Spinal Pain and Adult Deformity

 

Background

In our senior years degeneration of the discs in the neck and lumbar spine may take place in an orderly fashion and where protected by good postural muscle control may progress without causing symptoms.

However, when there has been a mild underlying curl “scoliosis” in the spine, then asymmetrical (uneven) loading of the spinal elements will occur. Equally where natural disc degeneration is occurring then lifestyle may play a part in the causation of changes that lead to symptoms.

 

Causation

Prolonged sitting at a desk and computer leads to loss of upright posture and deep fine control muscle strength and segmental control the lower back and neck. The pelvis rolls forwards, the lumbar spine over arches, the belly falls forwards and pouts. Often eating habits cause concomitant obesity.

The neck assumes a constant attitude of flexion with the shoulders excessively raised or drawn forwards.

The weight bearing line is drawn forwards and the back of the discs abnormally compressed and the back of the human disc is weaker than the front of the disc because we are still built to walk like an Orangutan or four-legged animal.

The disc then bulges. It may rupture as in a “slipped disc”. It may withstand the constant abuse but the fibres pull on the disc margin resulting in these fibres calcifying and producing spurs from the vertebral rim which irritate the nerve.

The jack-knifing of the discs overloads the facet joints in the back of the spine and nature tries to cope by widening their surface area. Whilst that may not matter around the knee, this overgrowth crimps the exit doorway or the spinal canal, compresses the exiting or descending nerves causing pain in the back, shoulders and arms or buttocks, groins and legs.

The loss of disc content often leads the vertebrae to slip forwards or backwards upon each other distorting the exit doorway, causing scarring around the nerves. The trapped nerves become inflamed and progressively throttled.

The patient may try to offset this deterioration or the slippage or twisting of one vertebra upon another resulting in “degenerate scoliosis”. All of these features may be aggravated by osteoporosis / osteopaenia with loss of height not only of the discs but of the vertebrae as well.

By this time the patient may be too mature for open corrective surgery and be further hampered by co-morbidities such as Diabetes, kidney and cardiac disease.

 

Presentation and Confusion

The patient may notice neck pain to which may be added:

  • Pain in the back of the head which radiates over one or both sides of the skull and may even reach to back of the eye.
  • The pain may radiate into the shoulder muscles and local trigger points.
  • The crimped nerves may start to cause pain in arms sometimes with numbness and weakness. The signature deteriorates and objects are dropped.
  • Pain may radiate down the back of the neck to the bra strap or even round the front of the chest to the pectoral muscle region.

In the lower back (lumbar spine) the presentation may be:

  • Low back pain with radiation to the buttock or groin or full blown sciatica with numbness and weakness in the lower leg or thigh.
  • The presentation may be that of “claudication” (after the limping Roman Emperor Claudius) – progressive weakness or pain on walking. This is caused by bone or scarring damming up the blood supply to the nerve roots and hampering nerve transmission. This results in a lack of impulses to drive the muscles and curtailment of the walking distance.  After a rest – usually leaning forwards the sufferer can march onwards for another short distance.  The walking distance becomes gradually more limited.
  • The claudication can affect both limbs, hamper climbing stairs despite using a stick or rollator.  In this situation, the deformity may be narrowing the spinal canal (tube) volume itself.
  • The degeneration can lead to progressive deformity with offset of the spine to one side and a misshapen appearance

 

Treatment and Outcome

Firstly, let us try to slow the progress of the condition. So in the first place, let us try to: 

  • Avoid becoming overweight by trying to correct diet and reduce alcohol intake.
  • Lose weight by taking regular exercise whilst always maintaining a correct posture. 
  • Avoid sitting for more than 20 minutes at a time without standing up, walking round and concentrating on correcting the spinal posture by rolling the pelvis backwards, tightening the abdominal muscles and pulling up the pelvic diaphragm.
  • Improve the ergonomics of the work place – elevating the computer, sitting upright in the work-chair, keeping the knees below the hips.
  • Attend Reformer Pilates or Muscle Balance Physiotherapy (Alexander Technique) and Postural re-training classes.
  • Carry out these self-help drills at home – daily as an integral lifestyle. 

When these fail, the initial conventional treatment will be anti-inflammatory and analgesia supplemented with infrequent pain killing spinal injections.  If age has caught up with you then this may be the only remedy offered – but there are alternatives.

 

But what else could we do?

  • Address the possible presence of osteoporosis or osteopaenia by investigations with weight bearing X-rays and Dexascans and taking the correct remedies of Vitamin D3 and Calcium and long-term therapeutic injections.
  • Diagnostic scans: weight bearing X-rays to show bone alignment and configuration, MRI scans for soft tissue and disc evaluation, CT scans to define bones and SPECT CT scans to detect inflammation.
  • EMG to assist in defining degree of nerve compression – an unreliable test.

On the basis of their findings, you can consider surgery depending on the relative presence of: 

  • protruding discs and/or narrowing of the spinal canal or foramen
  • bone spurs protruding from the joints or vertebral rim
  • tilting, twisting or slipping of the vertebrae and so-called “instability”.

Conventional surgery requires general anaesthesia which carries significant risks of heart attack, stroke, urinary or chest infection, venous thrombosis and pulmonary embolism, nerve damage etc.  The procedures are significant interventions: microdiscectomy, decompression (laminectomy) fusion with correction alignment or total disc replacement.

The minimal invasive alternative is transforaminal endoscopic lumbar decompression and foraminoplasty conducted under simple sedation with circulating powerful analgesia.  Together with low complication rates, patient feedback leads the surgeon to the exact origin of the pain and allows the patient to remain safe. The absence of general anaesthesia allows this multi-target technique to assist all age groups including the elderly and those with additional problems such as Diabetes, Strokes, heart attacks, shortness of breath for the majority of problems arising from spinal degeneration and deformity including those with failed back surgery

 

By Martin Knight MD FRCS