FUNCTION, OR A BIT ABOUT HOW YOUR BACK WORKS
The difference between your back and your spine
You know what your back is, right? We've all seen X-rays and drawings of the spinal column. Maybe your doctor used one of the little models to explain your problem and the proposed surgery to you.
Wrong-oh! That little model represents your spine , not your back. That stack of bones and disks is no more your back than your thigh bone is your leg.
In isolation, the spine that we commonly think holds us erect and gives us our body shape has just about no strength or stability at all. If a researcher hacked your spine out (yes, there are people who actually do stuff like that) and set it up in the biomechanics laboratory, it would only support about ten pounds or five kilograms of load before pitching over and collapsing like a rag doll. Research has shown the actual loads on your spine are much higher than that. Standing up straight, the load on a lumbar disc is roughly your full body weight. Twist or reach out a bit, and those loads multiply by three or four. In heavy lifting the loads get up towards twenty times body weight!
So how do we stand up, you ask?
Muscles and ligaments hold us up, like support wires holding up a telephone pole or the mast of a ship (the spine is the pole or the mast). Your back muscles are generating a balancing force of roughly that full body weight whenever you're standing. A lot more when you're jumping around, or working.
Your spine is just that thing in the X-rays. Your back is much more than that. Your back is the spine plus all the muscles and ligaments that support us.
You know what a muscle is. Muscles have tendons, the gristly bits at the end that attach the muscle to the bone. Tendon is that rubbery stuff on the meat at the skinny end of your chicken drumstick. So what's a ligament? Ligaments are stringy gristly things that connect one bone to another without a muscle in between. They're very strong, and a bit stretchy. They hold your knees together (ever heard of cruciate ligament injuries in sports? Bingo!). In your back, they stretch from one bone to another to help hold them in alignment.
In your back, there's a balance between the supporting loads taken by the muscle and the ligaments. Standing up straight, the stretchy ligaments are loose and the muscles work hard to hold you up. Electrophysiological muscle testing (EMG's) shows your back muscles going like mad even when you think you're taking it easy. If you lean forward a bit, the ligament "guy wires" stretch out and take some load - and the muscles work correspondingly less! When you lean all the way forward, you're balancing on your ligaments and the muscles relax so much they're electrically silent on your EMG. Physicians call that the "flexion/relaxation phenomenon". It's weird, but it makes sense. It's why those Oriental villagers we've all seen on TV can work their rice paddies all day bent over like a pretzel and not get backache.
How really important are your back muscles? Think for a second about how big and strong a gorilla is. They can weigh six or eight hundred pounds, maybe more. They're all muscle. Meet one of those suckers in the jungle on a bad day and he'll rip you apart. But he won't stand up and look you in the eye for very long before he does it. He can't, because his back muscles are not strong enough to hold him up for more than a few seconds! Proportionately, humans have the biggest and strongest back muscles of all creatures. This just make sense, we're the only critter that holds itself upright all day! We have the proportionately biggest feet too - more common sense, everything but us uses four feet to our two!). Let's all recognize that and respect our backs accordingly.
This distinction between "back" and "spine" tends to be ignored but it is very important for both patient and surgeon. We are all tempted to focus on the spine as the potential source of pain and subject of treatment because we can see it in the X-rays and scans (let's use the modern term "imaging" here from now on, so I can type fewer words in future, alright?). In fact, most cases of back pain are just that, soft-tissue "back" pain rather than spinal pain, and it's easy to be fooled.
We have no tests for soft-tissue back pain! There are no blood tests or scans that diagnose it. A skilled clinician (that's a doctor who treats patients, as opposed to the research people) often can make the diagnosis from the history and physical examination. Sometimes we pick it up when you have a test like a myelogram or discogram that involves a needle being stuck into your back, and the simple needle-stick hurts exquisitely. Sometimes we make the diagnosis "by exclusion", by testing for everything else that might hurt and finding nothing. Tragically, sometimes these soft-tissue pain cases slip through the cracks and have an operation that either doesn't change the pain at all (despite a major surgical change in the anatomy of the spine) or increases the pain severely as the surgical scar irritates the painful muscle. Often in these cases all the tests we can do are normal. Because of that, soft-tissue back pain patients are often given a hard time by the medical and other treatment communities. They're frequently told, "it's all in your head, your scans are normal".
That's very wrong. Imagine spraining your ankle badly. It's swollen up like a balloon, it's tender and bruised and it hurts. But your X-rays or CT scan or whatever would be normal because the bones aren't broken. Does that mean your ankle isn't hurt? Nope. Ditto your back.
Patients, be careful here. Your doctor is almost certainly not trained to think like this. The spine textbooks all recognize this great truth (the difference between back pain and actual spine pain), but they tend to brush over it in a few paragraphs and then devote hundreds of pages to surgical technique and the technology of modern medicine. Maybe that's understandable in the natural tendency to ignore or deny the things that we don't understand and can't do anything about, but it's wrong. It's also dangerous in often leading doctors away from our most important diagnostic tools, which are a good history from and physical examination of the patient.
The medical profession is increasingly recognizing that the single best predictor of outcome in surgery is how well we pick the patient, matching the problem to the solution, rather than the gory technical details of how a given procedure is performed. Your doctor has to be absolutely sure of what ails you before he or she can fix it. You the patient tell us that in describing your problem (verbally giving us the "history" of your pain and symptoms). Examining you will often confirm things. The imaging tests will give us anatomical details we need to plan your surgery, but they do not make a diagnosis and they don't decide who might or might not benefit from surgery!
Back pain suffers here because there is no single such thing as "back pain" any more than there is a single condition called "abdominal pain". There's a tendency to discuss the results of "the operation" for back pain - but would we discuss the results of appendectomy for gallstones? No. The surgery has to be matched to the problem. And just to make it a bit more complicated, spinal surgeries are often composites of many different parts - some "decompression" (unpinchings of nerves), maybe a "fusion" (permanent reinforcement and stiffening of worn-out and painful joints, generally done with bone graft), often "instrumentation" (insertion of screws and rods or other hardware, technically called "implants"), sometimes a "reduction" (realignment of worn-out, collapsing or "unstable" joints) or correction of deformity.
Understand why yours truly spinopod (this is my unofficial nickname for orthopedic spinal surgeons) has a lot of premature gray hair? I'm exhausted just trying to write all this, and we haven't gone anywhere near the OR yet! See why I wanted to write this book? I hope so. Thank you.
Back pain is normal
With your back muscles taking all the load they do it shouldn't be hard to understand how easy it would be to wrench or overwork them and get back pain, the same way your leg muscles might hurt if you took up jogging.
Most cases of back pain, even very severe ones that make you all stiff with pain shooting down into your legs and might stop you from working or doing many other things, seem to relate to muscle or ligament injuries like this. Most acute (acute means "ouch I just got it, as opposed to more permanent or "chronic" conditions) back pain has no relation to your spine or the X-rays at all. And it just about always gets better (90% or so within a few days or weeks, with or without treatment).
The word "normal" refers to the average or common condition, no? Research from around the world suggests that, in any population ever studied, at any given time, as many as six out of ten people (60%) have some back pain. In modern Western society, something like four out of five of us (80%) will be temporarily disabled or laid up by it at some point in our lives. That means that back pain really is a normal part of our lives, and nobody should panic about it. Humans asked for it seven million years ago when the first ape-man stood up to look over the tall grass of the African savannah, and we've been paying the price for that advance ever since.
What about muscular backache shooting (doctors would say "radiating") into your legs? People and doctors commonly think that if a low back pain zings down into your leg you must have a pinched nerve. Wrong. Research fifty years ago showed that, if you stick a needle into someone's back muscles or ligaments and inject some IV fluid through that needle, there will be pain not just at the point of injection but often lancing down into the legs. We're still not completely sure why that happens, but research suggests that it probably relates to little connections between the nerves that actually connect to your back and the bigger ones that run from your spine down into your legs.
Somehow this research information seems not to have become common knowledge or made it into the major textbooks. That's a tragedy because patients are commonly told they've got pinched nerves and might need surgery when they don't. This leads to a lot of stress and worry that nobody needs. It can also, unfortunately, lead to well-intended surgery that doesn't make people any better, and contributes to the bad reputation that spine surgery commonly has. Let's all be darn sure of what's wrong before we go to the OR, okay?
Consider back pain and stiffness. Your sore back is stiff because the arthritic joints don't move much, right? No. Young laborers with wrenched backs are stiff, and their twenty-year-old spines haven't had a chance to wear out yet! We get stiff with muscular backache, I think, because the sore muscles cramp and won't stretch. This explanation is one of those areas where I'm getting away from accepted fact a bit. Remember, I promised you I'd admit it when I did that.
