SPINAL CONDITIONS AND TREATMENTS

Spinal stenosis (narrowing of the spinal canal) is a narrowing of the sagittal diameter of the spinal canal through which the spinal cord passes, the lateral recesses and foramina in the entire spinal canal or a narrowing in one or two vertebrae. It can be congenital or it could develop over time or with aging. Spinal canal narrowing is most common in the lumbar (lower back) and cervical (neck) regions.

The normal diameter of the lumbar spinal canal is 15-25 mm. The main problem with a narrow spinal canal is insufficient spinal canal diameter. If the sagittal diameter is less than 10 mm, this is called absolute narrowing; if it is between 10-13 mm, this is “relative narrowing”. A special region called the lateral recess opens into the spinal canal from the inner side. This distance should not be less than 3-4 mm. A narrowing of this region of less than 3 mm is suggestive of lateral recess narrowing, while a narrowing of less than 2 mm is considered diagnostic.

Factors such as age, trauma, thickening of the ligaments in the spine and changes in the joints may compress the nerve structures and cause narrowing in the spinal canal, but may not cause pain or show other symptoms until later and more critical stages of nerve compression and canal narrowing.

Although spinal stenosis can occur at any age, it usually starts to show symptoms after the age of 50. It is generally more commonly observed in men.

The L3, L4 and L5 of the spine are the levels more commonly affected. Patients often complain of intense back, hip, leg and calf pain. The spread is usually bilateral. Walking and standing for long periods of time trigger the pain. As patients increase the diameter of the spinal canal when they lean forward, and as widening of the spinal canal alleviates pain, over time, patients suffering from spinal stenosis generally begin to hunch forward while walking to relieve their pain. They also relieve pain by sitting. However, when the disease progresses, sitting and lying down cannot relieve pain. In advanced cases, persistent pain and problems with urinary and bowel movements may develop. For this reason, urgent urination and frequent urination in patients with spinal stenosis is considered an important sign for the need of immediate surgery. Patients in this situation are recommended to undergo surgery as soon as possible.

Patients with a narrow spinal canal have a long history of pain, which they can manage with medication for a while. As the stenosis of the spinal canal increases, it becomes impossible for the patient to be able to benefit from any non-surgical treatment. Surgical treatment is strongly recommended for these patients.

Age, latent onset, long-term history and bilateral involvement usually distinguish a narrow spinal canal from other spinal pathologies. Herniated discs usually occur in younger people. Pain distribution is mostly unilateral and neurologic (nerve compression) findings are more common.

Four-way X-rays, computed tomography and MRIs are used to diagnose a narrow canal. In 80% of these patients, electro-diagnostic tests (EMG) can show findings. These tests can also more accurately assist in surgical planning and show the areas where the compression can be eliminated.

Cervical Narrow Canal (narrowing of the spinal canal in the neck)

Spinal canal narrowing can affect both the neck and lower back at the same time. However, it is rare for both regions to be affected at the same time. In older people, the symptoms are associated with myelopathic changes in the neck (cervical myelopathy). Cervical myelopathy refers to loss of function in the arms and legs as a result of compression of the spinal cord in the cervical region. In many patients, cervical myelopathy progresses gradually over time. There may be impairment in the function of the hands. Patients report decreased dexterity, frequent dropping of objects, inability to fasten shirt buttons easily, and/or a deterioration in handwriting. There may be a loss of balance and the need to hold on to objects while walking. In advanced cases, severe weakness and numbness in the arms and legs may occur. In cervical myelopathy, there may rarely be impaired bowel or bladder control. Cervical radiculopathy is defined as pain that starts in the neck and radiates to a specific part of the right or left arm, forearm or hand. In many cases, pain may be accompanied by weakness of certain muscles of the arm, forearm and hand.

Spinal Stenosis Treatment

Drug therapy is the most common non-surgical treatment for patients with a spinal stenosis. Non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduce back and leg pain. Epidural steroid injections are used to reduce symptoms in patients who are not suitable for surgery or in patients who may not need immediate surgery. Corsets or other devices wrapped around the waist have no place in the treatment of a spinal stenosis.

