Treatment of chronic back-pain has changed significantly over the last few years. In cases with chronic back-pain based on deterioration, especially of the disc, a reconditioning of the back by means of conservative therapy is advisable. Intense strengthening – therapy, seems most effective. If the conservative treatment fails, an accurate source-detection is mandatory. In the majority of cases the source turns out to be a mechanically induced nerve-irritation caused by disc-deterioration.

DIAGNOSTICS

In order to treat chronic back-pain, we first need to determine the exact source of pain, in order to treat them definitively.

The following diagnostic steps, generally lead to the diagnosis:

• Detailed history and clinical examination. Orthopaedic-neurological examination
• MRI (Magnetic Resonance Image) – delivers exact imagery of the spine and its various pathological changes (also MRT, MRI)
• Spine Motion Analysis (EMG) – motion-test, muscle-response-test
• Strength-test via MedX (isolated training and measurement of the lumbar and cervical extensors)
• X-rays – show pathological changes of the bony structures
• Blood-tests (aimed specifically at rheumatism, gout and other inflammatory process.
• Flexion / extension X-ray films to demonstrate instability.
• Discography for discogenic etiology of back pain.
• Facet blocks / lysis blocks.

Diagnosis: black disc, hernia or tear of the disc

If the previously mentioned examinations result in the diagnosis “disc-deterioration without additional degenerative signs”, the problems can be – most likely – fixed by means of minimally invasive measures.

An additional investigation, however – the so-called distension-test with contrast agent or discography – has to be conducted to determine the concerned, pain-triggering disc (culprit disc)

Discography

Discography is an investigation of the intervertebral disc that involves use of a contrast-agent. The discography should not be mistaken with a myelography. The spinal canal, however, is not affected during the discography, where a contrast-agent is inserted through a fine needle directly into the disc side effects. The discography is monitored by X-ray and conducted in a sterile operating theatre, where the patient is positioned comfortably on the side. After a local anaesthetization a fine needle is inserted up to the center of the disc and 1 cm3 of contrast – agent is injected into the disc-space. The patient has to indicate to what extend the contrast-agent triggers his complains. Additionally X-ray images are taken during this examination. According to these findings, the degenerated, painful disc can be graded. This provocative discography may be positive or negative, depending on patient's response. This procedure determines the painful disc, producing the discogenic backache.

This discography is justified whenever a tear of the disc that can not be detected by means of MRI is suspected. It is mostly applied in cases with chronic back-pain when the symptomatic disc could not be determined otherwise. The discography can furthermore evaluate the condition of the adjacent levels.

Discography is a safe, OPD procedure, with no complications and very helpful in determining the origin of pain.

PAINFUL DISC-DEGENERATION

• Artificial Disc Replacement
• Spinal Fusion

When are these kinds of treatments necessary?

Severe Disc-degeneration causes constant, sometimes immobilizing back-pain. Abnormal pathological changes of the disc are visualized by means of MRI. Subsequently the degenerated, symptomatic disc is verified by means of a discography. Typical symptoms of degeneration are strong, chronic back-pain and sometimes paralysis of the legs. The pain increases during change of postures, over activity, sudden spurt of activity and morning stiffness, which becomes slightly better as the day goes by. Many patients with degeneration had previous multiple episodes of slip disc with backache and leg pain off and on, over many years.

Alternative to fusion:
For treatment of chronic back ailments most clinics still favour spinal fusion-operations. In our opinion artificial disc replacement holds a benefit over the spinal fusion, that the movement of that spinal segment is maintained, which also reduces the excessive degeneration at the adjoining levels. For which patient may require additional surgery later on after spinal fusion.

ARTIFICIAL DISC REPLACEMENT

When is Artificial Disc Replacement indicated?

Artificial disc replacement is recommended in cases proven with a painful, exposure-inapt disc without a sizable disc-herniation it is suitable for patients following disc-surgery with remaining pain or symptoms. Patients who were recommended to undergo a fusion operation should first consider ADR.

What does the treatment consist of?

