Archives: Education

Welcome to First Choice Physical Therapy’s patient resource about low back pain.

Low back pain is one of the main reasons people visit their doctor. For adults over 40, it ranks third as a cause for doctor visits, after heart disease and arthritis.

Eighty percent of people will have low back pain at some point in their lives. And nearly everyone who has low back pain once will have it again.

Very few people who feel pain in their low back have a serious medical problem. Ninety percent of people who experience low back pain for the first time get better in two to six weeks. Only rarely do people with low back pain develop chronic back problems.

With these facts in mind, you can be assured that back pain is common, that it usually only causes problems for a short period of time, and that you can take steps to ease symptoms and prevent future problems.

This guide will help you understand:

• which parts make up the spine and low back
• what causes low back pain, and what the most common symptoms are
• what tests your doctor may run
• how to manage your pain and prevent future problems

Which parts make up the lumbar spine, and how do they work?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The mid back, or thoracic spine, curves outward. The outward curve of the thoracic spine is called kyphosis. The low back, also called the lumbar spine, curves slightly inward. An inward curve of the spine is called lordosis.

The lumbar spine is made up of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Some people have an extra, or sixth, lumbar vertebra. This condition doesn’t usually cause any particular problems.

Each vertebra is formed by a round block of bone, called a vertebral body. The lumbar vertebral bodies are taller and bulkier compared to the rest of the spine. This is partly because the low back has to withstand pressure from body weight and from daily actions like lifting, carrying, and twisting. Also, large and powerful muscles attaching on or near the lumbar spine place extra force on the lumbar vertebral bodies.

A bony ring attaches to the back of each vertebral body. When the vertebrae are stacked on top of each other, these rings form a hollow tube. This bony tube surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord extends down to the L2 vertebra. Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse’s tail.

As the spinal cord travels from the brain down through the spine, it sends out nerves on the sides of each vertebra called nerve roots. These nerve roots join together to form the nerves that travel throughout the body and form the body’s electrical system. The nerve roots that come out of the lumbar spine form the nerves that go to the lower limbs and pelvis. The thoracic spine nerves go to the abdomen and chest. The nerves coming out of the cervical spine go to the neck, shoulders, arms, and hands.

It is sometimes easier to understand what happens in the spine by looking at a spinal segment. A spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints that link each level of the spinal column.

The intervertebral disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without pain.

Two spinal nerves exit the sides of each spinal segment, one on the left and one on the right. As the nerves leave the spinal cord, they pass through a small bony tunnel on each side of the vertebra, called a neural foramen. (The term used to describe more than one opening is neural foramina.)

The lumbar spine is supported by ligaments and muscles. The ligaments are arranged in various layers and run in multiple directions. Thick ligaments connect the bones of the lumbar spine to the sacrum (the bone below L5) and pelvis.

The muscles of the low back are also arranged in layers. Those closest to the surface are covered by a thick tissue called fascia.

The middle layer, called the erector spinae, has strap-shaped muscles that run up and down over the lower ribs, chest, and low back. They blend in the lumbar spine to form a thick tendon that binds the bones of the low back, pelvis, and sacrum.

The deepest layer of muscles connects along the back surface of the spine bones. The muscles also connect the low back, pelvis, and sacrum. These deepest muscles coordinate their actions with the muscles of the abdomen to help hold the spine steady during activity.

Why do I have low back pain?

There are many causes of low back pain. Doctors are not always able to pinpoint the source of a patient’s pain. But your doctor will make every effort to ensure that your symptoms are not from a serious medical cause, such as cancer or a spinal infection.

The vast majority of back problems are a result of wear and tear on the parts of the spine over many years. This process is called degeneration. Over time, the normal process of aging can result in degenerative changes in all parts of the spine.

Injuries to the spine, such as a fracture or injury to the disc, can make the changes happen even faster. There is strong evidence that cigarette smoking also speeds up degeneration of the spine. Scientists have found links among family members, showing that genetics plays a role in how fast these changes occur.

The intervertebral disc changes over time. At first, the disc is spongy and firm. The nucleus in the center of the disc contains a great deal of water. This gives the disc its ability to absorb shock and protect the spine from heavy and repeated forces.

The first change that occurs is that the annulus around the nucleus weakens and begins to develop small cracks and tears. The body tries to heal the cracks with scar tissue. But scar tissue is not as strong as the tissue it replaces. The torn annulus can be a source of pain for two reasons. First, there are pain sensors in the outer rim of the annulus. They signal a painful response when the tear reaches the outer edge of the annulus. Second, like injuries to other tissues in the body, a tear in the annulus can cause pain due to inflammation.

With time, the disc begins to lose water, causing it to lose some of its fullness and height. As a result, the vertebrae begin to move closer together.

As the disc continues to degenerate, the space between the vertebrae shrinks. This compresses the facet joints along the back of the spinal column. As these joints are forced together, extra pressure builds on the articular cartilage on the surface of the facet joints. This extra pressure can damage the facet joints. Over time, this may lead to arthritis in the facet joints.

These degenerative changes in the disc, facet joints, and ligaments cause the spinal segment to become loose and unstable. The extra movement causes even more wear and tear on the spine. As a result, more and larger tears occur in the annulus.

The nucleus may push through the torn annulus and into the spinal canal. This is called a herniated or ruptured disc. The disc material that squeezes out can press against the spinal nerves. The disc also emits enzymes and chemicals that produce inflammation. The combination of pressure on the nerves and inflammation caused by the chemicals released from the disc cause pain.

As the degeneration continues, bone spurs develop around the facet joints and around the disc. No one knows exactly why these bone spurs develop. Most doctors think that bone spurs are the body’s attempt to stop the extra motion between the spinal segment. These bone spurs can cause problems by pressing on the nerves of the spine where they pass through the neural foramina. This pressure around the irritated nerve roots can cause pain, numbness, and weakness in the low back, buttocks, and lower limbs and feet.

A collapsed spinal segment eventually becomes stiff and immobile. Thickened ligaments and facet joints, scarred and dried disc tissue, and protruding bone spurs prevent normal movement. Typically, a stiff joint doesn’t cause as much pain as one that slides around too much. So this stage of degeneration may actually lead to pain relief for some people.

View animation of degeneration

Mechanical and Neurogenic Pain

To best understand the cause of your pain, spine specialists sometimes divide low back pain into two categories:

•         mechanical pain
•         neurogenic pain

Mechanical Pain

Mechanical back pain is caused by wear and tear in the parts of the lumbar spine. This type of pain is similar in nature to a machine that begins to wear out. Mechanical pain usually starts from degenerative changes in the disc. As the disc begins to collapse and the space between the vertebrae narrows, the facet joints may become inflamed. Mechanical pain typically gets worse after activity due to strain on the moving parts of the spine. Mechanical pain is usually felt in the back, but it may spread into the buttocks, hips, and thighs. The pain rarely goes down past the knee. Mechanical back pain usually doesn’t cause weakness or numbness in the leg or foot, because the problem is not from pressure on the spinal nerves.

Neurogenic Pain

Neurogenic pain means pain from nerve injury. Neurogenic pain occurs when spinal nerves are inflamed, squeezed, or pinched. This can happen when a disc herniates or when a nerve gets pinched where it leaves the spine. Recently it has also become known that when a disc ruptures, chemicals are released that inflame the nerves even if there is no pressure directly on the nerve. Neurogenic symptoms concern doctors more than mechanical pain because they can signal damage to the nerves and lead to weakness or numbness in the lower extremities.

The nerve pressure causes symptoms in the areas where the nerve travels, rather than in the low back. This happens because pressure on the spinal nerve affects structures away from the spine, such as the muscles. As a result, a person’s back may not hurt, yet the person feels pain, numbness, or weakness in the leg or foot. This indicates there’s a problem with the body’s electrical wiring. The pressure on the nerve affects how the body functions. Muscles weaken. Reflexes slow. Sensations of pins, needles, and numbness may be felt where the nerve travels.

The effects of spine degeneration or back injury can lead to specific spine conditions. These include:

•         annular tears
•         internal disc disruption
•         herniated disc
•         facet joint arthritis
•         segmental instability
•         spinal stenosis
•         foraminal stenosis

Our intervertebral discs change with age, much like our hair turns gray. Perhaps the earliest stage of degeneration occurs due to tears that occur in the annulus. These tears can result from wear and tear over a period of time. They can also be the result of a sudden injury to the disc due to a twist or increased strain on the disc that overpowers the strength of the annulus. These annular tears may cause pain in the back until they heal with scar tissue.

View animation of annular tearing.

Internal Disc Disruption

Multiple annular tears can lead to a disc that becomes weak. The disc starts to degenerate and collapse. The vertebrae begin to compress together. The collapsing disc can be the source of pain because it has lost the ability to be a shock absorber between the vertebrae. This condition is sometimes referred to as internal disc disruption. This type of problem causes primarily mechanical back pain due to inflammation of the disc and surrounding structures.

Herniated Disc

A disc that has been weakened may rupture or herniate. If the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc, or herniate. A disc herniation usually causes compressive problems if the disc presses against a spinal nerve. The chemicals released by the disc may also inflame the nerve root, causing pain in the area where the nerve travels down the leg. This type of pain is referred to as sciatica.

Even a normal disc can rupture. Heavy, repetitive bending, twisting, and lifting can place too much pressure on the disc, causing the annulus to tear and the nucleus to rupture into the spinal canal.

The facet joints along the back of the spinal column link the vertebrae together. They are not meant to bear much weight. However, if a disc loses its height, the vertebra above the disc begins to compress toward the one below. This causes the facet joints to press together. Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the facet joints can develop osteoarthritis as the articular cartilage wears away over time. Extra pressure on the facet joints, such as that from a collapsing disc, can speed the degeneration in the facet joints. The swelling and inflammation from an arthritic facet joint can be a source of low back pain.

Segmental instability means that the vertebral bones within a spinal segment move more than they should. In the lumbar spine, this can develop if the disc has degenerated. Usually the supporting ligaments around the vertebrae have also been stretched over time.

Segmental instability also includes conditions in which a vertebral body begins to slip over the one below it. When a vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, this extra movement in the bones of the spine can create problems. It can lead to mechanical pain simply because the structures of the spine move around too much and become inflamed and painful. The extra movement can also cause neurogenic symptoms if the spinal nerves are squeezed as a result of the segmental instability.

