Disc Herniation

This blog entry is part of a series of interview responses provided by Kevin Macadaeg, MD, a minimally invasive spine specialist with Indiana Spine Group. Dr. Macadaeg was recently interview about back pain and spinal treatments.

What are some of the different causes or reasons for chronic neck or back pain? What would you say is the most common cause of back or neck pain?

The most common causes of chronic neck or back pain are degenerative disc disease and degenerative spondylosis (degeneration of the spinal joints, development of bony spurs, disc degeneration and calcification of spinal ligaments).

Other causes include herniated disc, spinal stenosis (narrowing of the spinal canal) and spondylolisthesis (slipping of a vertebra).

What are the different options available to treat this type of pain?

Back Talk | A Comprehensive Review and Practical

Approach to Spinal Diagnosis and Treatment

One series of sessions at Indiana Spine Group’s continuing medical education / continuing education spine symposium will focus on the diagnosis of spinal disorders.  In one series of talks, speakers will highlight key issues and steps critical to spinal diagnosis. Topics will include:

• Spinal Anatomy – differentiating between normal and abnormal spinal anatomy (Speaker: Jonathan Gentile, MD, minimally invasive spine specialist with Indiana Spine Group)

• Diagnostic Pearls – identification of the critical components of the physical exam, and essential elements of the diagnostic work-up (Speaker: John Arbuckle, MD, minimally invasive spine specialist with Indiana Spine Group)

• Common Spinal Disorders – diagnostic indicators for disorders such as herniated discs, degenerative disc disease, spinal stenosis, spondylosis and more (Speaker: Kevin Macadaeg, MD, minimally invasive spine specialist with Indiana Spine Group)

• Disorders of the Bones – a review of conditions such as osteomalacia, Paget’s disease, spinal arthritis and osteoporosis (Rashid Khairi, MD, FACP, FACE, an endocrinologist with Diabetes & Endocrinology Associates) 

• Uncommon and Benign Disorders – a discussion of disorders such as infections and vascular disorders. (Kenneth Renkens, MD, FACS, spine surgeon with Indiana Spine Group)

•  The Role of EMG – the role and indications of EMG in the diagnosis of cervical and lumbar radiculopathy. (Larry Lett, MD, Center for EMG and Neurology)

Congratulations to Dr. Rick Sasso for his recent publication! (Dr. Sasso is a spine surgeon with Indiana Spine Group). Dr. Sasso recently co-authored an article published in the recent issue of the SAS Journal. This journal is a publication of the International Society for the Advancement of Spine Surgery and the Society for Minimally Invasive Spine Surgery.

This article entitled, Lumbar Extraforaminal Decompression: A Technical Note and Retrospective Study Looking at Potential Complications as an Outpatient Procedure, published the results of a recent spinal study. This spine study retroactively evaluated the medical records of 100 patients from the same spine surgeon, who underwent spine surgery for lumbar disc herniation or stenosis. The spine surgical procedure was a type of decompression. This study concluded that extraforaminal lumbar decompression can safely be done as an outpatient spine surgical procedure.

In a prior blog entry, the results of a lumbar disc herniation study were reviewed. This study evaluated the results of the length of time, referred to DOS or duration of symptoms, prior to seeking treatment for lower back pain caused by lumbar disc herniation.

Again, this study concluded that the less the length of the back pain/symptoms (DOS), the more favorable the treatment results. Here is a summary of this presentation in a SpineUniverse article.

At the annual American Academy of Orthopaedic Surgeons meeting one podium presentation discussed “if the length of a person’s back pain/symptoms affects the outcome of treatment”.  

This was researched in respect to lumbar disc herniation. The purpose of the study was to determine if the duration of symptoms (DOS) affects outcomes following the treatment of intervertebral lumbar disc herniation (IDH).  This was evaluated for both operative and nonoperative spine treatments. 

Patients were evaluated with back pain / symptoms who sought care with less than six-months of symptoms, and those that had greater than six-months of symptoms. The study did conclude that treatment results were more favorable for both surgical and nonoperative treatments when patients sought treatment sooner for IDH. 

To read the poster presentation of this study, visit this link.

Congratulations to Rick Sasso, MD, a spine surgeon with Indiana Spine Group, who was just awarded his eighth patent!  This is patent number 7,727,266 for a method and apparatus for retaining screws in a plate.  
 

This patent is for an anterior cervical plate, now called Venture.  This plate is used in spine surgery for patients suffering from a herniated disc or stenosis (disc degeneration), or after trauma, tumors or other conditions causing neck instability.  The plate is used to stabilize the cervical spine after removing the disc. 

Below is an abstract of this patent:

A retention system for maintaining a screw to a vertebral plate. One or more screws extend through apertures within the vertebral plate. A cavity is positioned adjacent to and overlaps into the aperture. A ring is positioned within the cavity and held in position by a cap. The cap attaches to the plate to prevent removal of the ring. The ring is deflectable between a first shape to allow the screw to be inserted and removed from the aperture, and a second shape to prevent screw back-out from the aperture. A method of using the system is also included and comprises positioning the ring within a cavity in the plate, maintaining the position of the ring to the plate by attaching a cap, inserting a screw through the aperture and attaching the plate to a vertebral member, and positioning the ring over the screw head and preventing the screw from backing-out.