Muscles are normally soft and stretchy and they work by "contracting" or shortening themselves. Consider the biceps muscle of your arm that runs from just below the shoulder to your forearm just below the elbow. Relax your arm and your elbow straightens out, the biceps stretching along with it and your arm getting thinner. When you contract your biceps the muscle shortens, and the corresponding pull between your arm and forearm flexes your elbow back up. As the muscle shortens it thickens and if you work out you might get a nice big bulge in your arm.
If a muscle hurts, it may automatically cramp up to protect itself from being stretched and hurt more. We've all had a leg cramp or a "charley-horse", right? Ditto the sprained ankle I like to talk about. You'll hold it stiffly so it doesn't hurt, right?
When we bend forward to touch our toes, most of the bending comes from our hips. The spine really moves just a tiny bit. Sometimes, if a child has scoliosis (that's an abnormal sideways twist of the spine, it's what Quasimodo from the Hunchback of Notre Dame had), we surgeons have to fuse the whole spine solid to stop the deformity from getting worse. Those kids can run, jump and play with their friends just fine. Their lumbar spines may be just about completely solid, but in the absence of any backache their muscles can stretch normally and they don't seem terribly stiff.
Remember those big back muscles that support us? They run across the hollow of your low back and connect to the pelvis (the "belt-line" bone, and the tailbone) below the level of your hip joints. When they're tightly cramped up, they can't stretch and you can't bend forward at the hips. Presto, stiff back!
The difference between back or spinal pain and sciatica
Sciatica. Pinched nerves in your back...imagine the horrible back pain, right?
Not necessarily, in fact not usually. Many people with pinched nerves in there don't have back pain at all.
Nerves basically work something like electrical wires. They take a signal from someplace (the wire takes electricity from the outlet it's plugged into, the nerve is simulated by a nerve ending somewhere in your body) and that signal is sent somewhere to cause a reaction (the wire's electricity lights up a light bulb, the nerve signal triggers a brain cell that tells you that you hurt). Your understanding that you hurt relates to the relevant brain cell being stimulated. You don't really "know" that your back hurts. If (for example) the right nerve were stimulated with an electrical device, you would think you had back pain all the time.
The major nerves in your back don't connect to your back. They connect to your leg. If they are stimulated (perhaps by being pinched) your brain will register the message "leg pain", often without much backache at all. Only when there's inflammation built up within or around the nerve root in your back will back pain happen in a big way.
Sciatica is that condition caused by a pinched nerve in your back, most often by a disc hernia or a bone spur. It causes leg pain, generally a leg pain that starts in the buttock because that is where the sciatic nerve exits the pelvis to run down into the leg.
Don't believe me here? Let me convince you. Ever heard of "phantom" pain, pain in a leg that has been amputated? That happens, and the pain is very real. Imagine that your leg has been mangled in a car crash. Doctors and surgeons try to save it, you're in terrible pain through several surgeries over months or years, eventually everyone gives up and your leg is amputated. By that point, the nerves in your amputation stump have been scarred up so badly that they're shooting off electrical signals all over the place. Those signals go up to your brain and stimulate brain cells that are programmed to tell you that your leg hurts - so your leg hurts, even after it has been removed!
So pinched nerves in your back often don't cause back pain. They cause symptoms in the leg, most often pain but also often weakness, numbness, tingling and possibly other symptoms too.
My nerve is pinched - So What?
Your nerves are like your fingertips, they've got a blood flow (and spinal fluid flow, too!) in them and they need that blood flow to survive. If they're pinched badly enough, the pinching pressure forces away the blood flow the same way your fingertip blanches when you push your thumbnail up against it. Eventually that fingertip is going to start to hurt, both from a lack of oxygen in the tissue and from inflammation that builds up. Sit there pinching your fingertip long enough, it'll turn black with gangrene and fall off! Ditto your spinal cord and nerve roots.
There's a lot of inflammatory chemistry and other stuff going on here. Disc material, particularly the soft central part called the nucleus, is very irritating to normal tissue and in lab experiments putting a small piece of it up against a nerve root without any squishing pressure at all will cause massive inflammation of that nerve. That's one reason why some very small disc hernias can cause a lot of pain and require surgery. The problem is not how big the disc hernia is, it's how inflamed the nerve root gets.
Your nerve roots are very tough, and your body can accommodate a lot. If they're squeezed down very slowly, perhaps over years as a bone spur slowly grows, they can be squished down to one-fourth of their normal diameter before becoming symptomatic in many people. Sometimes at surgery we'll find them compressed down to not much bigger than the size of a few hairs (normal is about three millimeters or an eight of an inch or so in diameter).
How tough are they? The "tissue pressure" inside your body (this is something like the barometric pressure in the air we breath) is normally just above zero. For some reason we measure pressure in medicine like they do in science, using the same "millimeters of mercury (abbreviated mmHg)" that the weatherman talks about on his barometer all the time. We know that 32 mmHg is enough pressure to shut down the circulation in the skin and "blanch" or whiten your fingertip as you pinch it, or to cause a bedsore in an immobile patient. Recent research data shows the pressure on a painful but still living and working nerve root stretched tight over a disc hernia can be as high as 250 millimeters of mercury or more! You can't do that to your fingertip!
What's a disc?
Your discs are the little pads between the bones (those are called "vertebrae") of your spine.
A disc is built a bit like a marshmallow with some jelly inside. Imagine squishing one of those between your fingers. You can see how the thing would be turgid (resist squishing) to provide support to the spine, and by rolling it between your fingers a bit you could understand how it might guide or direct motion somewhat (those are the two major functions of a disc).
They're shaped like little hockey pucks. They're built with a small soft jelly-like core called a "nucleus" and a thick, firm, gristly (sorry to use that word again!) outer shell called the "annulus".
They're a lot tougher than marshmallows. A soft hockey puck? More like a golf ball or a baseball gone a bit soggy, with a very firm outer rim or "annulus" wrapped around a "nucleus" that's something like a jelly-filled water balloon. They have to be tough. They're small, on average about an inch (that's 25 millimeters for you metric types) to an inch-and -a-half in diameter and about 3/8ths of an inch or 10 millimeters thick. Remember they carry up to several times your body weight. They come under load (as you bend and twist and do stuff) or are "cycled" (a term from biomechanics) something like a million times a year. They can do that for your whole life. No marshmallow's going to stand up to that!
They also don't "slip out of place". If they're going to transfer those huge loads between vertebrae, they've obviously got to be very strongly attached to them. They are, through a thin connecting disc (the top and bottom of the hockey puck) called an "end plate". The end plate connection is incredibly strong. When we surgeons go there in the operating room, it's actually very hard to cut the disc away from the vertebrae with the sharpest of surgical scalpels. When a disc hernia happens, only a very small piece of the disc generally moves out of place. More later.
What's a lamina anyway?
Up to now we've been largely discussing the front part or "anterior column" of the spine, made up of the barrel-shaped "bodies" of the vertebrae and the discs between them. Your spine also has a "posterior column" made up of several different interconnected bony parts that combine to wrap around the spinal cord and nerve roots to protect them. One of these is the "spinous process" which you can feel (and in a skinny person just about see!) through the skin as a row of firm bony bumps in the middle of your back. Deep to the spinous processes and lying under the two bands of muscle that run along either side of your spine are two flat bony plates, one on each side of the midline. They form the roof of the spinal canal (that's the bony tunnel through which the spinal cord and nerve roots pass). These are the laminae (one lamina, two laminae; why not "laminas" I have no idea).
The laminae cover and protect the spinal cord and nerve roots. They also have muscles attached to them that help support and move your spine, and in some positions (when your back is extended, like when you're arching your back or leaning backwards) they may carry some load.
The laminae are attached to the anterior column by two tubular bony bits called "pedicles", of which there is one on either side of the midline. Where the laminae and pedicles meet is another bony part called a "transverse process" that sticks out sideways into your back muscles. It's another important attachment point for them.
All about facet joints
Between the laminae, again one on each side of the midline, are two bony joints called "facet joints". They're roughly the size and shape of a small marble. Split the marble in two down the middle so the two halves can move against one another and voila! There's your joint. I guess they're called "facets" that because if you dissect them out, the surface of each joint makes a nice shiny white cup about ten millimeters across that looks vaguely like the facet of a jewel.
The combination of the disc and two facet joints between each pair of vertebrae makes up a three-joint complex that defines what in biomechanics is called the spinal "motion segment", that is the articulation or connection between two bones in your back. Sure, there are a couple of ligaments in there too, but let's not get too complicated.
The facet joint has two halves, one each coming from the vertebra above and the one below the disc at that level. The one above projects down from the lamina it originates from to hook over the one below. So the complete vertebra looks a bit like a fishhook turned on its side. The hooks all overlap one another. That's another thing that tends to hold us up.