Patients who have received adequate duration and dosage of drug therapy and epidural steroid injections but have not benefited are possible candidates for surgery. Physical therapy may be unnecessary and sometimes even harmful in patients with severe spinal stenosis. If weakness in the feet and problems with urination and defecation occur, urgent surgery should be planned for the patient. If such problems occur before surgery, there is a possibility that they may not improve after surgery. The basic surgical principle in spinal stenosis is to remove the pressure on the spinal cord and nerve roots (decompression) and to prevent bone and soft tissue elements from further compressing the spinal cord and nerve roots.

Instability (destabilization of the spine) may occur after decompression. If microsurgical or endoscopic surgical methods are not used and more facet joints (posterior joints of the spine) are removed than is necessary, the risk of spinal instability increases. In these patients, screws and rods are inserted with posterior instrumentation against the risk of instability. However, screws are not an appropriate approach for every patient. Today, the most current method for spinal canal stenosis is endoscopic surgery, which is performed through a 7 mm incision with the help of a camera. Since the normal structures of the spine are not disrupted using this method, screw and rod systems, commonly called platinum, are not required in the vast majority of patients. In our practice, this if the method we frequently use and is described in further detail in the relevant section.

The treatment of cervical spinal stenosis is similar to the treatment of lumbar spinal stenosis. Most patients with cervical radiculopathy are initially treated non-surgically. These typically involve modification of daily activities for a period of time. Patients should be aware that narrowing of the spinal canal predisposes them to myelopathy sometime in the future. Patients should be careful to avoid situations or injuries that put their spinal cord at risk. A short-term restriction of movement in a soft cervical collar may be helpful for some patients.

Similar to the lumbar region, cervical stenosis is treated surgically when other, non-surgical treatment options have failed. The surgeon may recommend surgery on the front (anterior), back (posterior) or both sides of the neck. The type of surgery is decided after determining factors such as: the exact pinch points on the spinal cord or nerve roots, the number of levels of compression, the alignment of the cervical vertebrae and the general medical condition of the patient. There are many treatment options available in surgery to include disc and bone removal from the front of the neck and fixation methods with metal cages and plates, and decompression methods such as laminectomy and laminoplasty from the back of the neck, followed by fixation methods with screws and rods or plate systems. The most current method used in cervical spinal canal stenosis is endoscopic, also known as closed surgery, performed with the help of a camera through a 7 mm incision. Since the normal structures of the spine are not disrupted using this method, screw and rod systems, commonly called platinum, are not required in the vast majority of patients. Endoscopic surgery also allows patients to return to their normal daily lives much faster than with traditional open surgery.

The lumbar part of the spine consists of five vertebrae and the cartilage (disc) between the vertebrae. The lumbar region (or the lower back) is the area that carries most of the body weight.

The vertebrae surround the spinal cord and protect it from damage. Lumbar disc herniation is a condition in which the cartilage between the vertebrae (also known as the disc) slips and tears as a result of severe strain (to include heavy lifting, staying in the same position for an extended amount of time, exposure to strain, suffering a fall, being overweight, having multiple births, etc.) and consequently compresses the nerves coming out of the spinal cord.

Symptoms of a herniated disc are as follows:

• Lower back pain
• Radiation of pain to the legs
• Difficulty walking and sitting
• Numbness in the feet
• Restriction in movements
• Difficulty in urinary retention
• Impotence

Non-Surgical Treatment Opions for Lumbar Disc Herniations

If a patient is diagnosed with a herniated disc, the doctor may recommend treatment such as rest, non-steroidal anti-inflammatory drugs (NSAIDs) to reduce the inflammation causing the pain, painkillers for pain control, physical therapy, exercise or epidural steroid injections.

If the herniated disc is not advanced and the patient needs to continue working, in addition to starting non-surgical treatment, the patient should ask his/her doctor for advice on how to carry out daily activities without putting additional excessive strain on the lower back.