In an earlier blog, I talked about the AO Spine International meeting that I presented at in December. With this blog entry, I wanted to define a few of the terms that were used. These were spine surgery topics that I presented on.

One term is cervical myelopathy. In defining cervical myelopathy – first I will define myelopathy. When the word myelopathy is used it refers to any condition that affects the spinal cord. Therefore cervical myelopathy is a condition of the cervical (neck) area of the spinal cord. In respect to cervical myelopathy it means that there is compression on the spinal cord that is either a result of disc herniation or spinal stenosis. Cervical myelopathy is a degenerative spine disease that is more common in the elderly. 

Another term used in the blog entry was cervical radiculopathy. The term radiculopathy refers to a disease of the spine nerve roots and spinal nerves.  Cervical radiculopathy is when a spinal nerve root in the neck (cervical) is compressed and/or irritated. This can be caused by disc herniation, spinal stenosis or other degenerative spine disorders. 

Currently, Dr. Kenneth Renkens participating in a clinical research study sponsored by Anulex Technologies. Dr. Renkens is a neurosurgical spine surgeon with Indiana Spine Group.   

The purpose of this study is to evaluate the benefits of performing soft tissue repair during a lumbar discectomy as compared to a disectomy performed without tissue repair. The product that is being used to repair the tissue is the Xcloseä Tissue Repair System.  

A discectomy is a spine surgery performed to relieve back pain caused by a herniated disc – sometimes called a bulging disc.  During a lumbar discectomy, the standard of care is to remove the portion of the disc that is applying the pressure to the nerve.  To perform this procedure, a small incision is made into the outer layer of the disc – this outer layer is called the anulus fibrosus.  As a result of this small incision in the outer layer of the disc, it could re-herniate in the future - resulting in back pain and discomfort. 

Typically, during this spine surgical procedure the soft tissue surrounding the disc, the anulus is not repaired.  As a result, this material can push outside the disc and compress the nerve rood resulting in back pain and discomfort.  With the Xclose device it provides a method to repair the anulus during the lumbar discectomy. 

For more information, here is a link to a summary of this study that Dr. Kenneth Renkens is participating in.

The advancements and preliminary research results for cervical artificial disc replacements as an alternative spine surgical treatment for degenerative disc disease are promising.  When spine surgery is required for degenerative disc disease, the traditional procedure has been a spinal fusion.  This has been considered the “gold standard” of treatment.  I predict that in the future, the “gold standard” of surgical treatment of certain types of cervical radiculopathy caused by a herniated disc will be a cervical artificial disc rather than a spinal fusion. 

A recent article that I co-wrote, provides an overview and summary of the different cervical artificial discs that are currently being used in FDA-trials.  The Prestige Disc was approved last summer (2007).  Also last summer, the BRYAN cervical artificial disc received preliminary FDA-approval and the Prodisc-C was approved earlier this year.

In some of my blog entries, I have discussed surgical procedures for a herniated cervical disc.  These surgical procedures include spinal fusion and artificial cervical disc replacement.  The good news is that very few individuals with a herniated cervical disc require surgery.  It is projected that only about 5-10% of patients with a herniated cervical disc need surgery.

Many times medical management is an effective treatment for herniated cervical discs.  To learn more about the non-operative spine treatment options for a herniated cervical disc, click here.  This is an article that I wrote for Spine Universe, which outlines the non-surgical treatments for herniated cervical discs. 

In some of my blog entries, I have discussed surgical procedures for herniated cervical disc.  These surgical procedures include spinal fusion and artificial cervical disc replacement.  The good news is that very few individuals with a herniated cervical disc require surgery.  It is projected that only about 5-10% of patients with herniated cervical disc need surgery.

Many times medical management is an effective treatment for herniated cervical discs.  To learn more about the non-spine surgical treatment options for herniated cervical disc, click here.  This is an article that I wrote for Spine Universe, which outlines the non-surgical treatments for herniated cervical discs. 

One common term used to describe pain is sciatica.  Sciatica is used to describe the pain that radiates along the sciatic nerve.  The sciatic nerve is the longest and largest nerve in the body – connecting the spinal cord with the leg and foot muscles.  When someone has sciatic pain, they generally describe it as “shooting pain”. 

This pain is caused when the nerves in the lower spine are either compressed or irritated.  There are many causes of sciatica and a few include:  pinching or stretching of the sciatic nerve, herniated disc, spinal stenosis or spondylolisthesis, just to name a few.  

Many times, this pain will go away with minimal treatments; i.e. avoiding the activity that causes the pain, cold / heat treatments, pain relievers and/or exercise.  If this pain continues for more than 6 weeks or becomes severe, it is recommended that the individual see their physician or a spine specialist. 