The facet joints provide support to the spine and also function to guide the motion between vertebrae. They carry only about 10%-15% of the spinal load when you're standing normally but perhaps as much as 50% or more when you're leaning backwards. Like any bony joint, they can become arthritic and cause pain. They can also swell up with arthritic spurs and pinch the neighboring nerves if you're not lucky.
Some basic biomechanics - curves, and how we stand or sit up
Doesn't it feel great to have a good stretch and stand up straight and tall in the morning after a good night's sleep?
We don't actually stand up straight, you know. We stand up crooked. No, not really, but your spine is not straight at all. It normally looks straight from the front, but not from the side. There are three long curves in it, but fortunately they balance out for most of us. Here's how they seem to develop.
A newborn baby's spine is largely straight. When infants begin to sit up, if they lean sideways or backwards they fall over (cute, eh?). If they lean forward, their little legs can prop them up. So they lean forward from the waist, and their young spines grow into a bent-forward-from-the-waist curve called "kyphosis" in the spine above the waist and between the shoulder blades. Of course, if that was all they did they'd be looking at their little belly-buttons all day long. So they lift their heads up to look around. That arches their necks backward into another curve called a "lordosis".
A little later, the baby starts to walk. At first they lean forward because of that kyphosis at the waist and toddle forward just a few steps into Mamma's arms. After a bit, their back muscles grow (or are trained through the exercise of trying to walk) strong enough to hold them up and balance the body through another "lordosis" curve in the low back. That's what the hollow in your low back is.
We never quite get balanced. Standing erect, the body's center of weight (also called the center of gravity) is actually just on the front edge of the spine. We all have a natural tendency to collapse or pitch forward like a rag doll. That's why our back muscles have to work so hard to hold us erect, remember?
When we get old our discs tend to wear out and thin down, and our bones get osteoporotic ("brittle") and often collapse a bit too. That tends to increase our pitch forward, which is one reason why old people often get hunchbacked. That's a kyphosis, too, just not a normal one.
You have a spondylowhat?
A common diagnosis in back pain patients is spondylolisthesis. Gesundeheit! What on Earth does that mean, you ask?
It's a kind of hole in your back. Sometimes it lets the bones slip out of place.
Let me explain a bit. This is a developmental abnormality that's present in 6%-7% of the normal Caucasian population. In some groups of people it can be very common - 1 in 4 Native Americans have it, and 1 in 2 Inuit (Eskimos) do too. Most of the time, it doesn't hurt and most people who have it don't know that they do, so don't panic. Doctors often pick it up by chance when we take your tummy or kidney X-rays. No kidding. One of the surgeons I trained under has it, and he's a maniac who could operate all day well into his 70's without complaining about it or having any more backache than I do at the end of the day. Yes, my back often hurts. You stand in one place all day leaning over somebody's spine in my operating room!
The word comes from Greek. "Spondylo" in Greek basically means "spine". The term "listhesis" means to slide or slip. Hence, "spondylolisthesis. Now, just to make it more complicated, there's another term "lysis" that refers to a gap or hole in something. So we Docs have another confusing term for you, "spondylo lysis ". That's for people who have the hole but are not slipped out of alignment. Lastly, there's an older word that's largely unrelated to this topic that means "arthritis of the spine", spondylosis , just to make things even more complicated.
How do people come to be running around with holes in their backs? Here's some more development. That newborn baby we've been talking about has very little bone in its spine. There's only a small bit of calcification in the vertebral body anteriorly. Most of the newborn vertebra is made of cartilage or gristle that calcifies in childhood, somewhere between six and ten years of age. For reasons we don't always understand, in six or seven out of a hundred kids the calcification is incomplete and that's a spondylolysis (at least, that's how one theory goes here).
Because it's not calcified, the spondylo (doctors cut the word short all the time because it has too many syllables!) looks like a hole in an X-ray. It's not actually a hole. It's a gap between the normally calcified parts of the vertebra that is filled with scar tissue and gristly stuff called cartilage. It's loose enough to let the two parts of what should be one solid bone wiggle a bit on one another, but even surgically we have to work at it to cut them apart.
Okay. Now, what about the slippage (which doesn't always happen and is usually without symptoms, remember)? Recall we're designed to slump forward, and we're held up by muscles and those overlapping fish-hook-like facet joints. The spondylolysis sits between part of the facet joint and the lamina, so the stem of the fish hook (the lamina and upper facet of that joint) is broken away from the curved business end (the inferior facet or lower part of that joint). With the two vertebra bones unhooked, the center of weight being in front of the spine may (but not always, in fact not usually) let your whole spine slide forward a bit through the disc. Think of squishing the marshmallow-disc forward between your fingers. That's a spondylolisthesis.
Doctors are often taught to think that the presence of a spondylo in your X-rays doesn't mean anything, because most people with a spondylo don't have a back pain problem. That may not be accurate. The presence of a spondylo can cause symptoms a couple of different ways. The gristly stuff can swell up and pinch your nerves. The sliding forward may stretch or pinch the nerves too. Also, the chance of premature degenerative disc disease in an adult spondylo patient is four times that of an anatomically "normal" spine - probably because the spondylo changes the normal pattern of biomechanical loading in these people.
The spinal degenerate balance; or, why your worn-out looking X-rays may be normal
This section will be my farthest departure from accepted fact. It has had to be, because Western medicine just doesn't explain this at all. My surgeon colleagues and I are expected to shrug and say "I don't know" to you a lot. Sorry, that's not good enough in my practice. I think I've got it figured out, in principle. Here goes.
Earlier I described the huge forces acting on your spine and the small size of the discs and joints. Our one-inch lumbar discs are being loaded with several hundred pounds of pressure a million or more times every year, and it's not hard to understand that they might wear out. They all do.
One hundred percent of the time, if we look at the disc of somebody in their 20's under a microscope, we'll see degeneration starting to happen.
The X-rays of somebody 50 years old will show major wear-and-tear or degenerative changes over half the time (that is, in one of every two cases) in people who have no problem back pain at all!
Take people without spine pain and do MRI scans on them. In the neck, the scan report says one in three need surgery. In the thoracic spine (that's the part between your shoulder blades, where your ribs connect), two out of three pain-free people need surgery according to their MRI reports! In the low back, it's 50/50.
Technically, we call these "false-positive" scans. This is part of why I've stressed that your story, the medical "history" of your symptoms, tells us what your problem is. The scans can only be interpreted intelligently in light of those symptoms, and don't ever let anyone operate on you because of a scan report. But what's going on here?
Balance. I'm off the beaten track a bit here again folks, but stay with me. It seems that, as our discs and facet joints wear out slowly with time, effectively they get replaced with scar tissue. Sometimes they'll thin down and collapse, angulate ("go crooked") or grow bone spurs. This is a bit simplistic, but that's basically what seems to happen. As we grow into our ripe old age, if all has gone well our spines may be worn out but they're scarred in solidly, nothing wiggles much and we have no great pain.
My Dad's was that. He had the worst X-rays you'll ever want to see, but he had major back pain for only one day in his life. It was after he wrenched his back shoveling snow. He'd probably never know about it if he wasn't my Dad. He called me in a bit of a panic that day. I was just an intern back then, didn't know any better and had him come down to the hospital to get some films done. They scared me to death and got the surgeons training me all excited and talking about surgery. Fortunately (and as one would expect) he was just about fully recovered by the next morning.
Effectively, it seems there's a "race" going on in all of us, between our spines wearing out because of the high loads we put on them and the worn-out structures scarring in solidly enough to provide support anyway. I think of this as "the normal spinal degenerate balance".
Why do some of us wear out quickly enough to become symptomatic, and others not so? Historically we blamed environmental factors or "things we do" (becoming massively obese, heavy work/excessive sports, exposure to certain vibrations, smoking and stress) for this but we know now from recent research that in the majority symptomatic disc degeneration is a genetic phenomenon. That's right, we inherit it from our parents! A great deal of high-end spine research now doesn't involve surgery at all but is focused on chromosome mapping and cellular manipulation/gene therapy options.
You'll only have spinal pain or sciatica if a nerve is (or sometimes many nerves are) pinched, if joints are more worn out than scarred in and they accordingly hurt, or if things are just so eroded that your spine can't support you and begins to collapse (we call that "instability", and it really happens!). The biggest disc hernias may not hurt if they're not pinching a nerve, and the biggest bone spurs may not be an issue either if they're scarred together and giving strength to the spine.
So, when you're seeing a doctor about your sore back, make sure he gets the story of your complaints as you start out together. He should examine you too, to try to confirm the nature of your complaints. If he flashes your scan and offers you surgery, he doesn't know what he's doing and you should go elsewhere. Even more so if he suggests surgery after getting your scan reports but without actually seeing the films.
