WHY DO PATIENTS COME TO SEE US?
On a very basic level, patients seek the advice and treatment of a spine surgeon for a relatively
1. Spinal deformity (scoliosis, kyphosis)
- axial (meaning neck or back)
- radicular (meaning nerve-related arm or leg pain such as sciatica), and/or neurologic dysfunction
3. Less common conditions
- Spinal infection
- Spinal tumor
- Other miscellaneous conditions.
Spine deformity is discussed in a separate section.
For pain-related issue, we typically think in terms of axial versus radicular pain because they have different causes and because the treatment is so different between the two.
First, understand that neck pain, back pain, axial spinal pain in general is common (almost normal) and usually self-limited (resolves on its own over time). There are typically fluctuations on a daily, weekly, or annual basis causing “flare-ups” lasting days to weeks. Episodes of severe neck or back pain can be quite disabling and responsible for billions of dollars of annual national productivity loss. While many patients feel during one of these episodes that life as they know it is over, the truth is that the human body has a remarkable capacity to heal and most often a little advice and conservative care is all that is needed. We might recommend medications, physical therapy, chiropractic care, acupuncture, but rarely have to resort to injections and even more rarely, surgery.
Once the episode and/or flare-up has resolved, we believe that preventive measures can reduce the frequency and duration of future painful events. A good balanced program of core strengthening, stretching, and aerobic exercise is very important. Obviously, carrying excess weight puts a strain on the spine, predisposing to symptoms. So diet, to the extent of keeping one’s weight under control, plays an important role. We typically meet patients in the midst of a severe episode of axial pain, help them through it, and leave them with advice about lifestyle changes that will hopefully be preventive.
Surgery can be considered for those patients with severe disabling axial spinal pain that does not respond to conservative care. This typically involves a fusion or disc replacement. There are many important considerations in evaluating a patient for surgery of this type. We first perform diagnostic tests to determine as accurately as possible the anatomic structure(s) causing the symptoms. This includes x-rays, MRI, CT, bone scan, and sometimes injections (facet blocks, discography).
Sometimes social and psychological issues need to be considered. At the completion of the evaluation it is important to have a frank discussion of what surgery can realistically expect to accomplish. The truth is that there are only a relatively few conditions that cause axial spinal pain that are appropriately treated with surgery, and despite all of the imaging tools available we frequently don’t know the anatomic pain generator with certainty. This, coupled with natural variations in response to treatment from one person to the next, make accurately predicting the outcome of surgery in this situation an exercise in probability.
Nevertheless, the right operation properly done, on the right patient, for the right pathology, can be dramatically helpful. It is our job to determine whether surgery can reasonably expect to result in a good outcome, then clearly explain the various options and their pros/cons, risks/benefits, so patients can decide whether surgery is right for them and which surgical option is best. We want our patients informed with all questions answered prior to considering surgery, especially for axial spinal pain.
Radicular Pain, Sciatica
Radicular pain refers to the pain caused by nerve compressions in the spine. This usually occurs at the level of the nerve root. Patients are often surprised to learn that spinal cord compression is not painful. This is because the spinal cord (and central nervous system in general) is not innervated by nerves that convey pain, so spinal cord compression is discussed separately under the heading of central spinal stenosis.
When nerve roots are compressed, there can be pain, numbness, and weakness in the distribution of the affected nerve. In the leg this is referred to as sciatica. There is no equivalent term for the arm version that is in general use. We refer to the upper extremity variety as radiculopathy, and use this as an alternative to sciatica in describing nerve root-caused arm pain.
The typical causes of radicular pain, or radiculopathy, are herniated discs and spinal stenosis. These are discussed elsewhere. It’s important to remember that the cause can be neoplasm (tumor, benign or malignant) or infection and occasionally MRI and CT scans are ordered to rule out these conditions.
Patients may or may not present with all three components of radiculopathy (pain, numbness, weakness). Treatment may be required for any or all of these three components.
Radicular pain, like axial pain, is typically treated initially conservatively, with the same modalities as axial pain. When this fails, surgery can be considered and typically has a high likelihood of achieving a successful outcome, as measured by reduction or elimination of symptoms and return to normal lifestyle (work, sports, daily activities). The surgery might consist of microdiscectomy, laminectomy, laminotomy, foraminotomy or sometimes fusion depending on the anatomic cause. These various operations are discussed in separate sections. Recent studies have shown better long term outcomes in patients that had their surgery within six months of onset of symptoms (in those patients who have failed conservative care and require surgery). While not “written in stone,” we certainly consider that long term nerve compression can result in irreversible nerve damage. In fact, fortunately rarely, this degree of nerve damage can be present with the initial onset of symptoms.