The spine is an incredibly complex structure. If you ask anyone that has worked with the spine for years, they will tell you that no one patient is the same. Somebody with a textbook problem on an MRI will present completely different to the next person and is why spinal treatment comes with its challenges.
That being said, we are much further along than where we were thirty years ago. Knowledge was very limited as to how the spine functioned, and it’s only after years of monitoring chronic pain patients with high disability and lack of independence that we now know more about how the biomechanics of the spine works.
Many of you reading this will know someone, or you may be suffering yourselves, with chronic back pain. Low back pain continues to be one of the highest sources of disability worldwide. Almost every single adult in the developed world will experience back pain at some stage throughout their life to a varying degree.
Is Spinal Surgery Safe?
Many spinal surgeons will try and defer spinal surgery for as long as possible. The reason being that many patients stay the same following a five-year follow-up review, many get worse.
This is because the spine is such an intricate structure, and when you change one portion it causes a dramatic effect on the rest of the spine. Many of you reading this will have had or know someone who has had spinal surgery and will have had differing results. Generally, one of the most common surgeries in the spine is a microdiscectomy. This tends to be in younger males and is where there is a disc injury in the lower portion of the spine. The surgeon will locate the disk where it has slipped—the scientific term is called herniation —he will then take this portion of the disc off. This can yield fantastic results immediately because the pressure has been taken off the nerve and the surrounding structures. It’s not till months or even years afterwards that the biomechanics of the spine will be altered and could cause a knock-on effect elsewhere. It’s not uncommon for people who have had one microdiscectomy to have a second purely because the other discs have to take up more weight.
The lower disc called the L5/S1 disc is the most common disc to herniate because it takes up the most weight. It is the biggest disc and therefore causes the most amount of problems. Discs will usually be herniated to the side and will press on the nerves going into the back and down the legs, often causing sciatica. Sciatica is where there is pressure from a disc which can cause shooting searing pain down the back of the leg all the way to the toes. This is not limited to a shooting pain; it can present itself as pins and needles, numbness, or lack of control or strength in the leg.
Do you need spinal surgery for a disc prolapse?
If this is the case with lots of preoperative patients, then a microdiscectomy taking pressure off the disc can immediately relieve stress on the sciatic nerve taking the pain away, allowing the patient to restore normal capability. The L4/5 disc is the one above and now will begin to take up more of the load bearing from the chest, the shoulders and the head.
Little does the patient know, that this disc will eventually degenerate as well. It could be a year, could be ten years, it could be thirty years, but it’s not designed to take up the enormous amounts of stress the body will place upon it.
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That being said every human judges how healthy they are by the way they feel, and this is how we automatically determine how our bodies are functioning. If there is no pain, we go back to doing the things we did before the operation. For example, a young rugby player who has a disc injury will avoid doing any gym work, weight-lifting, or running for fear of causing debilitating pain. He has surgery, and the pressure will come off the spine and sciatic nerve. It will allow him to return to normal activity, only placing more stress and force through an unstable spine.
Spinal surgeons will always try and delay any sort of surgery in the back for as long as possible and try to restore normal motion and pain free mobility through non-surgical methods.
Another very important structure in the spine is the spinal cord and the column which it runs through. The spinal cord is elastic, designed to bend, stretch and flex as the spine does when we go through our daily activities such as sitting, twisting, and walking up and downstairs. It send motor neurons from the brain, signalling to our body commands such as to lift a pencil up or to lift that glass of water. Going the other way, we have sensory nerves providing information to the brain about temperature and pain.
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If this structure becomes compressed or compromised, that is when we start to experience dysfunction, whether it be pain, pins and needles, numbness, hot and cold, or the inability to move as we desire. The spinal cord will exit at each level throughout the spinal column, and then branch with roots to the subsequent endpoints, like a river with its tributaries.
With the degeneration in the spine often the spinal column itself can become smaller with time and arthritic damage, and the exit points from the side of the vertebra can also become smaller. What this does is put pressure on the nerve, and when a nerve has pressure on it, it won’t be able to function as it normally does, thus creating symptoms.
There are twenty-four vertebrae in the spinal column, seven in the neck, twelve in the thoracic region, and five in the lumbar region. At the base of the spine there is a fused bone called the sacrum, which leads into the coccyx, often referred to as the tailbone. Originally, many thousands of years ago, we did have tails but with evolution this has changed into a small fused coccyx at the base of the buttocks. The spine is designed to be curved from the side to give springy shock absorption when we are lifting, bending and twisting, and it’s supposed to be straight when we look at a patient from the front.
With 21st century demands, the spine and its curves will change and cause different weight distributions to go through different areas and is one of the main causes of arthritic bony change. The most common change in the spine we see is something called a forward head carriage where the cervical curve starts to straighten the head and starts to move forwards making the chin jut out. This is because of sitting for long periods, working behind computers and the emergence of the smartphone. The head is the weight of a bowling ball, if we start to lose the cervical curve it puts pressure on the front of the bones in the neck. This can then cause the cervical discs to come under stress including cervical disc herniations which are incredibly difficult to fix due to a close proximity to vital arteries and nerves running in the neck.
The spine moves in every direction and does what it is designed to do, which is provide support for the rest of the body. If we didn’t have a spine, there would be nothing for muscles and ribs to attach to and no protection for vital organs including the heart, lungs, liver, and pancreas.
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