Must you have this operation?
Surgery for painful spinal conditions is just about never necessary . It's generally an option , to be considered only after extensive nonsurgical therapy has been proven ineffective.
Most spine pain conditions, even those cases with severe and disabling pain, usually get better without surgery. No kidding. Disc hernias are usually resorbed by your body, and as they shrivel up the nerves become unsquished. Bone spurs stay there but is seems that the nerves can slowly stretch around and over them, adapting until they don't hurt any more. Painfully worn-out discs and joints will eventually scar in and settle down if you can wait things out.
Only a small fraction of back pain or sciatica cases might come to the operating room. You and your surgeon should consider it only if you have a severe pain that medication and therapy can't control, a pain bad enough that it's affecting your quality of life in a way that's unacceptable to you. Spine pain conditions just about never get worse quickly. Be careful if you're told anything like "you'll be paralyzed unless you have the surgery", because that's almost always not true.
You might have a pain that stops you from doing only certain activities, sports or work. Be careful about risking surgery for that. There's always a small chance of death or paralysis in spine surgery. Consider giving up your sport or other painful activities, maybe changing jobs or retiring early. That may mean changing or compromising your lifestyle a bit, but if you can otherwise be comfortable and enjoy life the trade-off may be worth it. Surgery can never be guaranteed to do well enough to restore all your activities.
You might have pain that requires regular medication but which is well enough controlled with that medication that you're basically fine, able to do and enjoy everything that you want to do as long as you take your pills. In that situation, assuming your system tolerates the medicine well and you're not suffering from side effects, don't have an operation. Take the pills for the next fifty years, if need be!
In considering surgery for your back pain, you're making an elective decision about elective surgery for yourself . Of course you can't make that decision without considering how your surgery will affect your life and work and family, and you'll need information about your problem and the surgery from your doctor to make an informed decision for yourself, but the decision must come from you! Your X-rays don't make it, your surgeon doesn't, your husband or wife can't, and certainly your employer or insurance company shouldn't. You should be 100% sure in your head and your heart that you want your operation done, just as your surgeon should be 100% certain of your diagnosis and how to deal with it. If you can't say that you are, don't have it done. In most cases, you lose nothing but time here. Maybe you'll change your mind at some point. That's okay, you could have the surgery next week or next month or whenever!
What do you want from your operation?
This seems like such an obvious question. It's not so simple. The same way doctors often don't communicate to their patients very well, patients often don't communicate back to us about what they'd like from the procedure. We might want to take out your gallstones so you don't get liver poisoning, you may want your tummy to stop hurting so you can eat a gallon of ice cream every day. The two sides may or may not meet in the middle.
In spinal surgery, great misunderstandings often happen here in the difference between "relief of pain" and "return to work". That makes sense, doesn't it? A lot of back pain patients are so sore they can't do their jobs.
Surgery can be considered and should be done only for "relief of pain". Sure, often the patient will do well enough that they will get back out there, but in an individual case we can never guarantee it and is getting back to the office or factory or whatever worth that small but very real risk of death or paralysis?
These issues get really tricky when you have a work injury or job-related back pain. If you're disabled, the employer and your insurers of course want to get you back to it. But it's your risk. If you can live with your pain outside of your job, don't have surgery! If there's an alternative or another more tolerable job out there, go for it. Maybe you'll have to quit or retire early, and that might mean compromising your future plans or your lifestyle, but that's life. If your back pain is tolerable or goes away when you're not working, stop working or get another job.
The financial implications of all this are obvious. Because of the money involved, there has been lots of research done around the issue of what factors in spinal surgery might help predict "return to work". It turns out that what's seen in your imaging, the details of the operation, the strength of your back or the physical demands of your work do not relate at all to the odds of your going back. The only things that help us here are psychological tests that measure how much you like your job, and your salary. If you don't like your job and your wages are low, you're probably not going back no matter how well the surgery goes. If you like your work and make a good buck at it, you're there no matter how much slicing and dicing we do for you.
This sounds like such crap, but it's been proven by study after study over decades and around the world. In my own practice, for example, I've got dockworkers and steelworkers who are back working after big spinal fusion operations (bone grafts and screws and rods and whatnot). I've also got homebodies and office workers claiming they can't do a thing after little disc surgeries with incisions less than an inch long.
Work is not the only pain-causing activity that brings people into a surgeon's office. Sports and things are up there too. I practice in the Canadian province of Ontario, and I'm probably the only adult male up here who doesn't live for golf once hockey season's over. The number of people who I see in the office complaining of terrible back pain who turn out to have come in only when they've had to give up their golf games is unbelievable. Remember, twisting is just about the meanest thing you can do to your low back! These people are actually willing to go under the knife for that. I'm amazed. I'd argue against it, why take that risk? Take up another, gentler sport!
Doctors are trained to take a history of your symptoms, and that history is the most important part of figuring out what hurts. We are not generally taught to be really sure about how it affects you and your life. We would probably do a much better job of looking after our patients if we paid more attention to that. Help us. Please make sure your doctor knows what you want from the surgery.
What's spinal stenosis? Or, who's Claudio?
Spinal stenosis is a common and confusing diagnosis in spinal surgery, particularly for people who have Claudio symptoms.
Forget Claudio for a minute. The word "stenosis" means a narrowing. It can refer to anything. When a car wreck closes all but one lane on the highway and ruins your day, there's a stenosis in the traffic flow on the highway. When you put your fingertip over the end of a garden hose and squirt the water around, you're creating a stenosis at the opening of the hose.
Remember, normally parts of the vertebrae wrap all around the spinal cord and nerve roots to protect them from injury. Spinal stenosis refers to a narrowing of the bony tunnels or "canals" through which the spinal cord and nerve roots run.
Doctors make an important distinction between the "central" and "lateral" spinal canals.
The central spinal canal runs up and down the whole length of your spine. It's roughly two feet or half a meter long. Up in your neck, between your shoulder blades and along your rib cage it contains and protects the actual spinal cord. Below that, in the lumbar spine, there are only nerve roots. Why? When we're growing up, the spinal cord stops growing very early in childhood but our bones obviously do not, and your lower or "lumbar" spine grows down and away from the end of your spinal cord. Because of that, the adult spine is longer than the spinal cord. The cord in most people typically ends at the level of the L1/L2 disc space. That's up towards the top of the hollow of your low back, roughly at the level of your lowest ribs or about a hands-breadth above your belly button.
From the end of the cord, a bunch of nerve roots emerge to run down through the length of the central spinal canal in the lumbar spine of your low back before exiting through the lateral nerve root canals to run down into the legs. This bunch of nerve roots looks roughly like the tail of a horse, and it's referred to by the corresponding Latin term, "cauda equina", that literally means "horse's tail".
Stenosis, narrowing or "pinchings of the nerves" can happen in the central spinal canal, in the lateral canals, or sometimes both. This is most commonly caused by age-related degeneration with thickening and spurrings of the bones and spinal ligaments, sometimes with degenerative bulging of the discs. So, spinal stenosis is most commonly a disease of older people. Doctors call this "acquired" [you didn't have it originally when you were young, then for whatever reason you got or "acquired" it] stenosis.
Central canal stenosis can also happen just because of the way you're built; we call that "congenital" stenosis. How is that, you ask? There is obviously a range in how people are built - tall or short, lean or fat, fine- or heavy-boned, and so on. There is similarly a range of sizes of the space available in the spinal canal. Some people are roomy in there and can tolerate big disc hernias and bone spurs without their nerves being squished at all, while some are built on the narrow side or "tight" side and will have serious pain from even very small disc bulges. Certain populations have particularly narrow central canals. The most common types of dwarves or "little people" are called "achondroplastic" and they are notorious for suffering serious spinal stenosis and often needing surgery in their 20's or 30's. More trivia - beagles are achondroplastic dogs. That's part of why they often walk funny (they have a lot of congenital hip problems too)!
With central spinal stenosis your symptoms may include both back pain and/or weakness, usually with numbness or tingling and pains in the legs. Usually it's both legs but often worse in one than the other. Remember, these symptoms are "and/or". You won't necessarily have either back pain or leg symptoms, and you can certainly have just the one without the other. Nothing is ever written in stone in biology.
The lateral spinal canals are those very short sideways passages through which the individual nerve roots leave the central spinal canal to run out into the body. Terminology gets confusing here because doctors and anatomy people call these passages many different things, often without much rhyme or reason. The lateral nerve root canal is also called the "lateral recess" and the "foramen" and the "nerve root tunnel", among others. At each "level" in the spinal canal, that is between each two vertebrae, there are two lateral recesses (that's the term I most commonly use). One each runs to the left and the right.