Artificial disc-surgery is conducted over the abdominal approach and anterior approach for cervical spine (neck). The degenerated disc is removed during this operation and replaced by a polyethylene core. The core and its two corresponding endplates are firmly fixed between two vertebral bodies and remain stable, enabling normal flexibility of the spine. This procedure maintains the disc height and mobility of the spinal segment. We use Prodisc-C/Prodisc-L (Synthes, Swiss.) or Prestige /Mavrick ( Medtronics , USA ), for cervical and lumbar disc replacements.

Advantages of the Artificial Disc in relation to other operative techniques

• Flexibility of the spine remains intact after an artificial disc procedure.
• The natural height of the intervertebral space is restored and the degeneration of adjacent discs is prevented.
• The implant allows a direct, complete mobilization of the patient and makes a fast rehabilitation possible.

Non-surgical options for people with disc protrusions in the neck include rest, heat, pain medications and physiotherapy. When non-surgical treatment options fail, surgery is often the next step. This usually means spinal fusion surgery.
Neck pain with compression of the nerves in the neck or spinal cord is a common condition that affects the spine and may require surgery. If only nerves are compressed, with symptoms in one arm, a period of non-surgical management is instituted. If this fails surgery is contemplated.
Early surgery is performed if there is severe weakness or pain that cannot be effectively controlled with available analgesia (pain relieving medication). If the spinal cord is being compressed, surgery to decompress the spinal cord is usually recommended. Compression can be caused by a bulging disc or bony spurs (bony overgrowths).

Surgery on the spinal cord is performed either from the back of the neck ( laminectomy ) or through the front of the neck (cervical discectomy or vertebrectomy). If compression of the spinal cord is from the front, then the decompression must be done from the front (anterior decompression).
Typically, if the entire disc is removed, a wedge of bone is taken from the hip and put into the empty disc space. A plate and screws may be used to hold the bone wedge in place (see below). This is commonly referred to as an anterior cervical decompression and fusion.

< PROTRUSION” C6 CF MRI>

Figure 1: MRI scan of the cervical spine showing a typical disc protrusion between the 5th and 6th cervical vertebra compressing the spinal cord

Figure 2: A Schematic diagram of a typical anterior discectomy and fusion procedure. A block of bone graft is placed into the space left when the disc is removed

Figure 3: A post-operative x-ray on the patient shown to the left. The disc has been removed, a block of bone has fused the 5th and 6th vertebrae and a plate with screws holds it into place

This is a common operation and whilst it takes pressure off the spinal cord, it necessitates that at least two of seven bones in the neck are fused. This does reduce some of the movement in the neck, but patients typically do not notice it unless several levels are fused. Typically after this surgery, the patients wear a neck brace for six weeks.

The problem fusing bones in the neck are that adjacent levels in the neck are placed under more strain. This increases "wear and tear" at the surrounding disc space levels and has been termed "adjacent segment disease". We now know that if 10 people undergo single-level fusion, at 10 years three patients have had to undergo another operation to treat narrowing at the next level either above or below the original fusion.

Secondly, the bone does not always heal or "fuse" correctly. In fact, the overall success rates for these procedures range from 48% to 89%. Finally, spinal fusion at one or more levels increases stress to the rest of the spine. This transferred stress may cause new problems to develop at other levels, which may lead to the need for additional surgery.

Although the artificial disc replacement of the cervical spine has been implemented only 3 years ago, the international success rate has already reaches 85% - 90%, with a very low complication rate. The great success story of ADR in the neck is the reason why today fewer conventional treatments like fusion with plates, cages or bone graft are applied worldwide.

WE USE PRODISC-C (SYNTHES) FOR CERVICAL DISC REPLACEMENT OF OUR PATIENTS (WE WERE USING BRYAN CERVICAL DISC EARLIER)

The Prodisc-C total disc replacement has been determined to be safe and effective in the treatment of symptomatic cervical degenerative disc disease. The Prodisc-C total disc replacement surgery is intended to:

• Remove the diseased disc
• Decompress the neurological structures
• Restore normal disc height
• Preserve motion in affected vertebral segment
• Improve patient function

The Prodisc-C total disc replacement is in an IDE clinical study for the FDA approval in the US . The enrollment of the patients is completed.