Spinal Stenosis

Stenosis means closing in. Spinal stenosis refers to a condition in which the tissues inside the spinal canal are closed in, or compressed. The spinal cord ends at L2. Below this level, the spinal canal contains only spinal nerves that travel to the pelvis and legs. When stenosis narrows the spinal canal, the spinal nerves are squeezed inside the canal.

The pressure from the condition can cause problems in the way the nerves work. The resulting problems include pain and numbness in the buttocks and legs and weakness in the muscles supplied by the nerves. Because these nerves travel to the bladder and rectum, weakness in the these muscles can cause problems with control of the bladder and bowels.

Related Document: A Patient’s Guide to Lumbar Spinal Stenosis

Foraminal Stenosis

Spinal nerves exit the spinal canal between the vertebrae in a tunnel called the neural foramen. Anything that causes this tunnel to become smaller can squeeze the spinal nerve where it passes through the tunnel. This condition is called foraminal stenosis, meaning the foramen is narrowed. As the disc collapses and loses height, the vertebral body above begins to collapse toward the one below. The opening around the nerve root narrows, squeezing the nerve. Arthritis of the facet joints causes bone spurs to form and point into the foramen, causing further nerve compression and irritation. Foraminal stenosis can cause a combination of mechanical pain and neurogenic pain from the irritated nerve root.

Symptoms from low back problems vary. They depend on a person’s condition and which structures are affected. Some of the more common symptoms of low back problems are:

•         low back pain
•         pain spreading into the buttocks and thighs
•         pain radiating from the buttock to the foot
•         back stiffness and reduced range of motion
•         muscle weakness in the hip, thigh, leg, or foot
•         sensory changes (numbness, prickling, or tingling) in the leg, foot, or toes

Rarely, symptoms involve changes in bowel or bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause symptoms of low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder.

This is an emergency.

If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.

How will my health care provider find out what’s causing my problem?

The diagnosis of low back problems begins with a thorough history of your condition. When you visit First Choice Physical Therapy we may ask you to fill out a questionnaire describing your back problems. Our Physical Therapist will ask you questions to find out when you first started having problems, what makes your symptoms worse or better, and how the symptoms affect your daily activity. Your answers will help guide the physical examination.

Your Physical Therapist will then physically examine the muscles and joints of your low back. It is important that we see how your back is aligned, how it moves, and exactly where it hurts.

Our Physical Therapist may do some simple tests to check the function of the nerves. These tests are used to measure the strength in your lower limbs, check your reflexes, and determine whether you have numbness in your legs or feet. The information from your medical history and physical examination will help us decide which further tests to run.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides Physical Therapist services in Lynn Haven and Panama City Beach.

What can be done to relieve my symptoms?

Non-surgical Rehabilitation

Whenever possible, it is preferable to use treatments other than surgery. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.

Bed Rest

In cases of severe pain, your Physical Therapist at First Choice Physical Therapy may suggest a short period of bed rest, usually no more than two days. Lying on your back can take pressure off sore discs and nerves. Our Physical Therapists usually advise against strict bed rest and prefer that patients do ordinary activities using pain to gauge how much is too much.

Back Brace

A back support belt is sometimes recommended when back pain first strikes. It can help provide support and lower the pressure inside a problem disc. First Choice Physical Therapy patients recovering from back pain are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, back muscles begin to rely on the belt and start to shrink (atrophy).

Medications

Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication. Many different types of medications are typically prescribed to help gain control of the symptoms of low back pain. There is no medication that will cure low back pain. Medications are prescribed to help with sleep disturbances and to help control pain, inflammation, and muscle spasm.

Physical Therapy and Exercise

In addition to other nonsurgical treatments, patients with back pain often work with a Physical Therapist. Physical Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. Our Physical Therapist can design a rehabilitation program to address a particular condition and to help you prevent future problems. There is a great deal of scientific evidence that exercise and increased overall fitness reduce the risk of developing back pain and can improve the symptoms of back pain once it begins.

Although the time required for rehabilitation varies among patients, you can expect to continue therapy for two to four months for chronic back problems. Our treatments are designed to ease pain and to improve your mobility, strength, posture, and function. Your Physical Therapist at First Choice Physical Therapy will also teach you how to control your symptoms and how to protect your spine for the years ahead.

At first, our Physical Therapist may apply various forms of treatment to address your symptoms. These are especially helpful in the early weeks to improve your comfort so you can get back to your normal activities. We’ll show you ways to position your spine for maximum comfort while you move, recline, or sleep. To help calm pain and muscle spasm, your Physical Therapist in Lynn Haven and Panama City Beach may apply heat or ice packs, electrical stimulation, and ultrasound.

If you have severe back pain, our Physical Therapist may work with you in a pool. Physical Therapy done in water puts less stress on your low back, and the buoyancy allows you to move easier during exercise.

You may be tempted to limit your activity because of your back pain. However, as a result of pain and inactivity, your muscles may become weak and deconditioned, and your back won’t function optimally. Physical Therapists at First Choice Physical Therapy in Lynn Haven and Panama City Beach use active rehabilitation to prevent the harmful effects of deconditioning. With this active approach, you’ll be shown how to lift and move safely. And you’ll be shown how to strengthen your back muscles. In addition, aerobic exercises are used to improve your general fitness and endurance.

Aerobic exercises may include walking on a treadmill, riding a stationary bike, or swimming. These activities can relieve the stress of low back pain, and they can cause your body to release endorphins into the blood stream. Endorphins are your body’s own natural painkillers.

An active approach to Physical Therapy can help you attain better muscle function, so you can get your activities done easier. Active rehabilitation speeds recovery, reducing the possibility that back pain will become a chronic problem. Activity helps you resume your normal lifestyle as swiftly as possible. Though you’ll be cautioned about trying to do too much, too quickly, you’ll be guided toward a return to your usual activities. This approach gives you a greater sense of control. You’ll take an active role in learning how to care for your back pain. First Choice Physical Therapy treatment sessions focus on reassuring you that getting back to work and other normal activities swiftly won’t cause you harm and can actually help you get better faster.

When needed, your Physical Therapist in Lynn Haven and Panama City Beach will encourage you to take certain actions to improve your spine health. For example, if you smoke, you’ll be encouraged to get help to quit. Because of the limited blood supply in the tissues of the low back, smoking speeds the degenerative process and impairs healing. If you’re out of shape, you’ll be encouraged to get fit. This strategy makes it less likely that back pain or injury will strike again in the future.

Our Physical Therapist will show you how to keep your spine safe during routine activities. You’ll learn about healthy posture and how posture relates to the future health of your spine. And you’ll learn about body mechanics, how the body moves and functions during activity. Your First Choice Physical Therapy Physical Therapist will also teach safe body mechanics to help you protect your low back as you go about your day. This includes the use of safe positions and movements while lifting and carrying, standing and walking, and performing work duties.

As you recover, our Physical Therapist will gradually advance your treatment in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles can help you begin moving easier and lessens the chances of future pain and problems.

As our rehabilitation program evolves, you will progress with more challenging exercises. The goal is to safely advance your strength and function.

Your Physical Therapist will work closely with your doctor and employer to help you get back on the job as quickly as reasonably possible. You may be required to do lighter duties at first, but as soon as you are able, you’ll begin doing your normal work activities. We can also do a work assessment to make sure you’ll be safe to do your job. Our Physical Therapist may suggest changes that could help you work safely, with less chance of re-injuring your back.

Post-surgical Rehabilitation

Rehabilitation after surgery is much more complex. Depending on what operation you’ve had, you may leave the hospital shortly after surgery. Some procedures, such as fusion surgery, require that you stay in the hospital for a few days.

During recovery from surgery, you should follow your surgeon’s instructions about wearing a back brace or soft lumbar support belt. You should be cautious about overdoing activities in the first few weeks after surgery.

You may need Physical Therapy outside of the hospital. If you had a lumbar fusion, your surgeon may have you wait six weeks to three months before starting Physical Therapy. Although the time required for recovery varies, once you start Physical Therapy, you’ll usually go for one to three months, depending on your progress and the type of surgery you had.

When you first visit First Choice Physical Therapy after surgery, our Physical Therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Pool therapy is often helpful after lumbar surgery.

We will use exercises are used to improve flexibility in your trunk and lower limbs. Strengthening for your abdominal and low back muscles is started. Our Physical Therapist will instruct you in safe ways to sleep, sit, lift, and carry. And you’ll be given ideas on how to do your work activities safely.

Ideally, you’ll be able to go back to your previous activities. However, you may need to modify your activities to avoid future problems.

When treatment is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you’ll be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Diagnostic Tests

Radiological Imaging

Radiological imaging tests help your doctor see the anatomy of your spine. There are several kinds of imaging tests that are commonly used.

X-rays

X-rays show problems with bones, such as infection, bone tumors, or fractures. X-rays of the spine also can give your doctor information about how much degeneration has occurred in the spine, such as the amount of space in the neural foramina and between the discs. X-rays are usually the first test ordered before any of the more specialized tests.

Flexion and Extension X-rays

Special X-rays called flexion and extension X-rays may help to determine if there is instability between vertebrae. These X-rays are taken from the side as you lean as far forward and then as far backward as you can. Comparing the two X-rays allows the doctor to see how much motion occurs between each spinal segment.

MRI Scans

The magnetic resonance imaging (MRI) scan uses magnetic waves to create pictures of the lumbar spine in slices. The MRI scan shows the lumbar spine bones as well as the soft tissue structures such as the discs, joints, and nerves. MRI scans are painless and don’t require needles or dye. The MRI scan has become the most common test to look at the lumbar spine after X-rays have been taken.

CT Scans

The computed tomography (CT) scan is a special type of X-ray that lets doctors see slices of bone tissue. The machine uses a computer and X-rays to create these slices. It is used primarily when problems are suspected in the bones.

Myelogram

The myelogram is a special kind of X-ray test where a special dye is injected into the spinal sac. The dye shows up on an X-ray. It helps a doctor see if there is a herniated disc, pressure on the spinal cord or spinal nerves, or a spinal tumor. Before the CT scan and the MRI scan were developed, the myelogram was the only test that surgeons had to look for a herniated disc. The myelogram is still used today but not nearly as often. The myelogram is usually combined with CT scan to give more detail.