For individuals diagnosed with a contained herniated disc or protruding disc, which are suffering from leg or lower back pain - one newer treatment option for pain relief is nucleoplasty. 

Nucleoplasty provides a minimally invasive spine treatment alternative.  With this minimally invasive spine procedure, radio waves which produce energy are used to dissolve (ablate) the unwanted disc tissue, and this relieves the pressure causing the lower back pain or leg pain.

This procedure is performed by a physician who is a minimally invasive spine specialist.  During this spine procedure, which takes less than an hour, the patient is awake and the physician will use a local anesthetic.  Guided by fluoroscopy (internal X-ray), the physician will insert a catheter-like device to the affected spinal disc. This catheter will deliver small amounts of radio wave energy to the damaged disc that will create a molecular reaction that will result in the spongy tissue in the damaged disc to dissolve.  This will reduce the pressure in the damaged disc, and thereby allow the herniation in the disc to retract.  The goal of nuceloplasty, is to reduce the pressure on the affected nerve and therefore eliminate back pain.

One newer treatment option for lower back pain is Intradiscal Electrothermal Therapy (IDET).  This minimally invasive treatment uses heat energy delivered to the affected disc.  During the procedure, a heat coil is inserted into the disc of the spine by the use of a catheter that is guided by X-ray.  The coil is heated to a temperature slightly below that of boiling water.  This heat energy destroys the nerve endings that have been found to grow inside of painful, torn discs, therefore eliminating the cause of the back pack.

This minimally invasive IDET procedure is used for the treatment of lower back pain that is a result of spinal disc damage (tears or small herniations in the lumbar disc).  Prior to the procedure, testing is performed to clearly identify the affected disc and to confirm the diagnosis. 

Approximately five years ago (May 2002), I performed the first artificial cervical disc replacement in the U.S.  (Read the press release about this procedure.)  As a physician who is involved in the research and development of minimally invasive spine surgery techniques – I was excited to be involved in this research study.  It is my opinion that the cervical artificial disc will be the new gold standard to the traditional fusion procedure. 

Here is more information about the cervical artificial disc.  When a patient suffers with a herniated cervical disc – also called a ruptured disc or slipped disc – traditionally the standard surgical treatment is a spinal fusion surgery.  With a fusion – the damaged cervical disc is removed and then a bone is grafted into place to stabilize the spinal area affected.  The bone used is synthetic or grafted from a second surgical site.  The patient then undergoes a long recovery period – a cervical collar is worn to immobilize the neck for a period of time, and the patient may have two surgical sites undergoing recovery (depending on the source of the bone graft).  Then following the recovery period – the patient may have some stiffness (decreased) mobility in the neck region. 

Now with a cervical artificial disc, the damaged cervical disc is removed – and the cervical artificial disc is inserted into this area.  The cervical artificial disc is designed to mimic the action of the original disc. Following this procedure, the patient returns to normal activities in a few weeks.  The advantages of this procedure are:  shorter recovery time, no cervical collar, one surgical site which reduces the chance for post-op infections/complication, and a shorter hospital.  Additionally, the patient’s mobility is not decreased – and neck movement is normal and not limited.  Needless to say, patients that are active and want to remain active love this alternative! 

To learn more about his procedure visit our web site or  call Indiana Spine Group at 317.228.7000.

Prior to talking more about cervical artificial discs – here is an overview of cervical herniated discs sometimes called bulging discs.  The cervical artificial disc is a surgical treatment option.  The cervical artificial spine surgery procedure provides a minimally invasive spine surgery treatment for herniated discs. 

Here is the definition - a herniated disc is where the soft center of the spinal disc “bulges” or breaks through the weakened part of the disc. This usually occurs in the lower part (lumbar area) of the spine, but can occur anywhere; i.e. in the cervical (neck) or thoracic (chest) areas of the spine.   This is also called a slipped, prolapsed or ruptured disc. 

Last summer, I was asked to testify at the FDA  hearing for the Bryan® Cervical Disc.  For the last five years, I had participated in the clinical trial for this cervical artificial disc.  This cervical artificial disc provides a surgical alternative to a traditional fusion in spine surgery.

Also testifying at this hearing, was one of my patients.  This patient was accepted into the trial and had the cervical artificial disc implanted in 2002.  Suffering from a herniated cervical disc – this procedure brought him much needed relief.  As an avid golfer – he was excited to be accepted into the trial.  Now, he can easily be found on area golf courses or sometimes water-skiing in area lakes. 

This cervical artificial disc did receive preliminary FDA approval at the hearing (July 2007).  Final FDA approval is expected sometime late in 2008.

Additionally, in July 2007 – the Prestige Cervical Disc did receive FDA approval.  Here is the link to the media release.

People with back problems – may have more than just back pain.  Sometimes, if you suffer from leg pain – this can be related to your spine.  If a person has ongoing leg pain that is persistent and increases as you lift your knee to your chest or bend over – it could be related to your back.  One back problem – that causes a shooting pain down your leg referred to as “sciatica” is lumbar radiculopathy.