Spinal
Deformities
Spondylolisthesis
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Description-
“Spondylolisthesis” is Greek for spine slippage.
Typically, the slip occurs between the lowest lumbar vertebra (L5) and the
sacrum. The condition is due to a congenital weakness in the bone on the
posterior aspect of the 5th lumber vertebra. This weakness allows
the bone to separate during childhood. The lumbar spine then begins to slide
forward on the sacrum. The rate and extent of slip varies greatly among
patients.
In a small percentage of patients, often those with
so-called “dysplastic” anatomy, the slip will progress to cause significant
pain, hamstring tightness and physical deformity. Rarely, bowel and bladder
function is affected as well. In the worst cases, the lumbar spine dislocates
over the front of the sacrum, a condition known as spondyloptosis (spine
dislocation). These unfortunate patients loose height between their rib cage
and pelvis until their ribs rest upon their pelvis. Their rib cage projects in
front of their pelvis, their buttocks are flattened, and they walk with a
crouched posture.
Treatment-
We treat all grades of Spondylolisthesis in children
and adults. Some patients with small amounts of slip respond to intermittent
bracing, anti-inflammatory medications and rest. Others with persisting low
back pain, nerve irritation or slip progression require nerve decompression for
leg pain with fixation and fusion across the L5-S1 disc space for relief.
Dr. Edwards has gained the largest experience in
North America correcting major spondylo deformities including spondyloptosis. He
has numerous publications and authors most Spine textbook chapters on the
subject. Dr. Edwards and associates have developed advanced surgical methods
based upon stress-relaxation to restore normal spinal alignment, trunk height
and body proportions. Surgery is performed through one midline back incision.
Anterior surgery (across the abdomen) is not required. Both fusion rates and
spine biomechanics are enhanced by restoring the normal alignment of the spine.
Clinical research with over 10-year follow-up has documented long-term clinical
success with these procedures.
Kyphosis (Hunchback)
Description-
Several diseases can result in progressive forward
bending of the spine, or “kyphosis.” In the neck, the head hangs forward and
neck muscles become sore. In the upper back (thoracic spine) the spine bends
forward to produce a hunchback deformity. In the lower back (lumbar spine)
kyphosis (or flat back syndrome) forces the patient to lean forward when
standing or walking. Significant kyphosis is usually associated with low back
pain.
Types
(Causes)-
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Osteoporotic Kyphosis –
Osteoporosis most
often occurs in women with advancing age. Their bone becomes less dense and more
likely to break. Vertebral bodies near the bottom of the rib cage are
especially susceptible to fracture and collapse. The vertebral bodies on the
front side of the spine collapse while the back side of the vertebrae does not.
As a result, the spine progressively bends forward to place even more pressure
against adjacent vertebral bodies. Therefore, osteoporotic kyphosis usually
does not stop with one or two vertebrae, but continues to progress.
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Scheuermann’s Kyphosis –
This condition
results from an abnormality of the growth plates of the vertebral bodies. As a
result, during adolescence, the front of the vertebrae do not grow as tall as
the back side of the spine. This causes the spine to bend forward. Very rigid
deformities can develop and lead to pain in the adjacent normal portion of the
lower spine years later.
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Ankylosing Spondylitis –
This is an
inflammatory condition that affects the sacro-iliac joints and spine. In later
stages, the spinal ligaments contract and calcify. The spine steadily bends
forward into severe kyphosis and becomes one rigid bone.
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Following Fractures or Tumors
collapses.
- The most common patterns of spinal injury (flexion-compression injuries)
result in fracture of the vertebral body and rupture of the posterior spinal
ligaments. Tumors
often erode the vertebral body until it collapses. In either case, the spine
bends forward over time into kyphosis. The condition is often painful and can
cause pressure against the spinal cord.
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Laminectomy, especially in the neck, can eliminate the ligamentous “check-reins”
that prevent gravity from pulling the spine forward into kyphosis.