Discogram

The discogram is another specialized X-ray test. A discogram has two parts. First, a needle is inserted into the problem disc, and saline is injected into the disc to create pressure inside the disc. If this reproduces your pain, then it suggests that the disc is the source of your pain. During the second part of the test, dye is injected into the disc. The dye can be seen on X-ray. Using both regular X-rays and CT scan images, the dye outlines the inside of the disc. This can show abnormalities of the nucleus such as annular tears and ruptures of the disc.

Bone Scan

A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special X-rays of your back. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem. Other tests such as the CT scan or MRI scan are then used to look at the area in detail.

Other Tests

Your doctor may also ask you to do other tests.

Electromyogram

An electromyogram (EMG) is a special test used to determine if there are problems with any of the nerves going to the lower limbs. EMGs are usually done to determine whether the nerve roots have been pinched by a herniated disc. During the test, small needles are placed into certain muscles that are supplied by each nerve root. If there has been a change in the function of the nerve, the muscle will send off different types of electrical signals. The EMG test reads these signals and can help determine which nerve root is involved.

Laboratory Tests

Not all causes of low back pain are from degenerative conditions. Doctors use blood tests to identify other conditions, such as arthritis or infection. Low back pain can be caused by problems that do not involve the spine, such as stomach ulcers, kidney problems, and aneurysms of the aorta. Other tests may be needed to rule out problems that do not involve the spine.

Treatment   

Injections

Spinal injections are used for both treatment and diagnostic purposes. There are several different types of spinal injections that your doctor may suggest. These injections usually use a mixture of an anesthetic and some type of cortisone preparation. The anesthetic is a medication that numbs the area where it is injected. If the injection takes away your pain immediately, this gives your doctor important information suggesting that the injected area is indeed the source of your pain. The cortisone decreases inflammation and can reduce the pain from an inflamed nerve or joint for a prolonged period of time.

Some injections are more difficult to perform and require the use of a fluoroscope. A fluoroscope is a special type of X-ray that allows the doctor to see an X-ray picture continuously on a TV screen. The fluoroscope is used to guide the needle into the correct place before the injection is given.

• Epidural Steroid Injection (ESI): Back pain from inflamed nerve roots and facet joints may benefit from an epidural steroid injection (ESI). In an ESI, the medication mixture is injected into the epidural space around the nerve roots. Generally, an ESI is given only when other nonoperative treatments aren’t working. ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief.
• Selective Nerve Root Injection: Another type of injection to place steroid medication around a specific inflamed nerve root is called a selective nerve root injection. The fluoroscope is used to guide a needle directly to the painful spinal nerve root. The nerve root is then bathed with the medication. Some doctors believe this procedure gets more medication to the painful spot. In difficult cases, the selective nerve root injection can also help surgeons decide which nerve root is causing the problem before surgery is planned.
• Facet Joint Injection: When the problem is thought to be in the facet joints, an injection into one or more facet joints can help determine which joints are causing the problem and ease the pain as well. The fluoroscope is used to guide a needle directly into the facet joint. The facet joint is then filled with medication mixture. If the injection immediately eases the pain, it helps confirm that the facet joint is a source of pain. The steroid medication will reduce the inflammation in the joint over a period of days and may reduce or eliminate your back pain.
• Trigger Point Injections: Injections of anesthetic medications mixed with a cortisone medication are sometimes given in the muscles, ligaments, or other soft tissues near the spine. These injections are called trigger point injections. These injections can help relieve back pain and ease muscle spasm and tender points in the back muscles

Only rarely is lumbar spine surgery scheduled right away. Your doctor may suggest immediate surgery if you are losing control of your bowels and bladder or if your muscles are becoming weaker very rapidly.

For other conditions, doctors prefer to try nonsurgical treatments for a minimum of three months before considering surgery. Most people with back pain tend to get better, not worse. Even people who have degenerative spine changes tend to gradually improve with time. Only one to three percent of patients with degenerative lumbar conditions typically require surgery. Surgery may be suggested when severe pain is not improving.

There are many different operations for back pain. The goal of nearly all spine operations is to remove pressure from the nerves of the spine, stop excessive motion between two or more vertebrae, or both. The type of surgery that is best depends on that patient’s conditions and symptoms.

Laminectomy

The lamina is the covering layer of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are being squeezed by a herniated disc or from bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal nerves.

Discectomy

When the intervertebral disc has ruptured, the portion that has ruptured into the spinal canal may put pressure on the nerve roots. This may cause pain, weakness, and numbness that radiates into one or both legs. The operation to remove the portion of the disc that is pressing on the nerve roots is called a discectomy. This operation is performed through an incision in the low back immediately over the disc that has ruptured.

Many spine surgeons now perform discectomy procedures that require only small incisions in the low back (minimally invasive). The advantage of these minimally invasive procedures is less damage to the muscles of the back and a quicker recovery. Many surgeons are now performing minimally invasive discectomy as an outpatient procedure.

Lumbar Fusion

When there is excessive motion between two or more vertebrae, the excess motion can cause both mechanical pain and irritation of the nerves of the lumbar spine. In this case some type of spinal fusion is usually recommended. The goal of a spinal fusion is to force two or more vertebrae to grow together, or fuse, into one bone. A solid fusion between two vertebrae stops the movement between the two bones. The pain is reduced because the fusion reduces the constant irritation and inflammation of the nerve roots. There are many different types of spinal fusions.

• Posterior Lumbar Fusion: In the past, the traditional operation to perform a fusion of the lumbar spine was to decorticate the back surface of the vertebrae. Decorticate means to remove the hard outside covering of a bone to create a bleeding bone surface. Once this was done, bone graft was taken from the pelvis and laid on top of the decorticated vertebrae. The body tries to heal this area just like it would a fractured bone. The bone graft and the bleeding bone grow together and fuse to create one solid bone.

Spinal fusions were not always successful, mainly because the vertebrae failed to fuse together in up to 20 percent of cases. Surgeons began looking for ways to increase the success of fusions. For many years, metal plates and screws have been used to treat fractures of other bones. The more rigid two bones can be held together while the healing phase occurs, the more likely the bones are to heal. Spine surgeons began looking for ways to hold the vertebrae together while the fusion took place.

• Posterior Lumbar Instrumented Fusion: Major advances have been made in recent years in developing metal rods, metal plates, and special screws that are designed to hold the vertebrae together while the fusion takes place. These new techniques of spinal fusion are referred to as instrumented fusions because of the special devices used to secure the vertebrae to be fused. Today the most common type of posterior fusion is performed using special screws called pedicle screws that are inserted into each vertebra and connected to either a metal plate or metal rod along the back of the spine. The vertebrae are still decorticated, and bone graft is still used to stimulate the bones to heal together and fuse into one solid bone.
• Anterior Lumbar Interbody Fusion: A fusion of the lumbar spine can be accomplished in other ways. In some cases, surgeons feel that it is best to perform a fusion from the front of the spine. This is termed an anterior interbody fusion. This type of fusion requires an incision in the side of the abdomen to allow the surgeon to see the front of the spine. The intervertebral disc is removed between two vertebral bodies and bone graft is inserted where the disc was removed. The two vertebral bodies heal together and fuse.

• Anterior Lumbar Discectomy and Fusion with Cages: Degeneration of the intervertebral disc allows the vertebrae to move closer together, which narrows the openings (the neural foramina) where the nerve roots leave the spinal canal.

Surgeons realized that restoring the normal separation between the vertebrae would open the foramina and take pressure off the nerve roots. Over the last several years, devices called fusion cages have been designed that can be placed between the vertebrae to hold them apart while the fusion occurs. Enlarging the space between two vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through them. The extra space also pulls taut the ligaments inside the spinal canal so they don’t buckle.

Fusion cages are made of metal, bone, or graphite material. Some of these cages are shaped like cylinders. They are threaded like a screw on the outside and hollow on the inside. Some are rectangular in shape. The main purpose of the cage, regardless of the shape or material, is to hold the two vertebrae apart while the fusion becomes solid.

Posterior Lumbar Interbody Fusion: Finally, surgeons may combine the two methods of anterior fusion and posterior fusion. Fusing both the anterior and posterior portions of the spine gives the most solid fusion. Placing intervertebral cages between the two vertebrae also allows the surgeon to restore the disc height and help take pressure off of the nerve roots that exit at that spinal segment. A common method of doing this is called a posterior lumbar interbody fusion, combined with a posterior lumbar instrumented fusion (described earlier)

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Spine problems.

Knowing the main parts of your low back and how these parts work is important as you learn to care for your back problem.

Two common anatomic terms are useful as they relate to the low back. The term anterior refers to the front of the spine. The term posterior refers to the back of the spine. The section of the spine that makes up the low back is called the lumbar spine. The front of the low back is therefore called the anterior lumbar area. The back of the lower spine is called the posterior lumbar area.

This article gives a general overview of the anatomy of the low back. It should help you understand:

• what parts make up the low back
• how these parts work

The important parts of the lumbar spine include:

• bones and joints
• nerves
• connective tissues
• muscles
• spinal segments

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column is the body’s main upright support.

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The middle back, or thoracic spine, curves outward. The outward curve of the thoracic spine is called kyphosis. The low back, also called the lumbar spine, curves slightly inward. An inward curve of the spine is called lordosis.

Three Curves in Spine

The lumbar spine is made up of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Some people have an extra, or sixth, lumbar vertebra. This condition doesn’t usually cause any particular problems.

Lower Vertebrae

Each vertebra is formed by a round block of bone, called a vertebral body. The lumbar vertebral bodies are taller and bulkier compared to the rest of the spine. This is partly because the low back has to withstand pressure from body weight and from movements such as lifting, carrying, and twisting. Also, large and powerful muscles attaching on or near the lumbar spine place extra force on the lumbar vertebral bodies.

A bony ring attaches to the back of each vertebral body. This ring has two parts. Two pedicle bones connect directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other, the bony rings form a hollow tube that surrounds the
spinal cord and nerves. The laminae provide a protective roof over these nerve tissues.

Bony Ring

A bony knob projects out at the point where the two lamina bones join together at the back of the spine. These projections, called spinous processes, can be felt as you rub your fingers up and down the back of your spine. Each vertebra also has two bony knobs that point out to the side, one on the left and one on the right. These bony projections are called transverse processes. The projections in the low back are broader than in other areas of the spine because many large back muscles attach and impart powerful forces on them.

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

Facet Joints

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the ends of bones to move against each other smoothly, without friction.

Articular Cartilage

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc (described later) sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

Neural Foramen

Nerves

The hollow tube formed by the bony rings on the back of the spinal column surrounds the spinal cord. The spinal cord is like a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Spinal Cord

The spinal cord extends down to the L2 vertebra. Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse’s tail.