When a nerve is pinched in the lateral recess, you'll generally get sciatica (leg symptoms starting in the buttock, remember?) in only one leg and very often your back won't hurt to speak of at all. But just to be confusing, it's very common to have lateral recess stenosis at multiple levels (many different pinched nerves).
What's all this about "levels"? There are 24 mobile vertebrae in your spine. There are seven in your neck, twelve along your rib cage, and five in the low back area before we come to the sacrum (pelvis) and coccyx (tailbone). Between neighboring bones is a disc, and at the right and left edges of each of those discs there's a lateral recess and an exiting nerve root. Because this is where structure most commonly fails and pain comes from, this area needs a name. We call it a "level", meaning the level between the adjacent or neighboring discs. For example, disc hernia is common at the disc between the L4 and L5 vertebrae, at the "L4/L5 level". Okay?
Remember Claudio? He doesn't exist. But spinal stenosis patients meet him all the time when their doctors mumble about claudicant symptoms and don't explain themselves well. Claudicant symptoms, or claudication, are leg and/or back pains that get worse with walking and are relieved by rest. Sciatica is commonly claudicant in its nature. If you think about it for a minute, that makes sense. If your nerves weren't pinched at all, presumably you could be as active as you choose. If you were completely squished you'd be in terrible pain all the time, maybe even paralyzed. Somewhere in between is where most spinal stenosis patients are. Taking it easy, there's enough circulation in those nerve roots to meet their resting metabolic needs and you don't hurt. Go walking and increase the metabolic demands of your nerves as they drive the muscles in your legs, and pretty soon you're hurting. Rest a bit, that sluggish circulation catches up and your pain goes away.
There are imitators. Spinal stenosis is not the only condition that causes claudicant leg pain. Hardening and blockages of the arteries (atherosclerosis) causes it too. That's why your spine surgeon may send you for a circulation test before offering you surgery. A clue here is that spinal stenosis-related or "neuroclaudicant" symptoms most commonly appear in the hamstrings or calf at the back of the leg, while circulation problems or "vascular" (that word just means "relating to the blood vessels, or circulation") claudication more commonly present in the front of the leg at the shin or thigh. Also, when you stop walking and rest, if the problem is vascular you're usually fine in a few seconds or a minute. Nerve-related symptoms will take longer, usually at least five to ten minutes or more, to fade away.
Claudicant symptoms often involve a lot of numbness. Here's another curveball. Problems with the metabolism of the nerves themselves, called "peripheral neuropathies", can frequently cause leg symptoms too, and they more often cause numbness than pain or weakness. Diabetes and thyroid disease are frequent causes. They won't generally cause backache, but you just might have garden-variety muscular back pain at the same time. This combination can fool us all easily and lead to surgery that doesn't do any good. To check for this, your doctor may send you for nerve tests on your legs (they're called "EMG's" and "nerve conduction studies" or "evoked potentials") before offering you surgery.
Say you've got spinal stenosis. Don't panic! Those pinched nerves are not generally going to die off and leave you paralyzed tomorrow. That just about never happens. Remember, those bone spurs take years if not decades to grow. Japanese surgeons followed a group of patients with spinal stenosis causing symptoms for fifteen years and found that while yes, 85% got worse with time, none of those deteriorations were catastrophic. Patients were a bit more numb and tingly, walked a bit less - but nobody was paralyzed or wheelchair-bound. It seems our nerves can "stretch out" over time and adapt to our spurs and disc bulges. When a patient does gets worse, it's generally a very slow process that gives the patient months or years to get to the doctor.
My mother-in-law's a prime example of how there's no rush here. She's got serious back pain and sciatica from pinched nerves at four levels in her spine that we've known about for almost twenty years now. She's chicken and hasn't had anything done about it (maybe I shouldn't talk shop at the dinner table?), but she's no worse off now then she was when she had her myelogram. She doesn't like to walk but she can still look after a big house, travel, enjoy shopping and come over to help with our kids when I'm away.
Osteoporosis, bone density and spinal pain.
Osteoporosis is the softening of the bones that comes with age in so many people. It's often called "brittle bones disease" because of the mental picture people have of weakened bones snapping apart when old people stumble or fall over.
This is not just a disease of old people. We'll frequently see it in people as young as their 50's, sometimes younger. It can be caused by a bunch of things, and perhaps best be prevented by getting our kids and younger people to drink their milk because we reach our peak skeletal calcium at about age thirty. Smoking is probably the major risk factor in later life, though lack of exercise and certain drugs can do it too.
Osteoporotic bone isn't brittle, it's just soft.
So who cares? You probably know that osteoporosis causes fractures, but I'm supposed to be talking about spine surgery here.
Living bone is not completely solid, there's a bit of springiness or "give" to it. That "give" helps normal bone to absorb energy as we run around, to take the load. If the bone is soft, it'll have more "give" and if it's too stiff then "snap" and it might break.
Researchers are only just starting to suggest that that this "give" may actually hurt sometimes, particularly in cases where the bone is soft. Research data has shown that various parts of your vertebra may deform, "wiggle" or bend under load, and that might cause pain. Too much give might result in a fracture. Here's a reason for spinal pain even in cases where the discs, nerve roots and facet joints are not worn out.
Medical doctors (who don't do surgery) have been treating osteoporosis with bone-hardening medicines for some time now, and it often works. When it doesn't, we surgeons are starting to inject bone cement into these painful vertebrae to reinforce them in procedures called "vertebroplasty" or "kyphoplasty" that are relatively novel.
Why do you lean forward with back pain?
There are several reasons for back pain patients to lean forward.
Perhaps the most common in older people is simple disc degeneration. As your discs wear out with age, they "squish" and loose thickness. This loss of height effectively shortens the front part of your spine, where the discs are. The back part of your spine is all bony (laminae, facet joints) and can't shorten to match. If the front shortens and the back doesn't, everything gets pitched forward.
Osteoporosis can do it too. Some older folks just get so brittle that their spines fracture spontaneously during normal activity. This is probably much more a soft squishy "moosh" than a big "crack" sort of thing, in fact it may be a series of small "microfractures" happening one after the other over a number of years and most people don't even know when they happen. These fractures tend to shorten the front part of the spine too, and we pitch forward much the same way we do with disc space collapse.
The most common in younger backache patients whose discs haven't had enough time to wear out is muscular pain or fatigue. Remember my earlier discussion about how our muscles actually hold our backs up when we're standing up straight and in this erect position the supporting ligaments of the back are relatively loose. As we lean forward, the ligaments are stretched and tighten up to take more load while the muscles correspondingly relax. This is all normal and physiological ("that's how our bodies work"), but let's do some chicken-and-egg here. If your muscles hurt and have been cramping up all day they'll eventually get exhausted and have to relax. When that happens your body's center of gravity takes over and you pitch forward a bit, until the ligaments stretch out enough to take the load and support you. Make sense? Been there, done that!
Some older people get muscle diseases that weaken their back muscles and force them to slouch forward much the same way. Parkinson's disease (Michael J. Fox's disease?) can do that, and perhaps ankylosing spondylitis in younger people can too.
Another common reason that those older folks at your grocery store have to lean forward onto their shopping carts to get around is spinal stenosis. As our spinal canals get narrow with the growth of bone spurs, we naturally do everything we can to maximize the room for the nerves in there. The volume or amount of space in our spinal canals is a function of "posture" or the way we stand. Lean forward, there's more room, nerves are relatively unpinched and you can walk around. Arch backwards and the opposite happens, increasing your pain.
How can that be when the walls of the spinal canals are made of solid bone, you ask? Remember the ligaments and discs all bulge a bit. They bulge more bending backwards and less when we lean forward.
The lining ligaments at the back of the spinal canal are called "ligamentum flavum" because they're yellow and "flavum" means yellow in Latin. Because they're in back and behind the flexion/extension axis or "hinge point" of our spine which is actually in the posterior third of the disc, they stretch in flexion and correspondingly bulge less. Removing this bulge, among other things, effectively increases the space for your nerve roots.
Remember by "marshmallow" description of your discs. Hold a marshmallow between your fingers and squish it forward, what happens? The front part bulges forward, and the back part towards your palm stretches out and bulges less. Again, less disc bulge sticking into your spinal canal means more room for the nerve roots in there.
No kidding, all this stuff really happens and it's important. Some people with spinal stenosis may barely be able to stand up straight or walk for a few minutes at a time, but they can ride a bike all day because we lean forward to do that. They'll have trouble walking downhill because we arch our backs backward for balance there and that increases the bulges to pinch the nerve roots, but they can trudge uphill easily as they "lean into it".