Treatment-
We are able to fully correct the vast majority of
kyphotic deformities and restore normal posture for patients of all ages. By
using the Kyphoreduction stress-relaxation methods developed by Dr. Edwards, we
are able to correct the deformity through one midline back incision without the
need to open the chest or abdomen. This surgery has been highly successful in
patients of all ages. Fusion rates in our series exceed 90%.
For elderly patients with kyphosis due to collapse
of weak, osteoporotic vertebrae, “vertebroplasty” cement injection is available
for patients with painful collapse of one or two vertebrae. More often,
vertebral collapse afflicts many vertebrae and leads to a painful, hunch-back
deformity. In many of these patients the spine can be straightened and
protected with an “internal brace” using spinal instrumentation with or without
fusion.
Scoliosis
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Description-
Scoliosis is defined as a lateral (sideways)
curvature of the spine. This may cause one shoulder to be higher than the other
or one hip to be more prominent than the other. Scoliosis is usually associated
with rotation (twisting) of the spine. Rotation may cause prominence of one side
of the rib cage (rib hump.) Most forms of scoliosis progress rapidly during
adolescent growth years and then more slowly. Scoliosis can cause postural
imbalance with the patient’s head to the right or left of his pelvis. Severe
thoracic curves can even compromise the function of the heart and lungs.
Types-
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Congenital –
These deformities
originate in utero. They are caused by formation of extra partial vertebrae or
by vertebrae which fail to separate on one side as the fetus grows.
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Adolescent –
The most common form of
scoliosis does not become noticeable until the growth spurt begins in
adolescence. Its cause is unknown and so it is sometimes called idiopathic
scoliosis. It most commonly occurs in females.
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Degenerative – As the normal spine
ages, discs soften and arthritis may develop in the facet joints (back side of
the spine). If there is some curvature (scoliosis) in the lower back (lumber
spine), it can greatly increase when the discs soften and facet joints erode due
to arthritis. Increased curvature is often accompanied by increased instability
and pain with activity. The facet joints form additional bone to help stabilize
the failing spine. This extra bone can press upon nerves to cause leg pain. This
process most often occurs in the low back of middle aged adults and is known as
degenerative lumbar scoliosis.
Treatment-
In the early 1900s, Drs. Taylor, Voshell and
other surgeons pioneered new bracing techniques for improving scoliotic
deformities. Today, we use special spinal instrumentation that gradually
applies corrective forces in all 3-dimensions to address all aspects of the
deformity. It is rarely necessary to open the chest or abdomen. Using these
methods, we are able to achieve more correction of deformity than previously
available.
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Degenerative
Disorders
The individual
vertebrae which comprise the spine move through discs in the front and facet
joints in the back part of the spine. The spinal cord and nerve roots occupy a
canal in the center of the vertebrae. In young people the
discs are very elastic and have a high water content. As people age, they
naturally loose the disc molecules responsible for its elasticity and water
content. This process is known as disc degeneration. Genetic predisposition,
overuse or injury can accelerate the degenerative process. As disc elasticity
wanes and the central disc becomes soft, more stress is transferred to the
fibrous tissues surrounding the central disc (the annulus). With time, fibers in
the overloaded annulus begin to fail, the annulus bulges, and the disc becomes
narrower (shorter).
The right and left facet joints on the back side of the spine are
small versions of other synovial joints like those in the knee, hip, and
fingers. Both sides of the joint are lined with articular cartilage. The
cartilage is bathed in synovial fluid produced by synovial tissue which lines
the joint. Arthritis can affect any joint in the body, including the facet
joints in the spine. The synovium becomes inflamed and produces enzymes, which
damage and digest the articular cartilage. Facet degeneration can also follow
disc degeneration. When a disc becomes softer and shorter, more of the force
crossing the spine must be borne by the facet joints. This can accelerate their
rate of degeneration. When their articular cartilage is gone, the facet joints
become loose and unstable. The bone adjacent to the joint edge then begins to
grow in an attempt to stabilize the joint. These boney growths are known as
osteophytes.