Between vertebrae, two large nerves branch off the spinal cord, one on the left and one on the right. The nerves pass through the neural foramina of each vertebra. These spinal nerves group together to form the main nerves that go to the organs and limbs. The nerves of the lumbar spine (cauda equina) go to the pelvic organs and lower limbs.

Connective Tissues

Connective tissues are networks of fiber that hold the cells of the body together. Ligaments are strong connective tissues that attach bones to other bones. Several long ligaments connect on the front and back sections of the vertebrae. The anterior longitudinal ligament runs lengthwise down the front of the vertebral bodies. Two other ligaments run full-length within the spinal canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The ligamentum flavum is a long elastic band that connects to the front surface of the lamina bones (just behind the spinal cord). Thick ligaments also connect the bones of the lumbar spine to the sacrum (the bone below L5) and pelvis.

Ligaments

A special type of structure in the spine called an intervertebral disc is also made of connective tissue. The fibers of the disc are formed by special cells, called collagen cells. The fibers may be lined up like strands of nylon rope or crisscrossed like a net.

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

Two Parts of Intervertebral Disc

Muscles

The muscles of the low back are arranged in layers. Those closest to the skin’s surface, the superficial layer, are covered by a thick tissue called fascia. The middle layer, called the erector spinae, has strap-shaped muscles that run up and down over the lower ribs, chest, and low back. They join in the lumbar spine to form a thick tendon that binds the bones of the low back, pelvis, and sacrum. The deepest layer of muscles attaches along the back surface of the spine bones, connecting the low back, pelvis, and sacrum. These deepest muscles coordinate their actions with the muscles of the abdomen to help hold the spine steady during activity.

Low Back Muscles

Spinal Segment

A good way to understand the anatomy of the lumbar spine is by looking at a spinal segment. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal column at each vertebra, and the small facet joints that link each level of the spinal column.

The intervertebral disc separates the two vertebral bodies of the spinal segment. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal segment is connected by two facet joints, described earlier. When the facet joints of the lumbar spine move together, they bend and turn the low back.

Many important parts make up the anatomy of the back. Understanding the regions and structures of the lumbar spine can help you be more involved in your health care and better able to care for your back problem.

Welcome to First Choice Physical Therapy’s patient resource about Kyphoplasty.

Patients with osteoporosis are prone to compression fractures in the spine bones, or vertebrae. The bone cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States.

The fracture angles the spine forward and produces a hunchbacked appearance, called kyphosis. Patients with this condition are subject to debilitating pain, disturbed sleep, decreased lung and intestinal function, and difficulty completing routine activities.

Kyphoplasty restores the size and strength of the fractured vertebra. This realigns the spine and reduces pain. Nearly 95 percent of patients get immediate relief of pain with this procedure.

This article will help you understand:

• why the procedure becomes necessary
• what surgeons hope to achieve with kyphoplasty
• what to expect during recovery

What parts of the spine are involved?

The main section of each spine vertebra is a large, round structure called a vertebral body. Compression fractures cause the front portion of this round bone to collapse in height. Because the back section of the bone stays intact, the damaged vertebral body becomes wedge-shaped. It is this wedge shape that angles the spine forward into kyphosis. The vertebral body is the main structure treated in the kyphoplasty procedure.

What do surgeons hope to achieve with this procedure?

In the past, surgeons used standard open surgical procedures to fix compression fractures from osteoporosis. Open procedures require larger incisions to give the surgeon more room to operate. The results of open surgery for this condition have generally been poor, mainly because operating on bones that are weak and soft from osteoporosis is difficult. In addition, some aging adults with fractures may not be physically able to tolerate such a surgery.

Kyphoplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, which involves an incision and the use of larger instruments, kyphoplasty is a minimally invasive procedure. It requires a small opening in the skin and small instruments. This lessens the chance of bleeding, infection, and injury to muscles and soft tissues.

The goal of kyphoplasty is to return the fractured vertebra as close as possible to its normal height. This is done by inflating a balloon inside the fractured bone to restore the vertebral body to its normal size. Special cement is then injected into the bone, fixing it in place. The cement strengthens the broken vertebra and stiffens it in its original height and position. This reduces pain and spine deformity (kyphosis), enabling patients to get back to normal activities.

How will I prepare for the procedure?

The decision to proceed with kyphoplasty must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Kyphoplasty is normally done on an outpatient basis, meaning patients go home the same day as the surgery. You shouldn’t eat or drink anything after midnight the night before.

What happens during the procedure?

The patient lies on his or her stomach. To begin, the surgeon cleans the skin on the back with an antiseptic. Then the skin over the problem area is numbed using an anesthetic. Patients may also receive general anesthesia to put them to sleep during the procedure.

Two small openings are made in the skin on each side of the spinal column. Long needles are inserted through the openings. The needles are passed completely through the back of the spinal column into the fractured vertebral body. These needles serve as guides while the surgeon drills two holes into the vertebral body. The surgeon uses a fluoroscope to make sure the needles and drill holes are placed in the right spot. A fluoroscope is a special X-ray television that allows the surgeon to see your spine on a screen.

Drills Two Holes

The device works like a video, though the images are in the form of an X-ray. Metal objects show up clearly on X-rays. The needle is easy for the surgeon to see on the fluoroscope screen. This helps the surgeon know the needle goes into the correct spot.

A hollow tube with a deflated balloon on the end is then slid through each drill hole. The balloons are inflated with air. This restores the height of the vertebral body and corrects the kyphosis deformity.

Balloons Inflated

View Animation

Next, the surgeon removes the balloon and injects bone cement into the hollow space formed by the balloon. A chemical reaction in the cement causes it to harden in about 15 minutes. This fixes the bone in its corrected height and position. Bandages are then applied over the small incisions.

Injecting Bone Cement

What might go wrong?

Serious complications from kyphoplasty are rare, involving less than five percent of cases. As with other procedures, however, complications can occur. Some of the most common complications of kyphoplasty include

• problems with anesthesia
• thrombophlebitis
• infection
• cement leakage
• ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine procedures is rare but can be a very serious complication. Some infections may show up early, within the first few days after the procedure. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require surgery to treat the infected portion of the spine.

Cement Leakage

The cement used in kyphoplasty is squeezed into the fractured vertebra in liquid form. Because it is injected at low pressure, cement leakage during kyphoplasty is rare. If some of the cement happens to leak out of the vertebra, it usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.

Ongoing Pain

Many patients get nearly complete relief of symptoms from kyphoplasty. As with any procedure, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

Patients are monitored in the recovery room for two to three hours after the procedure before going home. You are instructed to move your back only carefully and comfortably. Some patients who are feeling extra pain or other problems after kyphoplasty may need to stay in the hospital overnight.

Patients rarely need to wear a brace after kyphoplasty, since bone cement immediately improves the strength and stiffness in the fractured vertebra.

What should I expect as I recover?

The cement used to fix the broken vertebra hardens quickly, within about 15 minutes. As a result, people often find it easier to do daily activities within one week. Pain also decreases rapidly, and most people require less pain medication within two weeks. Despite these improvements, most orthopedists consider that it takes about three months for the bone to heal after kyphoplasty.

Patients who continue to have problems with posture and pain or who have lost muscle tone and strength may need the help of a Physical Therapist, such as the Physical Therapists at First Choice Physical Therapy. Although every individual recovers at a different pace, as a guidline, patients typically need to attend Physical Therapy sessions for four to six weeks.

At First Choice Physical Therapy, the goal of our Physical Therapy is to help you safely improve strength and function. Our Physical Therapist may use treatments such as heat or ice, electrical stimulation, and massage to help calm your pain. Gentle exercise is used to improve strength of the spine and limbs. We will teach you how to move safely using healthy postures to reduce strain on the healing back. Exercises for the heart and lungs will be included to improve your stamina and help with pain control.

When the original fracture was due to osteoporosis, your Physical Therapist will suggest ways to prevent future problems. Patients may be advised on dietary supplements (calcium and vitamin D) to maximize bone health, and lifestyle changes, such as quitting smoking and starting an exercise program, may also be discussed.

Our patients are encouraged to walk and do moderate activity as they recover. However, you should avoid strenuous exertion until we approve resuming normal levels of activity.

As your Physical Therapy sessions at First Choice Physical Therapy come to an end, our Physical Therapist will help you get back to the activities you enjoy. Ideally, patients are able to resume normal activities. Yet you may need guidance on which activities are safe or how to change the way you go about your activities.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. We will continue to be a resource, but you will be in charge of doing our exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s patient resource about Vertebroplasty.

Patients with osteoporosis are prone to compression fractures in the spine bones, or vertebrae. The front of a vertebra cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States. These fractures often cause poor back posture, debilitating pain, and difficulty completing routine activities.

Vertebroplasty restores the strength of the fractured bone, thereby reducing pain. More than 80 percent of patients get immediate relief of pain with this procedure.

This guide will help you understand:

• why the procedure becomes necessary
• what surgeons hope to achieve with vertebroplasty
• what to expect during recovery

What parts of the spine are involved?

The main section of each spine vertebra is a large, round block of bone called a vertebral body. Compression fractures cause this section of bone to collapse. The collapsed vertebra gives the spine a hunched appearance, called kyphosis, and the loss of vertebral height shortens the muscles on each side of the spine. This forces the back muscles to work harder, causing muscle fatigue and pain. The vertebral body is the main structure treated in the vertebroplasty procedure.

Compression Fractures

What do surgeons hope to achieve?

In the past, surgeons used standard open surgery to fix compression fractures from osteoporosis. Open surgery requires larger incisions to give the surgeon more room to operate. The results of open surgery for this condition have generally been poor, mainly because it is difficult to do surgery on bones that are weak and soft from osteoporosis. In addition, some aging adults with fractures may not be physically able to tolerate such surgery.

Vertebroplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, vertebroplasty is a minimally invasive procedure. It requires small openings in the skin and small instruments. This lessens the chance of bleeding, infection, and injury to muscles and tissues.

Surgeons fix the bone in place by squeezing special cement into the broken bone. The cement strengthens and stiffens the vertebra, which reduces pain considerably and helps the patient return to normal activities.

This procedure doesn’t restore the original height of the broken vertebra, however. Nor does it prevent the kyphosis (hunchback) deformity that sometimes results from compression fractures.

How will I prepare for the procedure?