Design Philosophy

The Prodisc-C implant has been designed to maintain the physiological range of motion in the cervical spine. The implant was developed using the clinically proven ball and socket concept used in joint replacement implants for over 40 years. The Prodisc-C implant is composed of three components – two cobalt chrome alloy (CoCrMo) endplates and an ultra-high molecular weight polyethylene (UHMWPE) inlay.

ARTIFICIAL LUMBAR DISC REPLACEMENT

We use charite (depuy) or mavrik (medtronics) lumbar disc for our patients, requiring replacement of lumbar disc. We prefer the disc replacement over spinal fusion in younger patient who do no show excessive sign of degeneration at that level. However in presence of excessive degeneration with decreased disc height or spondylolisthesis (spinal instability due to slippage of one vertebral body over other). Spinal fusion is over preferred choice.

This revolutionary treatment option is an alternative to spinal fusion for patients that have one diseased disc level and have failed 6 months of conservative treatment. The benefits include:

• An alternative to spinal fusions that allows for motion with bending forward and backwards that a fusion doesn't allow.
• Pain relief with a quicker recovery period post- operatively.
• Spinal fusion can put additional pressure on the disc above or below the affected disc, due to the fixed stabilization, this can lead to additional damage and potential surgeries. The artificial disc is believed to eliminate this pressure, thus reducing any potential surgeries to adjacent discs.

This surgery is done as an inpatient surgical procedure that is completed with an abdominal approach. The patient will remain in the hospital 1-2 days after the surgery.
Activity is limited to 5 lbs weight lifting for 4 weeks. More strenuous activity such as jogging and tennis is allowed at 3 months. There are no restrictions at 6 months.

SPINAL FUSION

When is Fusion Indicated?

Prior to recommending a spinal fusion operation, all other alternatives for the treatment of chronic back-pain – like the endoscopic nucleotomy, abrasion or disc-prosthesis – are considered. However, certain spinal conditions can only by mended by means of a spinal fusion. Particularly for patients with a spondylolisthesis (“slipped vertebra”) or for patients after multiple spine operations, after vertebral distruction due to infection, tumors or fractures. It is required after deformity correction of spine like for scoliosis and kyphosis etc. Basically, the surgery is to joint the two vertebral bodies together, so that there is no movement between them hence there is no pain and risk of damage to the nerves. Hence this procedure is indicated wherever there is a situation of instability in the spine, because of any reason.

What does the treatment consist of?

A discography examination verifies the symptomatic disc prior to the Spinal Fusion. In certain cases screws, plates and cages are inserted in order to achieve direct and early stability. Bone-graft, donated from the pelvic rim, or bone-substitute is inserted for a permanent fixation that will ossify with the vertebrae within approximately 4 months.

We performed spinal fusions for any spinal instability caused by spondylolisthesis, infection, tumor, after extensive spinal decompression. We use various techniques like ALIF, PLIF, TLIF and XLIF, depending on the cases. We use pedical screw and cages to achieve the fusion. It has more then 80% success rate with minimal complications. We have performed more then 300 cases of spinal fusion so far, since 1995.

Bone morphogenetic protein, or BMP, may be the most exciting development in spine surgery in the past decade. Finally, it seems, there may be a better way to achieve spinal fusion with more success and less complications. Sound too good to be true? Perhaps, but studies are showing BMP to be very effective and may forever change the way fusion surgery is done.

Spinal fusion surgery is a common treatment for such spinal disorders as spondylolisthesis , scoliosis , severe disc degeneration or spinal fractures. Fusion surgery is usually considered only after conservative therapies to reduce pain have failed.

Spinal fusion surgery involves the joining or fusing of one or more vertebrae to reduce pain and stabilize the spine. This surgical technique includes a grafting procedure utilizing autograft. Autograft is when bone chips from a patient's pelvic bone are transplanted, or grafted, to the spinal vertebra to help fuse them together. (When bone is harvested from a bone bank or other source it is called allograft).

However, harvesting bone graft from a patient's own body carries with it numerous problems. Grafting prolongs surgical time and can increase the risks of blood loss and infection. It often prolongs the length of time a patient has to stay in the hospital. Many patients also report significant and long-lasting post-operative pain at the grafting site. In addition, grafting does not always produce successful fusion, even when used in combination with instrumentation such as screws, cages or dowels or when attempted for numerous vertebrae.