Sometimes, particularly up in the neck and in older people whose spines are worn out, sharp flexion/extension motions that might happen in a fall or when your car gets badly rear-ended can pinch the spinal cord so severely that a paralysis, generally called "central cord syndrome", occurs. This is not simple whiplash from a bumper tap, this is different. No fracture, no dislocation, nothing much to see in the X-rays, but you're paralyzed. It's usually only a partial paralysis, and it does usually get somewhat better with time, but you're rarely normal again. Drugs and surgery can help sometimes, but not always.
Even people with a disc hernias pinching their nerve roots will often lean forward as their bodies try unconsciously to unpinch things.
The last great cause of your sore back leaning you forward is our fault. Yup, surgical boo-boo. Early surgical implant systems like the Harrington rod you may have heard of tended to distract or lengthen the back part of the spine, flattening our the normal hollow of your low back to cause an iatrogenic (this word derives from the Greek words meaning "caused by the doctor" - oops!) "flatback" deformity. We've only begun to understand this phenomenon recently. These poor people can't stand straight no matter how hard they want to. Try to stand or walk around for a while leaning forward. You'll be hurting, big time, very fast. Sometimes we surgeons have to go back in there, take out the rods and cut the fused spine (that's an "osteotomy") to correct this. It's big surgery but very helpful surgery.
Fortunately, modern implants are designed to avoid causing this problem - but it still happens!
Okay, last but not least, bad hip arthritis can force your hip into a flexed position under you and that throws your body forward too. A careful spine surgeon will often examine your hips!
The difference between an "ectomy" and an "otomy"
Your surgeon offered you a disc ectomy operation and your neighbor had a disc otomy . Some folks have a lamin ectomy , some a lamin otomy . What gives here?
An "ectomy" is when we surgically remove some entire thing. If you've got appendicitis you have an append ectomy , we cut it all out. We wouldn't leave half of the infected organ in there, would we?
An "otomy" literally means "to cut into something", or perhaps to make a hole in it. Neurosurgeons do that when you have a brain tumor and they have to cut into your head, they do a "crani otomy ".
In disc surgery, we generally do an otomy. Sometimes we call it a discectomy because we're not picky about the words, but surgically removing the entire disc is almost never necessary, actually just about impossible to do and potentially quite dangerous. What need be done here is to remove the loose and misplaced pieces of your disc, and a simple discotomy is generally enough to accomplish that.
In spinal stenosis, it depends on what kind of stenosis you've got. If you've got lateral recess stenosis all you need are laminotomies that cut away the outermost bits of the lamina where it covers the beginning of the lateral recess. If you've got central stenosis, then you'll generally need the whole lamina removed - the classical neurosurgical operation called laminectomy. Just to be confusing, some surgeons may feel it's not safe to open the lateral recesses without first doing a laminectomy to get some working room in there. Oh, well.
Basics - the three simple things that spinal surgery can do for you
The spine is a complex and often subtle thing. It's often not easy to figure out what's hurting a given patient. When we do figure it out, often one finds that there are several things going on and ideally we'd try to "fix 'em all" in your operation. However, even the most complex spinal operations usually boil down to some combination of the three basic things that a surgeon can do to your spine.
The first is decompression , or the unpinching of your nerve roots. Discectomy, laminotomy, laminectomy and some reductions (new word here, more soon) are all different ways to get pressure off peoples' nerve roots. Sometimes we'll do several of these, in variable combinations, at one operation.
The second is fusion , the bigger operation where we use bone graft (generally harvested by us from your own pelvis, and sometimes we add in synthetics or other bone graft substitute materials too) to reinforce and permanently stiffen painful worn-out joints and discs. Fusion can sometimes be done in addition to decompression.
The third is reduction , a procedure where we use rods and screws and stuff to push and pull crooked or malaligned bones into a more normal alignment. The classical example of this is scoliosis surgery (straightening out Quasimodo). Reduction is almost always done with instrumentation (the screws and rods and other "hardware" are what pushes the spine straight) and must be accompanied by a fusion, which permanently holds the straightened-out spine in its normal position. Without a solid bony fusion, that instrumentation will eventually break or work loose and your spine will always go crooked again.
You'll hear a lot about instrumentation , or the insertion of screws and rods, and things called "cages" (all these things are technically called "implants", commonly "hardware") as an operation. Be careful here. It's not. There are no metal implants strong enough to hold together over the lifetime of your spine without the support of a solid bony fusion. Instrumentation is only part of a fusion operation! If somebody offers you an instrumentation procedure without a fusion, go somewhere else.
Spinal surgery timelines
If you cut your finger it takes a while to stop bleeding, right? If it's a bad cut, maybe you need a few stitches - but your finger's not perfect as soon as the stitches are in, is it? The skin takes a week or so to heal enough that the stitches can come out. You're probably going to be a bit stiff and tender for a week or so more than that. The bright red scar may be fading slowly for a year!
Likewise in spine surgery. In many cases your pain will be somewhat better as soon as the anesthetic wears off enough for you to be aware of how you feel, often a lot better, but the full healing and then rehabilitation (that really means "regaining your strength") takes a piece of time.
Remember, don't expect to feel perfect even after a very successful operation and complete recovery. More often than not, you'll be left with a bit of very low-grade soreness that may increase with intense activity and when the weather gets bad. You'll still have the normal muscular aches and pains that we all get. We can't change the fact that your spine has enough degeneration on board that you had a surgical problem in the first place, and you might get further problems in your future if you don't look after yourself. But you'll certainly feel different when the surgery is over, and in capable hands you'll almost always feel very much better!
Basic surgical pain takes some time. What seems to happen is that the immediate postop "pain of the cut" stays right up there for about three days, and then your body's healing processes somehow catch up to it and the severity of your pain is suddenly cut in half or so. This is true of all operations. That's when ladies fix their hair and makeup for the first time after surgery, men shave, and kids get hungry again. During this time you'll probably need some serious pain medicine, even if your surgery was a day case (yup, some spine surgeries are day cases! More on this later). Also, a lot of activity will hurt. Try to control your pain more by limiting your activity to what you're comfortable doing, rather than pushing things and having to use a lot of meds.
We come to a major principle in dealing with any spinal or even postop pain here. The best physician and therapist for you lives between your own ears, you're it, so it's very important that you pay attention to how your body feels and whether you hurt with activity. You're in charge! Don't be afraid to be active, in fact the risk of postop complications may go up if you don't. It's OK and normal to be a bit sore when you're up and around, but you should be ready to take it easy and rest a lot at the slightest hint of real pain after the surgery. That sounds wimpy but it's smart. Of course you're sore, but you can't treat real structural spinal pain like an athletic injury where people say "no pain, no gain". If you make it hurt you're stirring up more inflammation in there. More inflammation, more pain and eventually this cycle will feed on itself and your pain may become chronic no matter how well the surgery went!
After that first big "dropoff" of your surgical pain, at three or four weeks it'll seem to suddenly be cut in half again. At this point the "pain of the cut" is largely gone and you'll generally be quite comfortable in normal daily activity, though there's still a lot of deep healing of the spine going on.
With a decompression operation, when the surgery is finished the nerve roots are unpinched so blood and spinal fluid are flowing in them again. Since the inflammation is correspondingly "washing out" right away you'll often feel much better right away. But remember, the deep-seated irritation and scarring in those nerve roots was built up over months or years. You'll easily experience slow progressive improvement for months! Our "rule of thumb" is that you'll have 90% of the healing you're going to get at about six months postop.
However, say some parts of the nerves have to effectively "grow back" and connect into your legs. Nerves regenerate at a speed of a millimeter (that's roughly 1/25 th of an inch) a day. The distance from your bellybutton (that's usually the L4/L5 level, close to the center of most spinal operations) down to your toes is about a meter (one thousand millimeters) in most people. One thousand millimeters means one thousand days is roughly three years of progressive nerve healing!
This reconnection process itself can be painful. Not in all cases, only ones where the nerves have been very badly squished, or perhaps squished for a very long time. I'd estimate maybe one in ten or twenty of my patients experiences it. The process doesn't generally start up for a month or so. When it does, you may experience new symptoms in your legs that will scare the crap out of you and which can easily fool an inexperienced surgeon into cutting you open again. These reconnection or "re-innervation" symptoms generally involve a very hypersensitive tingly or burning pain, sometimes with cramping or spasms of your legs muscles. They'll start high on your leg at the thigh, slowly work down over a few weeks or months and fade away as spontaneously as they came on.
Re-innervation is a difficult thing. It's not in the books, and I don't know why. Surgeons observe it in their patients all the time, but it's never been well documented and we're not taught about it. Many physicians who read this will think what I'm explaining now is crap, but let me make another analogy (comparison by example).