The decision to proceed with vertebroplasty must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Vertebroplasty is normally done on an outpatient basis, meaning patients go home the same day as the surgery. You shouldn’t eat or drink anything after midnight the night before.

What happens during the procedure?

The patient lies on his or her stomach. To begin, the surgeon cleans the skin on the back with an antiseptic. Then the skin and muscles over the problem area are numbed using an anesthetic. Patients may also receive general anesthesia to put them to sleep during the procedure.

A small incision is made in the skin on each side of the spinal column. A long needle is inserted through each opening. The surgeon slides the needles through the back of the spinal column into the fractured vertebral body.

A fluoroscope is used to guide the needles. This is a special X-ray television camera adjusted above the patient’s back that lets the surgeon see the patient’s spine on a screen. Metal objects show up clearly on X-rays. The needles are easy for the surgeon to see on the fluoroscope screen. This helps the surgeon confirm that the needles reach the correct spot.

Once the needle is in place, special bone cement, called polymethylmethacrylate (PMMA), is injected through the needle into the fractured vertebra.

A chemical reaction in the cement causes it to harden in about 15 minutes. This fixes the bone so it can heal. Bandages are placed over the small openings where the needles were inserted.

What might go wrong?

Serious complications from vertebroplasty are rare, involving less than five percent of cases. As with other procedures, however, complications can occur. Some of the most common complications of vertebroplasty include

• problems with anesthesia
• thrombophlebitis
• infection
• cement leakage
• ongoing pain

This is not intended to be a complete list of possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine procedures is rare but can be a very serious complication. Some infections may show up early, within the first few days after the procedure. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require surgery to treat the infected portion of the spine.

Cement Leakage

The cement used in vertebroplasty is in a liquid form and is squeezed into the fractured vertebra under high pressure. Some of the cement commonly leaks out of the vertebra, but this usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.

Ongoing Pain

Many patients get nearly complete relief of symptoms from vertebroplasty. As with any procedure, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your doctor about treatments that can help control your pain.

What happens after surgery?

Patients are monitored in the recovery room for two to three hours after the procedure before going home. Patients are instructed to move their backs only carefully and comfortably. Some patients who feel extra pain or other problems after the procedure may need to stay in the hospital overnight.

Patients rarely need to wear a brace after vertebroplasty, since bone cement immediately improves the strength and stiffness of the fractured vertebra.

What should I expect as I recover?

People often report greater ease with daily activities within a week after vertebroplasty. Pain also decreases rapidly, and most people require less pain medication within two weeks. Despite these quick improvements, most orthopedists consider that it takes about three months for the bone to heal after vertebroplasty.

Patients are encouraged to walk and do moderate activity as they recover. However, patients should avoid strenuous activity until the surgeon approves it.

Patients who continue to have pain or who have lost muscle tone and strength may need to undergo Physical Therapy. At First Choice Physical Therapy, our Physical Therapists can design a personalized program to help speed your recovery. Although each individual recovers at their own pace, our vertebroplasty patients typically attend therapy sessions for four to six weeks.

When the original fracture was due to osteoporosis, our Physical Therapist will suggest ways to prevent future problems. Patients may advised on dietary supplements (calcium and vitamin D) to maximize bone health and lifestyle changes, such as quitting smoking and starting an exercise program, may also be discussed.

The goal of our Physical Therapy is to safely advance strength and function. Our Physical Therapist may use treatments such as heat or ice, electrical stimulation, or massage to calm pain. Gentle exercise improves the strength of the spine and limbs. We can help you learn how to move safely using healthy postures to reduce strain on the healing back. Exercises for the heart and lungs improve stamina and help with pain control.

As your Physical Therapy sessions at First Choice Physical Therapy come to an end, we will help you get back to the activities you enjoy. Ideally, our patients are able to resume normal activities. Our Physical Therapist may councel you on which activities are safe or how to change the way you go about your activities.

When recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

What parts of the spine are involved?

The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The main section of each vertebra is a round block of bone, called the vertebral body.

Spinal Column

The thoracic spine is made up of the middle 12 vertebrae. Doctors often refer to these vertebrae as T1 to T12. The thoracic spine starts at the base of the neck. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

Thoracic Spine

The upper half of the thoracic spine is much less mobile than the lower section, making disc herniations in the upper thoracic spine rare. About 75 percent of thoracic disc herniations occur from T8 to T12, with the majority affecting T11 and T12.

The intervertebral disc is a specialized connective tissue structure that separates the vertebral bodies. The disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity and during activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal canal is a hollow tube inside the spinal column. It surrounds the spinal cord as it passes through the spine. The spinal cord is similar to a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord. The spinal canal is narrow in the thoracic spine. Any condition that takes up extra space inside this canal can injure the spinal cord.

Blood vessels that run up and down the spine nourish the spinal cord. However, only one vessel, the anterior spinal artery, goes to the front of the spinal cord in the area between T4 and T9. Doctors call this section of the spine the critical zone. If this single vessel is damaged, as can happen with pressure from a herniated thoracic disc, the spinal cord has no other way to get blood. Left untreated, this section of the spinal cord dies, which can lead to severe problems of weakness or paralysis below the waist.

Anterior Spinal Artery

Why do I have this problem?

Thoracic disc herniations are mainly caused by wear and tear in the disc. This wear and tear is known as degeneration. As a disc’s annulus ages, it tends to crack and tear. These injuries are repaired with scar tissue. Over time the annulus weakens, and the nucleus may squeeze (herniate) through the damaged annulus. Spine degeneration is common in T11 and T12. T12 is where the thoracic and lumbar spine meet. This link is subject to forces from daily activity, such as bending and twisting, which lead to degeneration. Not surprisingly, most thoracic disc herniations occur in this area.

Less commonly, a thoracic disc may herniate suddenly (an acute injury). A thoracic disc may herniate during a car accident or a fall. A thoracic disc may also herniate as a result of a sudden and forceful twist of the mid-back.

Diseases of the thoracic spine may lead to thoracic disc herniation. Patients with Scheuermann’s disease, for example, are more likely to suffer thoracic disc herniations. It appears these patients often have more than one herniated disc, though the evidence is not conclusive.

The spinal cord may be injured when a thoracic disc herniates. The spinal canal of the thoracic spine is narrow, so the spinal cord is immediately in danger from anything that takes up space inside the canal. Most disc herniations in the thoracic spine squeeze straight back, rather than deflecting off to either side. As a result, the disc material is often pushed directly toward the spinal cord. A herniated disc can cut off the blood supply to the spinal cord. Discs that herniate into the critical zone of the thoracic spine (T4 to T9) can shut off blood from the one and only blood vessel going to the front of the spinal cord in this section of the spine. This can cause the nerve tissues in the spinal cord to die, leading to severe problems of weakness or paralysis in the legs.

What does the condition feel like?

Symptoms of thoracic disc herniation vary widely. Symptoms depend on where and how big the disc herniation is, where it is pressing, and whether the spinal cord has been damaged.

Pain is usually the first symptom. The pain may be centered over the injured disc but may spread to one or both sides of the mid-back. Also, patients commonly feel a band of pain that goes around the front of the chest. Patients may eventually report sensations of pins, needles, and numbness. Others say their leg or arm muscles feel weak. Disc material that presses against the spinal cord can also cause changes in bowel and bladder function.

Disc herniations can affect areas away from the spine. Herniations in the upper part of the thoracic spine can radiate pain and other sensations into one or both arms. If the herniation occurs in the middle of the thoracic spine, pain can radiate to the abdominal or chest area, mimicking heart problems. A lower thoracic disc herniation can cause pain in the groin or lower limbs and can mimic kidney pain.

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. These include questions about where you feel pain, if you have numbness or weakness in your arms or legs, and if you are having any problems with bowel or bladder function. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Then the doctor examines you to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

X-rays show the bones. They normally don’t show the discs, unless one or more of the discs have calcified. This is significant in the diagnosis of thoracic disc herniation. A calcified disc that appears on X-ray to poke into the spinal canal is a fairlyreliable sign that the disc has herniated. It isn’t clear why a problem thoracic disc sometimes hardens from calcification, though past injury of the disc is one possibility.

The best way to diagnose a herniated thoracic disc is with magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It gives a clear picture of the discs and whether one has herniated. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle. This test has shown doctors that many people without symptoms have thoracic disc herniations. This has led some doctors to suggest that thoracic disc herniations not causing symptoms are normal.

Before MRI, doctors relied mainly on myelography to diagnose thoracic disc herniations. By itself, myelography only helps diagnose this condition in about half the cases. Myelography is a kind of X-ray test. A special dye is injected into the space around the spinal canal. The dye shows up on an X-ray. It helps a doctor see if the disc is pushing into the spinal canal.

Computed tomography (CT scan) may be ordered. This is a detailed X-ray that lets doctors see the body’s tissue in images that also look like slices. The images provide more information about calcified discs. Doctors may combine the CT scan with myelography. When the CT scan is performed, the myelography dye highlights the spinal cord and nerves. The dye can improve the accuracy of a standard CT scan for diagnosing a herniated thoracic disc.

Doctors rely mostly on MRI for diagnosing thoracic disc herniations. However, they may use myelography and CT scans when preparing to do surgery to fix a herniated thoracic disc.

What treatment options are available?

Nonsurgical Treatment

Doctors closely monitor patients with symptoms from a thoracic disc herniation, even when the size of the herniation is small. If the disc starts to put pressure on the spinal cord or on the blood vessels going to the spinal cord, severe neurological symptoms can develop rapidly. In these cases, surgery is needed right away. However, unless your condition is affecting the spinal cord or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may recommend immobilizing your back. Keeping the back still for a short time can calm inflammation and pain. This might include one to two days of bed rest, since lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients do ordinary activities, using pain to gauge how much activity is too much. Another option for immobilizing the back is a back support brace worn for up to one week.

Doctors prescribe certain types of medication for patients with thoracic disc herniation. Patients may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Muscle relaxants may be prescribed if the back muscles are in spasm. Pain that spreads into the arms or legs is sometimes relieved with oral steroids taken in tapering dosages.

Your doctor will probably have a Physical Therapist direct your rehabilitation program. Physical Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A Physical Therapist can design a rehabilitation program for your condition that helps you prevent future problems.

Most people with a herniated thoracic disc get better without surgery. Doctors usually have their patients try nonoperative treatment for at least six weeks before considering surgery.