Scientists have searched for years for a better way to promote bone growth and alleviate the need for grafting. BMP was “discovered” in the 1960s when Dr. Marshall Urist, a pioneer in this field, identified a group of protein extracts that help bones grow.

In the 1980s, the proteins were individually identified and reproduced. It was strongly felt that this bone-growing material could be the answer scientists were looking for. Could this genetically produced synthetic grafting material, that actually stimulates cells in the body to make more bone, eliminate the need for grafting? Scientists quickly began to study it.

Additional clinical trials investigating the effectiveness of BMP have been conducted and continue to show its ability to successfully stimulate bone fusion. Studies have proven that BMP not only successfully creates fusion, but it seems to do so more quickly and reliably than autograft. For example, in a recent study * conducted at The Houston Clinic in Columbus Georgia , 46 patients underwent anterior lumbar interbody fusion surgery and were followed for 2 years. The patients who received BMP bone graft (InFUSE™) showed higher rates of fusion at 6, 12 and 24 months after surgery than the patients who received autograft bone. These patients recovered faster and had less back and leg pain than patients who received autograft. Furthermore, and most importantly, these patients were able to return to normal activities faster.

Recombinant Human bone morphogenetic protein-2 (rhBMP-2) is available for specific use in promoting spinal fusion. The surgical approach, reviewed by the FDA, was Anterior Lumbar Interbody Fusion (ALIF) with threaded fusion cages. For this use, the rhBMP-2 was delivered on a collagen sponge carrier, which was inserted inside two hollow threaded titanium cages in the lumbar spine. The study demonstrated that rhBMP-2 was safe and highly effective in promoting spinal fusion for ALIF. The fusion rate was higher than those achieved with patients own bone (allograft).

Which post-operative care and rehabilitation will be necessary after the Spinal Fusion?

The patient can walk by himself, supported by a previously custom-made back-brace, just three hours after a fusion operation. Hospitalisation for about 5 days. The patient will be allowed to sit, walk, drive a car or ride a bicycle right after the operation. Most activities, even back-straining sports like golf or tennis, can be picked up around 4 months after surgery.

Few examples of instrumented spinal fusion for lumbar disc degeneration and stenosis

SPONDYLOLYSTHESIS

A spondylolisthesis happens when one of the spine's vertebrae (bones) slips forward over the vertebra beneath it. Spondylolisthesis occurs most often in the lumbar spine (low back).

Some people never know they have a spondylolisthesis because they have no symptoms. When symptoms exist, they typically include one or more of the following:

• Pain in the low back, thighs and legs
• Weakness in the thighs or legs
• Tight hamstring muscles (back of the thighs)
• Loss of, or difficulty with, bowel or bladder control

Spondylolisthesis can alter your appearance. Some noticeable physical differences are:

• Stomach sticks out
• Torso looks shorter
• Swayback (low back curves too far inward)
• Waddle when walking

Doctors describe the severity of a spondylolisthesis using a grading scale from 1 to 5. Grade 1 indicates that 25% of a vertebra has slipped forwards over the vertebra below. A Grade 2 indicates a 50% slip, all the way up to a Grade 5, which represents a 100% slip, (known as spondyloptosis).

Has a spondylolysthesis or “slipped vertebra” been diagnosed, depending on the condition, age and secondary diseases a number of treatments are available at our section:

• Is the spondylolysthesis combined with a narrowing of the spinal canal, while the vertebrae do not significantly shift, (based on motion X-ray images) only the narrowing (stenosis) of the spinal canal is treated.
• An instable spondylolysthesis combined with a stenosis is decompressed by means of microscopy and fixed by means of a ligament.
• Younger patients with a spondylolysthesis but without a stenosis with one sided nerve-pain can be treated endoscopically.
• Younger patients with a spondylolysthesis and mainly back-pain are initially advised to undergo medical strengthening therapy. If unsuccessful, a fusion operation with bone marrow and – possibly – without implants and screws can mean the best possible solution.
• Besides spondylolisthesis, we treat patients with spinal infection, tumor and trauma.