bone spurs narrow the spaces that contain the spinal cord and nerves. Diagnosis of this condition can be made with an X-ray, a CT scan or MRI.
Arthritis of the spine is also called Osteoarthritis (OA), Degenerative Disc Disease (DDD) or Degenerative Joint Disease (DJD). Causes of spinal arthritis include (1) trauma (2) repetitive stress due to occupation, poor posture or other external factors and the (3) natural processes of aging. Osteoarthritis is the most common type of arthritis and is a non inflammatory degeneration of joint cartilage with secondary effects (such as “bone spurs”) on adjacent bone. Usually, the patient will present with local back pain, stiffness, crepitus (joint “popping”), joint deformity and swelling. Osteoarthritis due to trauma usually presents equally in males and females during their 20’s – 60’s. Osteoarthritis due to “old age” is more common in females and presents in their 50’s - 60’s and is most prevalent in weight-bearing joints, such as hips (see to right), knees and the spine. Arthritis causes a change in the biomechanical structure of the spine such as: a decrease in intervertebral disc space (due to degenerative disc disease), stress osteophytes (“bone spurs”), and joint “loosening” which causes “slippage” of the vertebrae and alteration of the spinal curves. Pain is usually due to biomechanical changes in the spine (decrease range of motion) and pressure on the diseased disc.
Facet syndrome, as it is typically called, is type of arthritis that is specific to the facet joints (comprised of superior & inferior articular processes of vertebrae) in the posterior aspect of the spine. As the name implies, it is a “syndrome” which consists of several symptoms with multiple interlinked causes. The cause of facet syndrome is largely unknown but it is thought to occur due to (1) Hyperlordosis (hyper-extended lumbar spine) which pinches on a pain sensitive meniscoid tab (which is like a little piece of cartilage) or (2) Degeneration of the joints causing laxity (loosening) of the joint capsule which can lead to a type of spinal stenosis called lateral canal stenosis. Lateral canal stenosis can cause “pinching” of the nerve at the intervetebral foramin where the spinal nerves exit your spinal cord to “innervate” or attach to the extremities (legs/arms) causing arm/leg pain and/or numbness/tingling. Further degeneration of the facet joints can cause bony outgrowths in the spine called osteophytes or “bonespurs”. This can lead to another type of spinal stenosis called central canal stenosis. When this occurs, it is not the spinal nerves that are “pinched” (as in lateral canal stenosis), it is the actual spinal cord.
Central canal stenosis can cause a variety of symptoms depending on its location. In essence, facet “syndrome” is due to several aspects: “Jamming” of the facet joints causing “pinching” of the small pain sensitive mensicoid tabs within the facet joints or Degeneration of the facet joints which can lead to lateral canal stenosis causing: “Pinching” of the spinal nerves as they exit the intervertebral foramin of the vertebrae. These nerves innervate (“connect to”) the skin and muscles in your extremities (arms/legs) which can cause pain/numbness/tingling in the extremities. Further degeneration of the facet joints can lead to central canal stenosis causing: “Pinching” of the actual spinal cord.
Spondylolisthesis - Spondylolisthesis is a condition in which a bone (vertebra) in the lower part of the spine slips forward and onto a bone below it. The condition can produce increased lordosis (swayback), but in later stages may result in kyphosis (roundback) as the upper spine falls off the lower spine. There are several types, or classifications of Spondylolisthesis, including isthmic and degenerative. A similar condition called, Spondylytic Spondylolisthesis is when there is a unilateral or bilateral fracture in the pars interarticularis. This can be congenital, where growth plates did not fuse correctly, occur due to trauma, repetitive stress (such as gymnasts that perform repeat extension movements) or degenerative and can occur with age.
Failed Back Surgery/Syndrome
Failed back syndrome (FBS) is a condition which is described as a chronic condition and is the end result or complication of a failed back surgery. Many reasons are thought to contribute to this disturbing and troubling reality of surgical intervention :
(1) The original (pre-operative) condition was not treated completely or a possible recurrence of the original condition (such as a recurrent disc herniation).
(2) A joint may be irritated because surgery had altered the patient’s posture.
(3) Scarring from the surgery may be irritating the spinal nerves and contributing to Biomechanical dysfunction.
(4) Other conditions such as depression or anxiety may be interfering with the patient’s ability to heal. These are called Psychosocial issues.
(5) Non-union of the vertebrae (vertebrae did not “fuse” together)
(6) Patient general health has deteriorated. Muscle atrophy (“shrink”) leads to a general loss of strength and physical activity is restricted due to pain and dysfunction. This is known as Deconditioning Syndrome.
Diagnosis of a failed back surgery is quite simple. Once the patient undergoes a spinal procedure and fails to achieve the desired surgical outcome (i.e. reduction or elimination of the pain), the patient is usually diagnosed with this condition. Symptoms usually include: the original symptoms that the patient initially presented with pre-operatively and/or diffuse, dull and achy pain in the back and/or legs and a sharp, prickling, and stabbing pain that radiates (“moves”) from the legs. In some cases, the post-operative (“after surgery”) results can be worse than the pre-operative (“before” surgery) condition.
Piriformis syndrome can mimick symptoms of "Sciatica" where the patient complains of buttock and posterior leg pain. The cause is often nontraumatic and may be a result of the Sciatic nerve being compressed by the pirifromis muscle. In most people, the Sciatic Nerve runs under the Piriformis muscle but in approximately 15% of the population, there are two muscle bellies with the Sciatic nerve coursing between them.
There are other very serious conditions that can either refer low back pain from internal organ structures or more insidious diseases such as cancer and infection. It is important to note that these conditions are relatively rare presentations of back pain but equally important to know that they do exist.
How do you determine what is causing lower back and neck pain? A thorough examination by your doctor may include X-rays, MRIs, diagnostic testing, and a complete medical history. It’s important to give your doctor any and all information that could relate to your back injury. Your doctor can determine the type of injury and treat it accordingly.