Surgeons may recommend surgery if patients aren’t getting better with nonsurgical treatment, or if the problem is becoming more severe.

When there are signs that the herniated disc is affecting the spinal cord, surgery may be required, sometimes right away. The signs surgeons watch for when reaching this decision include weakening in the arm or leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Surgical treatment for this condition includes

• costotransversectomy and discectomy
• transthoracic decompression
• video assisted thoracoscopy surgery (VATS)
• fusion

Costotransversectomy

Surgeons use  costotransversectomy to open a window through the bones that cover the injured disc. Operating from the back of the spine, the surgeon takes out a small section on the end of two or more ribs where they connect to the spine. (Costo means rib.) Then the bony knob on the side of the vertebra (the transverse process) is removed. (Ectomy means to remove.) This opens a space for the surgeon to work. The injured portion of the disc that is pressing against the spinal cord is removed (discectomy) with small instruments. Surgeons take extreme care not to harm the spinal cord.

Transthoracic Decompression

Transthoracic describes the approach used by the surgeon. Trans means across or through. The thoracic region is the chest. So in transthoracic decompression, the surgeon operates through the chest cavity to reach the injured disc. This approach gives the surgeon a clear view of the disc.

With the patient on his or her side, the surgeon cuts a small opening through the ribs on the side of the thorax (the chest). Instruments are placed through the opening, and the herniated part of the disc is taken out. This takes pressure off the spinal cord (decompression).

Video Assisted Thoracoscopy Surgery (VATS)

Recent developments in thoracic surgery include video assisted thoracoscopy surgery (VATS). This procedure is done with a thoracoscope, a tiny television camera that can be inserted into the side of the thorax through a small incision. The camera allows the surgeon to see the area where he or she is working on a TV screen. Small incisions give passage for other instruments used during the surgery. The surgeon watches the TV screen while cutting and removing damaged portions of the disc.

TV Screen

Cutting and Removing Damaged Portions

Categorized as minimally invasive surgery, VATS is thought to be less taxing on patients. Advocates also believe that this type of surgery is easier to perform, prevents scarring around the nerves and joints, and helps patients recover more quickly.

Fusion

After removing part or all of the disc, the spine may be loose and unstable. Fusion surgery may be needed immediately afterward. The medical term for fusion is arthrodesis. This procedure locks the vertebrae in place and stops movement between the vertebrae. This steadies the bones and can ease pain. Fusion surgery is not usually needed if only a small amount of bone and disc material was removed during surgery to fix a herniated thoracic disc.

In this procedure, the surgeon lays small grafts of bone over or between the loose spinal bones. Surgeons may use a combination of screws, cables, and rods to prevent the vertebrae from moving and allow the graft to heal.

What should I expect as I recover?

Nonsurgical Rehabilitation

Even if you don’t need surgery, your doctor may recommend that you work with a Physical Therapist. Patients are normally seen a few times each week for four to six weeks.

The first goals of treatment are to control symptoms, find positions that ease pain, and teach you how to keep your spine safe during routine activities.

As patients recover, they gradually advance in a series of strengthening exercises. Aerobic exercises, such as walking or swimming, can ease pain and improve endurance.

After Surgery

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may be visited by a Physical Therapist soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients need Physical Therapy outside of the hospital. They see a Physical Therapist for one to three months, depending on the type of surgery. At first, Physical Therapists may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to calm pain and muscle spasm. Then they teach patients how to move safely with the least strain on the healing back.

As patients recover, they gradually begin doing flexibility exercises for the hips and shoulders, and mobility and strengthening exercises to address the back muscles. Patients may also work with the Physical Therapist in a pool. Patients progress with exercises to improve endurance, muscle strength, and body alignment.

As the rehabilitation program evolves, patients do more challenging exercises. The goal is to safely advance strength and function.

Ideally, patients are able to go back to their previous activities. However, some patients may need to modify their activities to avoid future problems.

When treatment is well under way, regular visits to the Physical Therapist’s office will end. The Physical Therapist will continue to be a resource, but patients will be in charge of doing their exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s patient resource about Thoracic Spine problems.

The section of the spine found in the upper back is called the thoracic spine. It goes from the base of the neck to the bottom of the rib cage. Knowing the main parts of the thoracic spine and how these parts work is important as you learn to care for your back problem.

Two common anatomic terms are useful as they relate to the thoracic spine. The term anterior refers to the front of the spine. The term posterior refers to the back of the spine. The front of the thoracic spine is therefore called the anterior thoracic area. The back of the thoracic spine is called the posterior thoracic area.

This guide gives a general overview of the anatomy of the thoracic spine. It should help you understand:

• what parts make up the thoracic spine
• how these parts work

The important parts of the thoracic spine include:

• bones and joints
• nerves
• connective tissues
• muscles
• spinal segment

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column is the body’s main upright support.

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The thoracic spine curves outward. The low back, also called the lumbar spine, curves slightly inward. An inward curve in the spine is called lordosis. An outward curve, as in the thoracic spine, is called kyphosis. The kyphosis is shaped like a C with the opening in front.

The middle 12 vertebrae make up the thoracic spine. Doctors often refer to these vertebrae as T1 to T12. The large bump on the back of the lower part of the neck is the seventh cervical vertebra, called C7. It connects on top of T1. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

Each vertebra is made of the same parts. The main section of each thoracic vertebra from T1 to T12 is formed by a round block of bone, called the vertebral body. Each vertebra increases slightly in size from the neck down. The increased size helps balance and support the larger muscles that connect to the lower parts of the spine.

A bony ring attaches to the back of each vertebral body. This protective ring of bone surrounds the spinal cord, forming the spinal canal. Two pedicle bones connect directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other, the bony rings form a hollow tube that surrounds the spinal cord and nerves. The laminae provide a protective roof over these nerve tissues.

A bony knob projects out at the point where the two lamina bones join together at the back of the spine. You can feel these projections, called spinous processes, as you rub your fingers up and down the middle of your back. Bony knobs also point out from the side of the bony ring, one on the left and one on the right. These projections are called transverse processes.

Projections

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the thoracic spine allows freedom of movement as you twist back and forth or lean side to side.

Facet Joints

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a slick, rubbery material that covers the ends of most joints. It allows the ends of bones to move against each other smoothly, without friction.

Articular Cartilage

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc (described later) sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

Neural Foramen

Nerves

The hollow tube formed by the bony rings on the back of the spinal column surrounds the spinal cord. The spinal cord is like a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord travels down from the brain through the spinal column. In the thoracic spine, the spinal canal is narrower than in the rest of the spine, giving very little extra space for the spinal cord as it passes through the thoracic spine.

Narrow Spinal Canal

Between the vertebrae, two large nerves branch off the spinal cord, one on the left and one on the right. The nerves pass through the neural foramina of each vertebra. These spinal nerves group together to form the main nerves that go to the organs and limbs. The nerves of the thoracic spine mainly control the muscles and organs of the chest and abdomen.

Nerves in Spinal Canal

Connective Tissues

Connective tissues are networks of fiber that hold the cells of the body together. Ligaments are strong connective tissues that attach bones to other bones. Several long ligaments connect on the front and back sections of the vertebrae. The anterior longitudinal ligament runs lengthwise down the front of the vertebral bodies. Two other ligaments run full length within the spinal canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The ligamentum flavum is a long elastic band that connects to the front surface of the lamina bones. Thick ligaments also connect the ribs to the transverse processes of the thoracic spine.

A special type of structure in the spine called an intervertebral disc is also made of connective tissue. The fibers of the disc are formed by special cells, called collagen cells. The fibers may be lined up like strands of nylon rope or crisscrossed like a net.

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

Two Parts of Intevertebral Disc

Discs in the thoracic spine are much thinner than in the cervical and lumbar spine. As a result, there is generally less movement between the vertebrae of the thoracic spine.

Muscles

The muscles of the thoracic spine are arranged in layers. Those closest to the skin’s surface run from the back of the vertebrae to the shoulder blades. Others wrap around the rib cage and connect to the shoulders. Strap-shaped muscles called erector spinae make up the middle layer of muscles. These muscles run up and down over the lower ribs and thorax (the rib cage), and cross to the low back. The deepest layer of muscles attaches along the back of the spine bones, connecting the vertebrae. Muscles also connect from one rib to the next.

Muscles

Spinal Segment

A good way to understand the anatomy of the thoracic spine is by looking at a spinal segment.

Spinal Segment

Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal column at each vertebra, and the small facet joints that link each level of the spinal column.

Many important parts make up the anatomy of the thoracic spine. Understanding the regions and structures of the thoracic spine can help you become more involved in your health care and better able to care for your back problem.

Welcome to First Choice Physical Therapy’s patient resource about Anterior Cervical Discectomy and Fusion.

Anterior cervical discectomy and fusion (ACDF) is a procedure used to treat neck problems such as cervical radiculopathy, disc herniations, fractures, and spinal instability. In this procedure, the surgeon enters the neck from the front (the anterior region) and removes a spinal disc (discectomy). The vertebrae above and below the disc are then held in place with bone graft and sometimes metal hardware. The goal is to help the bones to grow together into one solid bone. This is known as fusion. The medical term for fusion is arthrodesis.

Operating on the back of the neck is more commonly used for neck fractures. That procedure is called posterior cervical fusion.

This guide will help you understand:

• why the procedure becomes necessary
• what surgeons hope to achieve
• what to expect during your recovery

What parts of the neck are involved?

Surgeons perform this surgery through the front part of the neck. Key structures include the ligaments and bones, intervertebral discs, the spinal cord and spinal nerves, and the neural foramina.

Front Part of Neck

In most cases, ACDF is used to stop symptoms from cervical disc disease. Discs start to degenerate as a natural part of aging and also from stress and strain in the structures of the neck. Over time, the disc begins to collapse, and the space decreases between the vertebrae.

When this happens, the openings around the spinal nerves (the neural foramina) narrow and may begin to put pressure on the nerves. The long ligaments in the spine slacken. They may even buckle and put pressure on the spinal cord. The outer rings of the disc, the annulus, weaken and develop small cracks. The nucleus in the center of the disc may press on the weakened annulus and actually squeeze out of the annulus. This is called a herniated disc. The herniated disc may press on ligaments, nerves, or even the spinal cord. Fragments of the disc that press against the outer annulus, spinal nerves, or spinal cord can be a source of pain, numbness, and weakness. Pressure on the spinal cord, called myelopathy, can also produce problems with the bowels and bladder, changes in the way you walk, and trouble with fine motor skills in the hands.

