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VARIOUS FORMS OF LOW BACK PAIN
Back pain refers to pain any where from the area of the neck to the tailbone. The back includes the bones of the spine (vertebrae), the joints that guide the direction of the movement of the spine, the discs that separate the vertebrae and absorb shock as a person moves, and the muscles and ligaments that hold them all together. Back pain may be caused by an injury to one or more of these structures, or it may have nothing to do with an injury. For our purposes we will deal only with the lower or lumbar area.
Herniated Disc. Many times this is called a ruptured or bulging disc. Herniated discs are caused by aging or degeneration of the disc (degenerative disc disease) or injury to the spine. Disc disease may result from tiny tears or cracks in the outer shell(capsule) of the disc. The jellylike material inside the disc (nucleus) may be forced out through the tears or cracks in the capsule. This causes the disk to bulge ,break open (rupture), or break into fragments.
The herniated disc itself generally does not cause pain, the pain is usually caused when the disc presses against a nerve, and the nerve becomes inflamed and swelling occurs causing the associated pain.
Sciatica is a symptom frequently associated with a lumber herniated disc. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that extends from the buttock into the leg and sometimes into the foot.
The Back Pro CPM provides a motorized exercise that through compression and decompression of the lumbar vertebrae, plus moving the spine in an anterior (forward) motion on the compression stroke, and a posterior (rearward) motion on the decompression stroke, helps bring an increased blood flow to the area to help flush away the irritating toxins that may accumulate in tissues as a result of muscle spasm and disc injury.
By using the Back Pro CPM Motorized Table for as little as two times a day for 15 minutes each time, your back pain can be decreased significantly or eliminated completely and remember the results of Back Pro CPM are guaranteed or the cost of the machine will be returned to you with no questions asked (less S&H). As with any exercise you should check with your physician prior to starting. Remember the only thing you have to lose is your back pain.
Treatment Options for Ruptured Discs in the Low Back
As published in spineuniverse.com
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Kevin T. Foley, M.D.
Associate Professor
University of Tennessee
Memphis, TN, USA |
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| A shooting, stabbing pain that shoots from your back or buttocks into your leg is called sciatica or radiculopathy. It can be associated with numbness or weakness of your leg and foot. The most frequent cause of this condition is a ruptured disc in the lower back. In this article, we review disc problems of the lower back, also known as lumbar disc disease. Most ruptured discs respond to nonsurgical treatment. When this does not work, back surgery may be necessary. |
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| The content of this article addresses the anatomy, pathology, diagnosis, treatment options, and care for the patient who suffers from pain secondary to lumbar disc herniation.
Anatomy of the Lowback
The lumbar spine is made up of the last five vertebrae of the spine. The vertebrae are the bones of the spine. Their function is to provide support and protection to the spinal cord. The facet joints allow the vertebrae to be linked. They provide mobile connections between each vertebra. An intervertebral disc sits between each individual vertebra. The annulus is the outer ring and is the strongest part of the disc. It is responsible for connecting the vertebrae. The nucleus pulposus is the soft, inner portion. This material is about the consistency of crabmeat and is responsible for the shock absorption properties of the spine. |
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The nerve roots of the spine carry signals between the lower extremities and the brain that allow us to move our legs and perceive sensations such as touch, temperature, and pain. To better understand how the parts of the spine affect each other, we sometimes focus on a spinal segment. A spinal segment is composed of two vertebra, the intervertebral disc between, and the two nerve roots that exit from that spinal level, one from each side.
The intervertebral discs have cartilaginous endplates at the top and bottom and are surrounded by the annulus. Through degeneration or injury, the fibrous tissue (annulus fibrosus) constraining the soft disc material (nucleus pulposus) may tear. This may result in bulging (protrusion) of the disc or even extrusion of disc material into the spinal canal or neural foramen. This condition has been called herniated disc, ruptured disc, herniated nucleus pulposus, or prolapsed disc. |
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Understanding the anatomy
in cross section is helpful as well |
| Herniated Discs
One of the more common problems of the lumbar spine is a herniated disc. In this condition, a tear in an annulus fibrosus allows the nucleus pulposus to squeeze into the spinal canal. If a nerve root is compressed by the disc material, there can be pain, numbness, and weakness in the areas supplied by the nerve (often down the back of a leg). It is not unusual for the back itself to be painless, or nearly so. Accordingly, a herniated lumbar disc characteristically produces buttock and leg pain but not back pain per se. This pain is termed radiculopathy or sciatica.