Imagine sitting with your legs crossed for long enough that your foot falls asleep. This happens because some of the nerves in our legs are just under the skin and with legs crossed we can easily put enough pressure on them to cut off the blood flow, just like a pinched nerve root. What happens when you get up to walk around? For the first few steps you don't have any pain because the nerve's not working, and you may stumble on the floppy foot because the temporarily-paralyzed muscles don't work. After a second or two the blood rushes back into the nerve and that huge tingle sets in. Often you'll have to stop walking, lean against something to balance for a few seconds and shake your foot like mad until it settles down. Voila! That's reinnervation! This seems exactly what may happen postop for a badly squished nerve root, though the timing after surgery is much more drawn out.
Reinnervation symptoms, even when we recognize what they are, are very difficult to treat. Because they're not caused by trauma or inflammation, they're not well treated by most pain medicines or anti-inflammatory meds. They really represent a "raw nerve ending" kind of pain, but they're a healing pain and there's no new damage going on. Even morphine may not help here! What does seem to work a bit, never completely, are drugs designed to quite the activity of nerve cells (I like one called Neurontin, or Gabapentin; there are several). This makes sense. Your nerve cells work by sending small electrochemical signals to one another, and to your muscles. It's not hard to imagine all those microscopic connections short-circuiting a bit as reconnections are made. If we can chemically make the nerve cells less excitable (kind of like insulating them), they won't short-circuit as much.
If you've had a fusion the bone chips will take about three or four months to knit and become solid in most cases. During that time, your surgeon may ask you to wear a back brace or limit certain activities - common sense here! Early on you may feel great because of internal support from instrumentation (if you've had it - more in the section on fusions, coming up) but the grafts have to knit to support you in the long run.
Muscular pain can be a problem after surgery too, particularly after the bigger operations. Presumably your spinal pain has limited your activity for a long time before the surgery. During all that time, your back muscles weaken for lack of normal use. We surgeons can beat them up pretty bad in the OR too, and then you've got to take it easy for a while after surgery as the incision heals. Usually you're getting pretty active by a month or so. As things heal, of course you gradually become more active. Typically at two or three months postop, your activity level bumps into the weakened ability of your muscles to support you and bingo! Muscular backache, what we surgeons typically call "deconditioning [out-of-shape] pain appears!
Deconditioning pain can be acute (short-term) as I've just described, or chronic (long-term, sometimes permanent) in people who never get any exercise. Acute deconditioning pain is what you feel when you start to get up after you've been ill with a bad flu or some other sickness that knocks you off your feet for a few days. A similar thing may happen in people who are very overweight, not so much because their muscles are necessarily weak but because their weight puts more load on their muscles than those muscles were designed to carry.
This is usually a low-grade ache at the bottom of your low back that extends from side to side along your beltline. It often isn't an issue when you first get up but tends to increase with activity and towards the end of the day. It makes you feel stiff, you may want to stretch and have to rest a bit every so often.
Not everybody goes through this after spinal surgery, but don't panic if you do. It's another thing that can fake an inexperienced surgeon into charging you back into the OR. Relax, and tell your surgeon to take it easy too. The treatment is not more surgery. It's a combination of both limiting your activity to a level you're comfortable with, and gentle exercises that will build up the strength of your back muscles.
The two-way street to successful recovery
You the patient put yourself in the doctor's hands. He or she is going to take care of you and you're going to get all better, right?
Not so simple in spinal surgery. There is a great deal of nerve and possibly bone healing going on inside you for several months after a spinal operation that's just as important in the long run as the actual cutting. Your later rehab is important too. The results of the most technically excellent of surgeries can wrecked if you do the wrong things postop, or if your aftercare is inappropriate.
That's what I mean by the two-way street. You the patient have to do your part in this, for at least four or six months after the operation. We do our bit, you do yours, and all will generally go well. Either side can screw it up. Do not expect to do well after surgery if you're not willing to follow your surgeon's instructions for at least a few months. And make sure you've discussed this "what happens after" stuff before your operation, so you have a clear idea of what's coming up the line.
Guidelines here get really controversial. There are no hard-and-fast rules for postoperative care, and a lot depends on the technical details of your case and your surgery as much as your surgeon's experience and philosophy. I can give you some principles here that I use, just as examples, but talk this over with your surgeon beforehand. If he or she is not willing to provide this information to you, go somewhere else.
One big issue after spine surgery is that of managing your pain. Remember that after the surgery you'll be really sore for two or three days before your healing catches up to the surgical injury and all of a sudden your pain is cut in half, then at three or four weeks the cut is really healed and the pain is halved again. The rest fades slowly over the next few months. Certainly for those first few days, maybe the weeks, you'll have earned some serious pain medication. If you were taking a lot preop, you'll need more for longer postop than the average person because your system is used to it (please be honest with your surgeon about the drugs you might be taking, otherwise he or she may not be able to control your postoperative pain). But do remember, the best physician and therapist for you is between your own ears . Listen to how your body feels and act accordingly. Don't "make it hurt" and then try to get on top of it by chugalugging a lot of drugs, that may force your pain to feed on itself like a biofeedback loop and you can end up a cripple no matter how well the actual operation went. You're much better to take it easy and limit your activity to what's comfortable.
If you have little pain, go ahead and do whatever you like! Also, if you don't have much pain, you don't have to take pain medicine at all! Use it only as you must to feel comfortable.
Remember again, feeling comfortable doesn't necessarily mean having no pain at all. There's a cut back there, it's going to hurt for a while! But it does mean having only pain you can easily tolerate.
Another important issue in your postoperative care is the use of other medications. People are forever asking what they can take, calcium pills or vitamins or whatever, to make their backs heal better or faster. We can't help you here, we don't know of anything that will speed up the healing, but there are several things you should avoid because they may slow the healing and increase the risk of failure or complications after the surgery.
Steroid medications (cortisones) are well recognized to slow the healing of wounds and increase the risk of infection. Ideally they should probably be stopped for a while preop and stay stopped for at least a month or so afterwards.
Certain cancer drugs called "antimetabolites" that are also used for the treatment of some types of severe arthritis (rheumatoid arthritis, for example) should be a big issue for similar reasons, though the medical literature to date lacks proof of this.
Antiinflammatory drugs ("arthritis pills") can affect the chemistry of healing bone (it involves inflammation) and should also probably be avoided for at least three or four months after fusion surgery. I once operated on a fellow who'd been done twice by a colleague and who resorbed his bone grafts both times because he was on one of these drugs. We stopped the medicine around the surgery and he's got a wonderful fusion mass in his X-rays now. My operation was essentially no different from what he'd had done unsuccessfully twice before, other than for the medication having been stopped.
Most important around fusion surgery is the use of nicotine. Never mind the other bad things this weed does to you, it's increasingly associated with poor healing of bone. A simple crack in the shin bone (the "tibia") of a smoker will take twice as long to heal as the same crack in a nonsmoker. The failure rate of lumbar spine fusion in smokers is at least three times what it is in nonsmokers! Many surgeons won't put a smoker on their lists short of impending catatrophe, and I'd support that.
So how to quit? Nicotine patches only work 10% of the time, and they both put a high level of nicotine into your bloodstream and cost serious money. The much-advertised and more expensive new drug Zyban is twice as effective - still only a one-in-five chance! The Lung Association is free. They're in the telephone book, they have chapters everywhere, all you've got to do is show up. They are successful 50% of the time! Go there. And then save up your cigarette money while you're recovering from the surgery so you can go on a vacation to celebrate the relief of your back pain!!!!
Remember osteoporosis? We don't yet have any evidence to suggest that calcium supplements will help a spine fusion to heal, but some bone metabolism people are suggesting that a healing fusion site (and, for that matter, a healing major fracture) may effectively steal calcium from your body and possibly increase the risk of future osteoporosis. Taking simple oral calcium pills may help here. They can be bought over-the-counter at most pharmacies. Current recommendations suggest an adult should take 500 milligrams three times a day, ideally combined with some vitamin D (400-800 units is suggested). Try to get the "citrate" type of calcium; too much calcium supplementation can cause kidney stones, and citrate preparations may be less likely to do that. If the citrates are too expensive for you, at least make sure to drink a big glass of water with every calcium pill to flush your system.
Another big issue postoperatively is rehab. The entire world seems to assume that one must always have rehab after an operation, and that rehab should start immediately in all cases. Wrong.