Discectomy is the removal of the disc (and any fragments) between the vertebrae that are to be fused. When symptoms are coming from the disc, it is hoped that this stops the symptoms.

Once the disc is removed, surgeons spread the bones of the spine apart slightly (distraction) to make room for the bone graft. This is bone material that can be taken from the top of the pelvis bone (autograft) or from a natural substitute (allograft). The bone graft separates and holds the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through them. Also, the ligaments inside the spinal canal are pulled taut so they don’t buckle into the spinal canal.

No movement occurs between the bones that are fused together. By holding the sore part of the neck steady, the fusion helps relieve pain. And it prevents additional wear and tear on the structures inside the section that was fused. This keeps bone spurs from forming, and it has been shown that fusion causes existing bone spurs to shrink. By fusing the bones together, surgeons hope that patients won’t have future pain and problems from cervical disc disease.

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

The patient’s neck is positioned facing the ceiling with the head bent back and slightly to the right. A two-inch incision is made two to three fingers’ width above the collar bone across the left-hand side of the neck. Surgeons often choose the left side to avoid injuring the nerve going to the voice box. Retractors are used to gently separate and hold the neck muscles and soft tissues apart so the surgeon can work on the front of the spine.

A needle is inserted into the disc, and an X-ray is taken to identify the correct disc. A long strip of muscle and part of the long ligament that covers the front of the vertebral bodies are carefully pulled to the side. Forceps are used to take out the front half of the disc. Next, a tool is attached to the vertebrae to spread them apart. This makes it easier for the surgeon to see between the two vertebrae. A small rotary cutting tool (a burr) is used to carefully remove the back half of the disc. A special microscope is used to help the surgeon see and remove pieces of disc material and bone spurs near the spinal cord.

A layer of bone is shaved off the flat surfaces of the two vertebrae. This causes the surfaces to bleed. This is necessary to help the bone graft heal and join the bones together.

The surgeon measures the depth and height between the two vertebrae. A section of bone is grafted from the top part of the pelvis. It is measured to fit snugly in the space where the disc was taken out. The surgeon increases the traction pull to separate the two vertebrae, and the graft is tamped into place.

The traction pull is released. Then the surgeon tests the graft by bending and turning the neck to make sure it is in the right spot and is locked in place. Another X-ray may be taken to double check the location of the graft.

A drainage tube may be placed in the wound. The muscles and soft tissues are put back in place, and the skin is stitched together. The surgeon may place your neck in a rigid collar.

What might go wrong?

• anesthesia
• thrombophlebitis
• infection
• nerve damage
• problems with the graft
• nonunion
• ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most common.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat and may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to these structures can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

The nerve to the voice box is sometimes injured during surgery on the front of the neck. Surgeons usually prefer to do surgery on the left side of the neck where the path of the nerve is more predictable than on the right side. During surgery, the nerve may be stretched too far when retractors are used to hold the muscles and soft tissues apart. When this happens, patients may be hoarse for a few days or weeks after surgery. In rare cases in which the nerve is actually cut, patients may end up with ongoing minor problems of hoarseness, voice fatigue, or difficulty making high tones.

Problems with the Graft

Fusion surgery requires bone to be grafted into the spinal column. The graft is commonly taken from the top rim of the pelvis. There is a risk of having pain, infection, or weakness in the area where the graft is taken.

After the graft is placed, the surgeon checks the position of the graft before completing the surgery. However, the graft may shift slightly soon after surgery to the point it is no longer able to hold the spine stable. When the graft migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align the graft and to apply metal plates and screws to hold it firmly in place.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthosis. (The term pseudarthrosis means false joint.) If the joint motion from a nonunion continues to cause pain, you may need a second operation. In the second procedure, the surgeon usually adds more bone graft. Metal plates and screws may also be added to rigidly secure the bones so they will fuse together.

Ongoing Pain

ACDF is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

After ACDF, patients usually wear a special neck brace for several months. These neck braces are often bulky and restrictive. However, the bone graft needs time to heal in order for the fusion to succeed. This requires the neck to be held still.

Recently, surgeons have begun using metal hardware, called instrumentation, to lock the bones in place. This hardware includes metal plates and screws that are fastened to the neck bones. They hold the neck bones still so the graft can heal, replacing the need for a rigid neck brace.

Patients may stay in the hospital for one to two days after surgery. When the surgery is done on an outpatient basis, patients may even go home the same day of surgery. Patients can get out of bed as soon as they feel up to it. They are watched carefully when they begin eating to make sure they don’t have problems swallowing. They usually drink liquids at first, and if they are not having problems, they can start eating solid food.

Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal.

What should I expect as I recover?

Rehabilitation after ACDF can be a slow process. You will probably need to attend Physical Therapy sessions at First Choice Physical Therapy Physical Therapy sessions for two to three months, and you should expect full recovery to take up to eight months.

At first, our treatments are used to help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Our Physical Therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

We will then slowly add active treatments. These include exercises for improving heart and lung function. Walking and stationary cycling are ideal cardiovascular exercises. Our Physical Therapists
also teach specific exercises to help tone and control the muscles that stabilize the neck and upper back.

Our Physical Therapist also works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your neck in safe positions as you go about your work and daily activities. At first, this may be as simple as helping you learn how to move safely and easily in and out of bed, how to get dressed and undressed, and how to do some of your routine activities. We will teach you how to keep your neck safe while you lift and carry items and as you begin to do other heavier activities.

As your condition improves, our Physical Therapist will begin tailoring your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires heavy and strenuous tasks. Our Physical Therapist may suggest changes in job tasks that enable you to go back to your previous job or to do alternate forms of work. You’ll learn to do these tasks in ways that keep your neck safe and free of extra strain.

Before your First Choice Physical Therapy Physical Therapy sessions end, our Physical Therapist will teach you ways to avoid future problems.

Welcome to First Choice Physical Therapy’s patient resource about Cervical Artificial Disc Replacement.

Artificial disc replacement (ADR) is relatively new. In June 2004, the first ADR for the lumbar spine (low back) was approved by the FDA for use in the US. Replacing a damaged disc in the cervical spine (neck) is a bit trickier. The disc is part of a complex joint in the spine. Making a replacement disc that works and that will last is not an easy task. Cervical artificial disc replacement devices are currently undergoing study for FDA approval in the United States.

The artificial disc is inserted in the space between two vertebrae. The goal is to replace the diseased or damaged disc while keeping your normal neck motion. The hope is that your spine will be protected from similar problems above and below the affected spinal level.

This guide will help you understand:

• what parts of the spine are involved
• what your surgeon hopes to achieve
• who can benefit from this procedure
• how do I prepare for surgery
• what happens during the procedure
• what to expect as you recover

What parts of the spine are invovled?

Disc replacement typically occurs at cervical spine levels C4-5, C5-6, or C6-7. The first seven vertebrae make up the cervical spine. Doctors often refer to these vertebrae as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine (the chest area) at the first thoracic vertebra, T1.

Each vertebra is made of the same parts. The main section of each cervical vertebrae, from C2 to C7, is formed by a round block of bone, called the vertebral body. A bony ring attaches to the back of the vertebral body. This ring has two parts. Two pedicles connect directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other, the bony rings form a hollow tube that surrounds the spinal cord. The laminae provide a protective wall around the spinal cord.

Vertebral Body

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits behind the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

A special type of structure in the spine called an intervertebral disc has two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

What does the surgeon hope to achieve

Disc replacement surgery is done to stop the symptoms of degenerative disc disease. Discs wear out or degenerate as a natural part of aging and from stress and strain on the neck. Eventually, the problem disc collapses. This causes the vertebra above to sink toward the one below. This loss of disc height affects the nearby structures – especially the facet joints.

When the disc collapses, it no longer supports its share of the load in the cervical spine. The facet joints of the spine begin to support more of the force that is transmitted between each vertebra. This increases the wear and tear on the articular cartilage that covers the surface of the joints. The articular cartilage is the smooth, slippery surface that covers the surface of the bone in any joint in the body. Articular cartilage is tough, but it does not tolerate abnormal pressure well for long. When damaged, articular cartilage does not have the ability to heal. This wear and tear is what is commonly referred to as arthritis.

Shrinking disc height also reduces the size of the neural foramina, the openings between each vertebral pair where the nerve roots leave the spinal column. The arthritis also results in the development of bone spurs that may protrude into these openings, further narrowing the space that the nerves have to exit the spinal canal. The nerve roots can end up getting squeezed where they pass through the neural foramina.

The traditional way of treating severe neck pain caused by disc degeneration is a procedure called an anterior cervical discectomy and fusion. In this procedure, the surgeon makes an incision in the anterior (front) of the neck, performs a discectomy (removes the disc) and fuses the two vertebrae together. A fusion simply means that two bones grow together. Usually, when two vertebrae are fused together, a small piece of bone called a bone graft is inserted between the two vertebrae where the disc has been removed. This bone graft serves to both separate the vertebrae and to stimulate the two bones to grow together – or fuse.

The fusion procedure usually involves the use of hardware, such as screws, plates, or cages to keep the bones from moving. Fusion restricts movement in the problem area, but it creates greater strain on the healthy spinal segments above and below. The added strain may eventually cause these segments to wear out. This is called adjacent-segment degeneration.

Replacing the damaged disc with an artificial disc, or implant, called a prosthesis can restore the normal distance between the two vertebrae. The artificial disc sits between the two vertebrae and “jacks up” the upper vertebra. Enlarging the disc space relieves pressure on the facet joints. It also opens up the space around the spinal nerve roots where they pass through the neural foramina.

Another benefit of the artificial disc replacement is that it mimics a healthy disc. Natural motion is preserved in the spine where the new disc is implanted. And it helps maintain stability in the spinal joints above and below it.

Who can benefit from this procedure

The indications for a cervical disc replacement are generally the same as for a cervical discectomy and fusion. A person must have symptoms from a cervical disc problem. Symptoms include neck and/or arm pain, arm weakness, or arm and hand numbness. These symptoms may be due to a herniated disc and/or bone spurs called osteophytes pressing on adjacent nerves or the spinal cord. This condition typically occurs at cervical spine levels C4-5, C5-6, or C6-7.