Disc and facet degeneration can occur without major symptoms. If
the process works according to nature’s plan the instability that results from
disc and facet degeneration is counterbalanced by increased stiffening from
osteophyte formation. The osteophytes on either side of the disc and facet
joints tend to grow together until very little motion occurs between the two
vertebrae. Indeed, the majority of patients with degenerative discs or facets
have no serious pain or nerve problems. Patients with a benign course of disc
and facet degeneration may need only a regimen of intermittent anti-inflammatory
medications, spine support and abdominal exercises to get them through brief
exacerbations until their spine stabilizes.
On the other hand, the combination of disc and facet degeneration
can crowd the spinal canal and the openings through which nerve roots pass out
of the spine. This crowding can irritate the spinal nerves, resulting in pain
and weakness. If there is any imbalance in the spine, it can quickly accelerate
if one side of the spine degenerates more rapidly than the other. This can lead
to degenerative lumbar scoliosis, nerve impingement, progressive imbalance and
deformity.
Disc Herniation
(Rupture)
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Description-
Although disc degeneration is most common in older patients, it
can occur in young adults as well. It is most common in the lowest two joints
of the lumbar spine and near the base of the neck. As mentioned earlier, when
the central disc material becomes soft, more stress is transferred to the
surrounding annulus. A sudden exertion or extreme turn can tear the weakened
annulus and allow some of the central disc material to squeeze through the tear
into the spinal canal. This is known as a disc rupture or disc herniation. Disc
rupture or herniation usually causes pain in the low back or base of the neck.
If the disc herniation occurs in the vicinity of a spinal nerve root, the root
is either irritated by the presence of the disc material or, worse yet, the disc
material presses upon the nerve. In this case, the patient feels pain down the
arm or leg along the course of the affected nerve.
Treatment-
The great majority of disc herniations resolve
without medical treatment. After an initial inflammation, scar tissue forms and
contracts about the disc fragment. At the same time, the nerve adjusts its
shape to share the space with the remaining disc fragment. Hence, most patients
require only anti-inflammatory and muscle relaxation medications combined with a
cervical collar for neck disc ruptures and restricted activity for lumbar disc
ruptures.
When pain is intolerable or does not steadily decline over the first few weeks, more
potent anti-inflammatory medications or injections may be indicated. Surgery is
only needed when there is progressive loss of nerve function or when the level
of pain is too severe or its duration too long to tolerate despite anti-inflammatories.
Surgery to remove the herniated disc fragment and relieve pressure against a nerve has a
very high rate of success. Much is said about very small incisions for disc
removal. However, smaller is not always better. The most common error of disc
surgery is failure to locate and completely remove the offending fragment. The
smaller the incision, the greater the chance of a missed fragment. Therefore,
we prefer the smallest incision that still reveals all relevant local anatomy.
Most patients are free of nerve pain shortly after surgery and are able to go
home within 2 or 3 days.
Degenerative Disc Disease
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Description-
The early form of this condition is also sometimes referred to an “Internal disc
derangement.” As discussed above, disc degeneration is part of the normal aging
process. It usually causes little pain unless followed by disc herniation,
facet arthritis or spinal stenosis. However, there are a few patients who do
appear to have significant pain associated with early disc degeneration per se.
Treatment-
Both surgeons and patients are bombarded with information about new, hi-tech procedures and devices aimed at patients with
“disc disease.” Most are marketed to be a simple, “quick-fix” that require less
surgery than standard operations. Unfortunately, the great majority of these
new techniques are “over-sold” and abandoned by most surgeons a few years
later. Although our surgeons are at the forefront of new spine procedures, they
never embrace a “new” gadget or operations over highly successful standard
procedures until scientifically valid research documents their superiority. The
good news is that standard operations to either remove herniated disc material
or fuse a painful spine are usually very successful when carefully performed by
experienced spine surgeons.