The point of rehab is to get you strong, limber and comfortable enough to do the things you want to do. If your pain goes away straightforwardly after surgery (a simple disc operation, done on the right patient and at the right time, does that best) you may not need any rehab at all. You will need to do some exercising to get your strength back after surgery, though. If you're just a bit stiff and sore, you might (on your doctor's suggestion and in accord with his instructions, of course - don't ever charge take up a postoperative exercise program by yourself!) exercise on your own or go to a gym or health club rather than having to spend money at some clinic. I should say that this is an area where my personal practice philosophy may differ from many of my colleagues. Only about one in four of my personal surgical cases is sent for formal rehab. I believe that only if you're really badly off will you need formal, supervised, and usually costly therapy. However, it is true that many surgeons feel otherwise and you should always follow your personal surgeon's instructions after surgery to the letter.
When should your exercises or rehab start, you ask? Not right away. That cut hurts, remember? Charge off into an exercise program before it has a chance to heal a bit, and you'll only hurt yourself. Remember my comparison to spraining your ankle. You wouldn't start exercising a bad sprain right away, would you? You'd rest for a few days or weeks, maybe use a splint or in a severe case go into a cast. Only once the pain an swelling start to fade away would walking on it and exercising it make sense. Ditto your back. No serious rehab work before the pain of the cut has faded quite completely, and that's generally about three to for weeks after the operation.
What should rehab involve? In principle, three things.
The first is conditioning , or getting generally back into some kind of shape. Exercise walks can sometimes start within a few days or surgery, if you're comfortable. Swimming or home exercises should generally wait until the stitches are out so that you don't get them all sweaty, or wet. Serious running around (gym, health club or physio) should probably wait at least until the pain of the cut is gone at a month or so after the surgery.
The second part of rehab is stretching , or regaining range of motion. Oh boy, there's trouble coming in this paragraph! The rehab industry (it's a business, after all - just like surgery!) focuses a great deal on range of motion, and those of us actually focused on looking after patients often don't understand why. I think it's because disability-insurance rating systems use range-of-motion a lot to determine how badly off you are, probably because it's easy to measure. It seems you're much worse off if you can't touch your toes than if you can! Crap. I can't touch my toes! The disabled backache patient cares about how much they hurt, not how much they can bend. I personally don't send my patients for regular range-of-motion exercises at all, because these very often hurt the postsurgical patient. I send them for conditioning and strengthening instead. As strength builds up, stiffness usually "kicks out".
I feel the most important part of rehab is the actual strengthening that everybody talks about but just about nobody really helps you with. The strength of your back muscles is what holds you erect through the day, it's what you need. Believe it or not, strengthening your back muscles is very hard to do. It's particularly hard to isolate you back muscles to exercise them, and rehab people are taught to try to isolate muscle groups in therapy programs all the time. When they can't, they're frustrated. There's arguably only one piece of exercise equipment that comes close to achieving isolated strengthening of the back muscles it's called a "Med-X" machine), and it's so expensive that the fees paid for rehab by most health care and insurance plans won't cover the cost...so no one has it, particularly in Canada's uniquely socialized health care system.
To strengthen a muscle you have to exercise it against some a resistance . Schwarzzennegger's biceps didn't get big from stretching his elbows, toning his arms with those little rubber "therabands" or by prancing around in a pool exercise program. He got big by pushing some serious iron around (OK, steroids may have helped too). You'll have to do something similar.
He didn't get big by pumping iron every day or all day , either. Your body needs time to respond to a resistance training program, and if you exercise every day you'll just exhaust yourself. Think about it. If exercising hard all day worked, heavy industrial factory workers around the world would all feel great and look like Arnold. They don't; they're exhausted. Physiologists tell us that a muscle cell needs 48 hours to revive fully after it's been exercised to the point of exhaustion. That's what cross-training is all about. Most body builders do resistance training only every other day or so.
The spine surgery patient needs a back strengthening program that doesn't involve a lot of painful stretching or twisting. That big raw surgical incision will hurt if you do that. Strengthening exercises where the muscle doesn't stretch or twist are called "isometric", because the length or "meter" of the muscle doesn't change much. Sometimes we call these "stabilization" exercises, because we hope the muscle strength will make our spine stable.
Many of my surgical and injury patients can't get decent rehab care at all, sometimes because they just live too far out in the woods but perhaps more often in Canada because socialized medicine just won't pay for it. Patients in other health care systems may have a similar problem with private insurance coverage. I've needed some way for people to get resistance training safely and cheaply, on their own at home, for a long time. How to do that? A military man gave me the idea when he started doing old-fashioned deep knee bends after surgery.
Consider this. When you come up from the crouched position in a deep knee bend you're doing almost exactly what body builders are doing when they do "squats" with huge barbells on their shoulders - and, among other things, they do those to "cut" their low back muscles for their competitions!
You wouldn't believe it but we often start this when we take the stitches out around two weeks postop. I've got little old ladies regularly doing 30 or 35 deep knee bends at a time, feeling great and being discharged from my clinic without ever going near a therapist! Younger males can sometimes work up to doing two or three times that. It obviously doesn't isolate your back muscles. You're also strengthening your legs, you get some balance training and some cardio too (once the repetitions get up there). I think thirty or so is a "normal" strength level and that's when I generally let people go back to heavier work and sports.
This is a very old-fashioned and low-tech kind of exercise that's not very popular, but it's still used and works in the military and there's no reason it can't work for you.
It works like a charm but it has some limitations. One is the one in four or so of my patients who have knee or hip pain that won't let them do this. Another is the fact that very debilitated and older folks can be just too weak to do even one rep. Also, there are folks who just can't understand the point or who won't exercise and need the therapist to "encourage" them.
Please recognize that I'm getting really controversial here. The principles I'm talking about are common sense and well accepted but the details of this deep knee bends idea are unique to my practice, as far as I know. You'll never hear about this from any fool but me, because there's no therapy clinic that makes a nickel for you exercising on your own at home. Having said that, when the time comes please discuss the details of your personal postoperative rehab program with your doctor and follow his or her instructions to the letter!
The way I have my patients do these deep knee bends, both timing and form, is most important. On the question of how often to exercise, just once a day is enough. Several times a day will just fatigue (tire) your muscles. Remember, muscle ideally needs two days to recover from and react to exhausting heavy exercise (read the Merck manual if you don't believe me, I reread this again in my daughter's copy just recently). If you skip your exercises once in a while the world won't end either.
As to form or technique, you should stand very straight as you do these. If you're bending back and forth with each repetition you'll throw your back out. To stay straight you've got to hang on to something sturdy (a heavy piece of furniture, the vanity in the bathroom...a doorframe works well and you can hold onto it with both hands, but stand just back of it a bit) and that something has to be beside you. If you hang on to something in front of you, you'll be forced to flex forward as you go up and down and you'll throw your back out for sure. Thinking about holding yourself straight, go down to a full squat and stop for a second down there . If you bounce right back up you're just using the energy in your leg muscles. To balance in a straight-up posture at the bottom, your feet can't stay down flat on the ground. You must be up on your toes. Ready to come up? Take in a big breath, remember to stay straight, breath out on the way up and piston straight up until you're standing normally. You've done one!
This is hard on your knees, you may need to fiddle around with the position of your legs and feet until you're comfortable. Done one? Do another, and repeat with careful attention to your technique - standing straight, breathing out on the way up. At the first inkling of something hurting, quit. Usually what hurts is a knee or your thigh muscles, but it might be your back or a toe or whatever. Don't be proud, even if you've only done one or two repetitions.
For convenience most people seem to like to do this exercise before their morning shower, and when you're done just jump right in there and the water will make you feel great!
The next morning do the same number of repetitions again, then again the next day and again and again until after a week or so you'll realize that you're comfortable with however many you're doing. Then do one more repetition. Comfortable after a few days? One more again, and slowly work the numbers up
You won't feel much benefit in a day or a week, but do it for a month and I can just about guarantee you'll feel stronger and tire less easily. Most people are slowly improving their strength, their comfort and the number of reps they can do for several months, but eventually you'll "peak out" at some maximum (for you) number of repetitions. When that happens, don't keep doing them every day - you'll wreck your knees! It seems that two or three times a week is enough to maintain your strength, and I wouldn't ask anybody to do this regularly for more than a year (watch those knees!).
This program won't get everyone fully functional, but it does work for many. I've been having my patients do it regularly for close to ten five years now. Certainly nobody's been hurt by it. You can do other exercises or participate in a formal rehab program while doing these, too.
The last big issue in postoperative care is, how long should you keep working in rehab? The general principle is to keep working at it until either you stop gaining strength and comfort or until you're comfortable enough to do everything you want to in a normal day of your life. Remember, most of the benefit to be received from a spinal operation will be realized by six months or so postop, though some people may slowly be improving appreciably for a year or more. You shouldn't be in rehab forever, and often not very long at all. When you stop improving that's it, even if you're still quite sore and limited in what you can do by your back pain symptoms. The goal of the surgery, after all, was to make you better .