If sensory function of the impinged nerve root is impaired, numbness will result. The exact area of numbness is determined by the particular root, and may be in the big toe, the heel, the outer ankle, the outer leg, or a combination of these. Impairment of motor function of the root will cause weakness which again depends on the particular root.
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Disc Level |
Root Comp. |
Weakness |
Reflex Involvement |
Sensory Loss |
Pain Distribution |
L3-L4 |
L4 |
quadriceps, tibialis anterior |
knee jerk |
medial knee and shin |
anterior thigh |
L4-L5 |
L5 |
extension of big toe |
no significant |
big toe |
back of thigh, lateral calf |
L5-S1 |
S1 |
gastrocnemius (ankle plantar flexion) |
Achilles |
lateral foot and heel |
back of thigh and calf |
In disc herniations, the L5-S1 disc is involved 45% to 50% of the time, L4-5 40% to 45%, and L3-4 about 5%. Disc herniation at the other lumbar levels is rare.
The root compressed is the one exiting the level below the disc in the vast majority of cases. However, if the herniation is lateral, i.e., into the foramen, then the root compressed will be the one exiting above. This is known as a far lateral disc herniation and occurs in about 3% to 10% of cases. It is also important to note that while the signs outlined in Table 1 are helpful in the diagnosis and decision making regarding type of treatment, not all of the signs and symptoms associated with a root may be present in an individual, and multiple root signs may even be present. |
| Conventional Treatments for Lumbar Disc Herniations
There are many treatment options available for disc herniation. Treatments fall into two major categories: nonoperative and operative treatment.
Nonoperative Treatment
The mainstay of therapy for herniated lumbar disc is conservative treatment, i.e., nonsurgical. This is because in the majority of patients the symptoms resolve or subside to a level allowing normal activity within 4-6 weeks. There are numerous nonoperative treatment modalities. Most encompass a combination of bed rest, physical therapy, chiropractic care, and medication. Analgesics or muscle relaxants can sometimes help relieve pain. The most commonly prescribed drug therapy involves NSAIDS (non steroidal anti inflammatory drugs). These reduce inflammation that may be the causative factor underlying nerve root pain. Proper exercise can also help prevent back problems and is included in many treatment regimes. A physical therapist or chiropractor can work to create an individualized exercise plan to best suit each patient. The vast majority of patients are treated with nonoperative techniques. Surgery should only be considered when aggressive nonoperative treatment has failed.
Operative Treatment
When nonoperative treatment fails to relieve symptoms, surgery may be indicated. Careful evaluation is done before any surgery. The type and timing of any operation depends on many factors: Type and location of herniation, severity of the disorder, amount of nerve compression, previous operations, etc. Most spine surgeons use the most advanced technology and the least invasive approach when applicable. Conventional discectomy surgery for the removal of a herniated lumbar disc is one of the most commonly performed procedures in the United States. An incision is made vertically along the midline of the back, usually about 2 inches long. Paraspinous muscle is stripped off the spinous process and the lamina. A small window is created in the lamina overlying the disc herniation. The nerve root is identified and gently retracted to expose the offending disc herniation. The disc material is then removed and wound is closed in a way that restores the normal anatomic layers.
Postoperative recovery is relatively fast. Relief from nerve root compression is often immediate, but back pain associated with the surgical approach can be intense. Patients are up walking the same night or the next morning after the surgery, and usually discharged home in 2 to 3 days. The vast majority of patients experience significant pain relief. Recovery of motor and sensory function may be variable.
Evolution of Posterior Minimally Invasive Spine Surgery Technical and research developments have provided new treatment modalities for the patient with spinal disc disease since the disease's description by Mixter and Barr in 1934.
Percutaneous Treatment Options
Percutaneous techniques (performed through the skin) derive their origins and continued success from these medical advances and patients' desire for a less invasive yet effective therapy for this common ailment. Advances in percutaneous techniques and endoscopy have allowed for a rapid expansion of interest and work in the field of minimally invasive discectomy that complements the current popularity of outpatient surgery. Percutaneous techniques include chemonucleolysis, manual and automated discectomy, and endoscopic-assisted discectomy. These approaches, although diverse in their methodology, share some common, desirable qualities; for example they: i. may be performed under local anesthesia; ii. afford a minimal amount of soft-tissue dissection; and iii. do not preclude the use of open surgery in the future.