Many patients with pain from spinal arthritis and/or
degenerative disc disease will obtain satisfactory relief with a combination of
short-term bracing, medications and then physical therapy. For patients who do
not find adequate relief or suffer recurring problems, we place great emphasis
on finding the precise source of pain before considering surgery. If surgery is
indicated, we must then determine the least amount of surgery necessary to solve
each patient’s problem.
In order to confirm the diagnosis of pain due to disc degeneration without herniation or nerve root impingement, we often use
provocative discography. This is an outpatient procedure in which fluid is
injected in the disc thought to be the source of pain. If the fluid replicates
the symptoms, then the probability that disc is causing the pain is very high.
When surgery is truly indicated, our most frequently performed operation for disc disease in the neck is disc removal with iliac
crest graft to stabilize and fuse the painful segment. The surgery is performed
through a short transverse incision on the left side of the neck. Anterior
plates are sometimes helpful when fusing multiple levels, but usually
unnecessary for one level procedures. Most patients have rapid relief of pain
and are discharged with a neck collar 2 – 3 days after surgery.
Our most common surgery for painful disc degeneration in the lumbar spine is a one
or two level posterior surgical fusion. Although this is not a small procedure,
it is well established and safe; success rates are high, and the results are
permanent.
Spinal Stenosis
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Description-
When the combination of disc degeneration and facet arthritis narrow the spinal canal
or openings (foramen) for exiting nerve roots enough to irritate or compress the
nerves, the condition is known as spinal stenosis. Typically, the nerves are
caught between the disc annulus in the front and expanded facets on the back
side of the spinal canal. When the disc loses height, the surrounding annulus
bulges back into the canal, much like a tire without sufficient air pressure.
The arthritic facet joint capsules thicken due to chronic inflammation. Facet
osteophytes grow ever larger in their attempt to stabilize the spine. The space
left for the nerves continues to get smaller. If this occurs gradually, the
nerves can accommodate to a surprising extent. However, eventually the space
gets so small that normal nerve function is no longer possible.
Patients with spinal stenosis often experience increased leg pain with perhaps
numbness, weakness or clumsiness when walking or when lying or standing in one
position too long. Their leg symptoms are often worse than their back symptoms.
They find relief by resting or changing position.
Treatment-
Since physical narrowing of the spinal canal causes spinal stenosis, the only treatment with lasting effectiveness is to remove
those overgrown tissues pressing upon the nerves. Prior to surgery, we obtain
a CT-myelogram to accurately visualize the course of each spinal nerve and the
structures pressing upon them. For the surgical decompression, Maryland Spine
Center surgeons have perfected a “diagonal decompression” technique that
provides complete decompression of the nerves, but preserves all major spinal
ligaments and facet joint capsules. Although more tedious and time-consuming,
this techniques diminishes subsequent spine instability and saves many patients
from much more extensive fusion operations.
Degenerative Listhesis
Description-
When softening of the disc and erosion of the facet joints occurs at a faster rate
than osteophyte formation, the upper vertebra of the pair often slips forward.
This condition is known as degenerative listhesis (slippage). It is most common
between the 4th and 5th lumbar vertebrae low in the spine
where the vertebrae are tilted forward. The overgrown superior facets of L5
often entrap the exiting nerve roots to cause leg pain in addition to low back
pain. The condition steadily progresses.
Treatment-
Experienced surgical judgment is particularly important in deciding whether a
particular patient is better served by non-operative or operative treatment. If
the patient has a stable pattern of spine alignment and vertebral architecture
combined with rapid growth of osteophytes, natural stabilization may well
suffice. On the other hand, if the rate of slip progression, nerve root
impairment or spinal geometry suggest future worsening, surgery is indicated.
Prior to surgery, we obtain a CT-myelogram to precisely determine the points of
nerve compression. Since degenerative listhesis leaves nerves compressed and
the spine unstable, successful treatment requires a combination of nerve
decompression with stabilization and fusion. Our practice is to restore normal
spine alignment with the same instrumentation used to achieve spine
stabilization and then perform a standard fusion of only the painful level or
levels.