Artificial disc replacement is still somewhat experimental in the United States. Patients are only having this type of surgery as part of a clinical trial. A clinical trial is a type of research where a drug or device is being tested in real patients in a very controlled way. In the United States, surgeons are currently only replacing one cervical disc in a patient’s cervical spine at this time. In Europe, surgeons are replacing more than one disc. Surgeons in the United States may be cleared for replacing more than one cervical disc in the near future.

Prior to being admitted into a clinical trial, the patient must meet strict defined entrance criteria. The patient must have completed a trial of conservative (non-operative) treatment for at least four to six weeks, usually consisting of anti-inflammatory medication and intense Physical Therapy. The patient must have no history of previous neck surgery and the patient must be determined by the surgeon conducting the research to be a good surgical candidate for the ADR.

Cervical artificial disc replacement is indicated for the treatment of radiculopathy (pressure on the spinal nerve) and myelopathy (pressure on the spinal cord) at one or two levels. In the future, it may be used for the treatment of three or more symptomatic levels or levels adjacent to a cervical spine fusion. This use is still under investigation.

More data is needed before the uses of cervical artificial disc replacements are expanded to other problems in the cervical spine. Cervical artificial disc replacement is not advised when there is cervical spine instability, significant facet joint damage, or infection.

How should I prepare for surgery?

Your spine surgeon will gather a variety of information before recommending disc replacement surgery. In addition to taking a history and doing a physical exam, your surgeon may order various diagnostic studies, such as x-rays, magnetic resonance imaging (MRI) scans, CT scans, or discograms.

Once you and your surgeon have agreed that disc replacement surgery is indicated, certain preparations for the surgery are important. Your doctor may tell you to be NPO for a certain amount of time before the procedure. This means that you should not eat or drink anything for a certain amount of time before your procedure. This means no water, no coffee, no tea – not anything. You may receive special instructions to take your usual medications with a small amount of water. Check with your doctor if you are unsure what to do.

You should tell your doctor if you are taking any medications that thin your blood or interfere with blood clotting. The most common blood thinner is Coumadin. Other medications also slow down blood clotting. Aspirin, ibuprofen, and nearly all of the anti-inflammatory medications affect blood clotting. So do medications used to prevent strokes such as Plavix. These medications usually need to be stopped seven days prior to the procedure. Be sure to let your doctor know if you are on any of these medications.

You should stop smoking or using tobacco in any form as soon as possible before surgery. This is very important to reduce complications from heart and lung problems. Tobacco use, especially smoking, also decreases the success rate of spine surgery. Stopping smoking will increase your chances of a successful result.

Discussions will be held with your family and people who may be assisting you once you return from the hospital. You may need to visit your primary care physician or internal medicine specialist to obtain medical clearance for surgery. This will ensure that you are in the best medical condition possible prior to the surgery.

Hospitals often have preoperative teaching for patients undergoing major spinal operations. These teaching sessions can help you under­stand what to expect both while you are in the hospital and after you return home. A doctor who will be performing your anesthesia (an anesthesiologist) will evaluate and counsel you regarding anesthesia.

What happens during the operation?

Before we describe the procedure, let’s look first at the artificial disc itself.

The cervical artificial disc has several different designs. Some look like a sandwich with two endplates separated by a plastic spacer. The two endplates are made of cobalt chromium alloy, a safe material that has been used for many years in replacement joints for the hip and knee.

A plastic (polyethylene) core fits in between the two metal endplates. The core acts as a spacer and is shaped so that the endplates pivot in a way that imitates normal motion of the two vertebrae. There are small prongs on one side of each endplate. The prongs help anchor the endplate to the surface of the vertebral body.

Another artificial disc replacement design is a ball and socket articulation to allow for normal translation of motion at that segment. The implant may be made of titanium and polyurethane in a metal-on-plastic design. Some are made of stainless steel and are all metal-on-metal.

Inserted between two vertebrae, the prosthesis reestablishes the height between two vertebrae. As a result of enlarging the disc space, the nearby spinal ligaments are pulled tight, which helps hold the prosthesis in place. The prosthesis is further held in place by the normal pressure through the spine.

The Operation

The operation is done from the anterior (front) of the body. This surgical approach is the same as that presently used for a discectomy and fusion operation. To do this, the patient is placed on his or her back. An incision is made through the skin and the thin muscles of the front of the neck. The blood vessels, the trachea (windpipe), and the esophagus are moved to the side so that the surgeon can see the front of the cervical spine. The disc that is to be replaced is identified using the fluoroscope. The fluoroscope is an x-ray machine that allows the doctor to actually see an x-ray image while doing the procedure.

Working from the front of the spine, the spine surgeon removes a large section from the middle of the damaged disc. Next, the bones of the spine are spread apart to make more room to see and work inside the disc space. Using a surgical microscope, any remaining disc material toward the back of the disc is removed. The surgeon will also remove any disc fragments pressing against the nerve and shave off any osteophytes (bone spurs).

The disc space is distracted (jacked up) to its normal disc height. This step helps decompress or take pressure off the nerves. At this point, x-rays or a fluoroscope, is used to insert the artificial disc device into the prepared disc space. This allows the doctor to watch where the implant goes as it is inserted. This makes the procedure much safer and much more accurate.

Finally, the prosthesis is tested by moving the spine in various positions. An X-ray may be taken to double check the location and fit of the new disc.

What might go wrong?

All types of spine surgery, including artificial disc replacement, have certain risks and benefits. Weigh these as you gather advice and information. Be sure to discuss the possible risks of disc replacement with your spine surgeon.

Medical complications arising from spinal surgery are rare but could include stroke, heart attack, spinal cord or spinal nerve injury, pneumonia, or possibly death.

However, information from the disc replacement operations shows a low rate of complications. There have been no reports of death, significant infection, or major neurological problems.

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications are:

• anesthesia complications
• thrombophlebitis
• infection
• blood loss
• nerve injury or paralysis
• spontaneous ankylosis (fusion)
• subsidence (sinking)
• implant failure (need for further surgery)

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat and may require additional surgery to treat the infected portion of the spine.

Blood Loss

Cervical disc replacement surgery carries risks associated with operating from the front of the spine. Blood vessels that travel near the front of the spine may be injured during anterior cervical surgery.

Nerve Injury

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to these structures can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

The nerve to the voice box is sometimes injured during surgery on the front of the neck. When doing anterior neck surgery, surgeons prefer to go through the left side of the neck where the path of the nerve to the voice box is more predictable than on the right side. During surgery, the nerve may get stretched too far when retractors are used to hold the muscles and soft tissues apart. When this happens, patients may be hoarse for a few days or weeks after surgery. In rare cases where the nerve is actually cut, patients may end up with ongoing minor problems of hoarseness, voice fatigue, or difficulty making high tones.

Spontaneous Ankylosis (fusion)

Some things can go wrong with any implant. In the case of artificial disc replacements for the cervical spine, sometimes the spine fuses itself, a process called spontaneous ankylosis. Loss of neck motion is the main side effect of this problem.

Bone may also form in the soft tissues around the vertebrae. For example, cartilage turns to bone or bone-like tissue. This process is called ossification. Ossification may not affect the implant or your final results in terms of motion or function.

Some patients are left with pain, numbness, and weakness. This can occur when there’s been incomplete neurologic decompression. In other words, there is still pressure on the spinal cord or spinal nerves.

Subsidence (sinking)

Subsidence is another possible problem. The implant actually sinks down into the vertebral body above or below it. This results in a loss of the normal disc height. Neurologic compression with neurologic symptoms can occur.

Implant Failure (need for further surgery)

Over time, wear and tear just from the physical process of motion across a bearing surface can cause tiny bits of debris to flake off the implant. The body may react to these particles with an inflammatory response that can cause pain, implant loosening, and implant failure. So far, significant inflammatory reactions have not been reported for spinal artificial disc replacements. In rare cases, the artificial disc replacement can dislocate.

After Surgery

What happens after surgery

Most people spend one or two days in the hospital. You may require an extra day or two if for some reason you’re having extra pain or unexpected difficulty. Patients generally recover quickly after the artificial disc procedure.

You should be able to get out of bed and walk within a few hours. Move carefully and comfortably, and avoid extending your neck (bending backward). You may need to wear a brace or soft collar for a short while after the operation to support your neck muscles.

As you recover in the hospital, a Physical Therapist may see you one or two times each day until you go home. You’ll be shown ways to move, dress, and do activities without putting extra strain on your neck. Your Physical Therapist will help you begin a walking program in the hospital. You are encouraged to continue the walking program when you return home.

When you leave the hospital, there are very few activity restrictions. You should be safe to sit, walk, and drive. However, you should avoid lifting items for at least four weeks. Your surgeon will probably release you to return to work in two to four weeks. If your job requires moving and lifting heavy items, you may require a longer period of recovery. Your surgeon may give you the okay to do all your activities by the sixth week after surgery.

If you spend large amounts of time in front of a computer or other machine, you may need to change the height and angle of your work surface and/or the computer. Finding a position that puts minimal stress on your neck is important. You should avoid spending hours in one position reading, sewing, or doing other handwork. The Physical Therapist can help you find optimal positions and advise you about ways to stretch your neck muscles.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What should my recovery be like?

Your surgeon may prescribe outpatient Physical Therapy within one to two weeks after surgery. Although the time required for recovery varies, as a guideline, plan on attending Physical Therapy
two to three times each week for four to six weeks.

The first few visits include treatments to calm soreness and pain from the operation. Our Physical Therapist may apply gentle soft-tissue treatments such as massage as well as ice and electrical stimulation to calm muscle spasm and to help take away any lasting pain.

Our Physical Therapist will teach you how to protect your neck. You’ll learn ways to position your neck when you sleep, sit, and drive. We’ll show you ways to keep your neck safe during routine activities, such as getting in or out of bed, getting dressed, and washing your hair.

Many patients are afraid to move the head and neck for fear of damaging or dislodging the disc. Using normal motion for everyday activities will not harm your new disc in any way. Our Physical Therapist will help you learn how to move your neck and show you any limits necessary.

Active treatments are then used to improve flex­ibility, strength, and endurance. Our therapist will generally prescibe gentle stretching exercises for the neck. You’ll begin a series of strengthening exercises to help tone and control the muscles that stabilize the neck and upper back. It is also important to build strength in your arms. Our endurance exercises may include treadmill walking, swimming, or stationary biking.

When your symptoms are under control and you’re comfortable doing your exercises, your formal Physical Therapy sessions at First Choice Physical Therapy will end. You’ll then continue your exercises as part of a home program.