Chemonucleolysis
Intravenous papain injection in rabbits was found to result in floppy ears from a transient loss of cartilage. This discovery was cleverly applied to disc disease, and found to dissolve the nucleus pulposus in humans. The initial experience was presented in 1964. Its use has been the subject of much controversy in subsequent years.
Percutaneous Nucleotomy
The first report of percutaneous discectomy was in 1975, using a dorsolateral approach to the disc. Although the dorsolateral approach was the most widely used, a more lateral, retroperitoneal approach (behind the membrane lining of the abdominal or pelvic cavities) was proposed. This was not widely accepted due to the risk of damage to retroperitoneal structures.
The next significant improvement in the technique came in the 1980s with the use of an automated discector, giving rise to the automated percutaneous lumbar discectomy. The automated discector is a suction shaver that can perform controlled removal of disc material. The laser has been applied with some success using a similar approach. Although most of the experience has been in the lumbar spine, a series of cervical cases has been reported, but is not the focus of this chapter. Controversy and criticism surround the many reports concerning percutaneous nucleotomies. These techniques may all be considered indirect techniques because they remove the central disc but do not directly address the offending pathology causing nerve root compression.
Central disc removal reduces the pressure within the disc space, an effect casually known as "popping the balloon". Furthermore, it creates a defect in the annulus fibrosus through which disc material may herniate in the future. This herniation is directed away from the nerve root. Also, with an indirect approach to the pathology, scar formation around the nerve roots may be minimized. The crux of the medical debate is regarding these techniques' efficacy. Several studies have shown that percutaneous nucleotomy, whether automated or manual, does not have the same success rate as open lumbar discectomy.
Endoscopic Discectomy
The marriage of the endoscope with the percutaneous technique was logical progression. Percutaneous evaluation of the spinal canal and endoscopic visualization of disc pathology were described in 1938. Endoscopy was used to improve the blind technique of percutaneous nucleotomy by allowing the surgeon to confirm instrument placement and to observe disc removal from within the disc space. The next limitation to overcome in the case of a percutaneous procedure was the inability to directly remove the herniated disc from beneath the nerve root in the spinal canal. Intradiscal approaches could only indirectly remove herniated disc material by pulling it down into the disc space. Endoscopic approaches with a working channel were developed to directly visualize and address the disc at the nerve root level.
Direct Endoscopic Approaches
The desire to expand the utility of endoscopic techniques led to the development of direct endoscopic approaches. With these techniques, compressed nerve roots could be directly decompressed. The endoscopic transforaminal approach (also termed the foraminoscopic approach) was the first percutaneous approach directly visualize the pathology during nerve root compression. The epidural space and the nerve root can be seen through the neural foramen. A percutaneous approach with a small fiberoptic scope and 6-mm working channel is performed. The nerve root is identified and disc material that is compressing the root is removed through the working channel. The technique seems particularly well suited for the treatment of far lateral discs herniation, although this represents less than 10% of symptomatic disc ruptures. Limitations include the small size of the scope and working channel, which can preclude the removal of large herniated disc fragments. Also, the neuroforamen itself can be quite small, limiting access to the compressed nerve root.
The MED System
The endoscopic revolution has impacted virtually every surgical field. The benefits of small incisions, limited tissue disruption, enhanced visualization and illumination, shorter hospital stays, and faster recovery times have been fruits of these changes. In the case of lumbar discectomy, the primary objective is to decompress the affected nerve root. The compressed nerve must be left fully decompressed and freely mobile. This may require extensive bony decompression, nerve root manipulation, and/or removal of the herniated nucleus pulposus. Prior minimally invasive techniques for lumbar discectomy, despite their popularity, have not been able to reproducibly achieve this goal.
The objective of the MED System is the same as conventional open surgery - to decompress the nerve root. This is accomplished by applying open surgical techniques through a tubular retractor under endoscopic visualization. For the first time, a laminotomy, medial facetectomy, foraminotomy, nerve root retraction, and discectomy can be performed endoscopically. In so doing, the MED System combines the reliability of conventional open surgery with the advantages of a minimally invasive technique. |
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