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Spinal Injury
Spine Trauma
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Description-
Spinal trauma may rupture ligaments or fracture vertebrae in the neck or back. More severe injuries can damage the spinal cord
or nerve roots to cause paralysis or regional pain and weakness. Some injury
patterns do not initially appear to be alarming, but can leave the spinal column
unstable and subject to progressive deformity and/or chronic pain.
Treatment-
Dr. Edwards was co-founder and director of the Spinal Injury
Service for the Maryland Shock Trauma Center. He has developed new and
improved operations for reconstructing the injured spine, and published over 50
papers on spinal injury. The Maryland Spine Center has round- the-clock spine
surgeon coverage to provide immediate evaluation and treatment for patients with
spinal injury. Once the spine is stabilized with bracing or surgery, intensive
occupational and/or physical therapy helps speed recovery.
Spinal Tumors
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Description-
Cancerous tumors can arise within the vertebral column. Many can be cured if
diagnosed early and completely removed before they spread. Dr. Edwards and
associates have successfully removed some of the largest spinal tumors ever
recorded. They have published articles & chapters on the diagnosis and surgical
treatment of spinal tumors. Metastatic tumors arising from other organs
commonly lodge in the spinal vertebrae. As these tumors grow, they erode bone
resulting in vertebral collapse and pain. Metastatic tumors are often best
treated with a combination of radiation or chemotherapy to shrink the tumors and
spinal surgery to straighten and stabilize the spine.
Treatment-
Maryland Spine Center surgeons have had excellent results using both spinal
injury instrumentation and the same Kyphoreduction instrumentation and methods
described above under “Kyphosis.” These procedures straighten and stabilize the
spine. This eliminates most of the pain, restores patient mobility and protects
the spinal cord from injury due to fractures from weakened vertebrae. When it is
necessary to remove large portions of the spine, our surgeons have extensive
experience in reconstructing one or more vertebrae with custom artificial spinal
segments.
Surgeons at the Maryland Spine Center work together with
oncologists and numerous other specialists for management of cancerous conditions.
Extended rehabilitation is available.
Diagnostic
Dilemmas
Many patients are afflicted with neck or back pain and/or arm or leg weakness
without a clear explanation. Some have had unsuccessful surgical procedures.
Chronic back pain or weakness may result from continued nerve root compression
after disc or decompression surgery, early degenerative changes that do not show
up on x-ray or unsuspected non-union after fusions that were thought to be
successful but were not. We utilize a systematic approach that may include MRI,
myelography, CT scans, facet injections, nerve root blocks, provocative
discography and quantitative motion studies and trial casting. A careful
history and exam combined with one or more of the listed studies often yield a
clear explanation for the previously unexplained pain or weakness. If a cause
can be identified and verified, treatment is usually successful.
Failed Fusions
(Non-unions)
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Description-
The purpose of a spinal fusion is to stop motion between painful vertebrae. A
fusion between two spinal vertebrae is similar to a weld between two pieces of
metal. In a good weld, you are left with one piece of metal. After a
successful spinal fusion, the bone graft joins two vertebrae into one immovable
piece of bone. Hence, any painful joints or discs in between no longer move and
are, therefore, no longer painful.
It can be very difficult to determine if a spinal fusion is successful. The x-ray can
show substantial new fusion bone, but that does not mean the two vertebrae have
actually fused into one piece of bone. CT scans and other studies are equally
inaccurate. As a result, a surgeon can believe that he has achieved a solid
fusion, when, in fact, motion remains and can explain the patient’s persistent
pain.
Treatment-
Dr. Edwards and associates have presented the nation’s largest experience in the
diagnosis and repair of failed fusions. They developed a quantitative motion
study technique that recorded an over 90% success rate in spotting non-unions.
To repair the non-unions, they use a well-established surgical method that
employs compression instrumentation, fresh iliac bone graft and post-operative
bracing. 85% of lumbar non-unions are successfully repaired after one posterior
operation. For patients with recurrent non-unions, anterior surgery can be
added to raise success rates to 95%.
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