The goal of non-surgical herniated disc treatment is to reduce the nerve irritation caused by the herniated disc and to improve the patient’s general condition, protecting the spine and improving overall functionality.

Among the first treatments that may be recommended by the physician for herniated discs is physical therapy. These sessions can reduce herniated disc pain, inflammation and muscle spasm and, later, facilitate the start of an appropriate exercise program.

Medication methods in lumbar disc herniations

Medicines to control pain are called painkillers (analgesics). In most cases, back and leg pain responds to common (over-the-counter) painkillers such as aspirin or acetaminophen. If the pain cannot be controlled with these medications, some analgesic/anti-inflammatory drugs called non-steroidal anti-inflammatory drugs (NSAIDs) may be added to control the inflammation caused by the herniated disc, which is the main source of the pain.

If the pain is severe and persistent, the physician may also prescribe narcotic analgesics for a short period of time. In some cases, muscle relaxants may be added to the treatment. The patient should be monitored by a doctor for side effects (such as upset stomach or bleeding, kidney problems, etc.) that may occur with long-term use of painkillers and NSAIDs.

There are also other drugs with anti-inflammatory effects. Cortisone drugs (corticosteroids) are sometimes prescribed for very severe back and leg pain because of their strong anti-inflammatory effect. It is important to understand that, like NSAIDs, corticosteroids can also have side effects.

Epidural Steroid Applications – Selective Nerve Root Block

Selective nerve root block is an extremely safe procedure when performed by experienced physicians. It is applied in patients with lumbar and cervical hernias, foraminal narrowing and narrow canal in the spine, but who do not require surgical treatment and have not benefited from medication and physical therapy. Since this procedure is a regional injection, the systemic side effects of cortisone are not experienced in this procedure. When it is performed locally on a single affected nerve, it is called a nerve root block.

The goal of this procedure is to reduce the inflammation around the nerve tissue due to hernia tissue or spinal cord narrowing, relieve the nerve and prevent the release of pain-causing substances.

This procedure is usually repeated 2 times at 20 days to 1 month intervals. It is performed a maximum of 3 times a year. It has very good results in the medium term. In some cases, with an appropriate lumbar rehabilitation program, it can be observed that the hernia does not recur and sometimes even regresses.

During this procedure, cortisone can also be applied to the nerves responsible for the sensation of pain in these joints and to the facet joints themselves to relieve the pain caused by the facet joints in the lower back. This is a very effective method in the treatment of lower back pain caused by facet joints.

Intradiscal Radiofrequency (RF) or Laser Nucleoplasty

Intradiscal radiofrequency or laser nucleoplasty are two procedures that aim to eliminate the compression caused by lumbar and cervical hernias using either radiofrequency or laser energy. These procedures are used as the gold standard in the treatment of small hernias that do not require surgical intervention.

The patient is prepared under completely sterile conditions in the operating room and the area to be treated is confirmed by entering the disc tissue with a thin guide needle with the help of imaging devices. A probe with a movable tip is inserted through the guide needle to deliver “bipolar radiofrequency” energy or “laser” energy. Since the tip of this probe is movable, the targeted, herniated area can easily be reached using the operating room x-ray. The procedure lasts about 2 minutes. This painless and non-surgical application without anesthesia is an effective method and shrinkage and contraction of the disc is achieved with radiofrequency or laser energy. As the disc shrinks, the patients is relieved of pain.

The patient can return home 1 hour after this procedure. After 2 days of bed rest, we recommend that the patient does not to stay standing for extended periods of time and to not lift heavy loads, especially in the first week after the procedure. These procedures are highly effective methods with a success rate of around 90% in suitable patients whose is solely suffering from a herniated disc that does not require surgery.

In addition to these two procedures, another widely used method for patients with this indication for lower back pain is using radiofrequency to ablate the nerves leading to the joints in the lower back as these nerves can be the source of the pain due to facet joint arthrosis. This is a highly reliable method, especially in patients who have had cortisone treatment in the facet joints and whose pain disappeared but then recurred, because this procedure results in the nerve causing the pain to be permanently burned, hence alleviating pain permanently.

Ozone Discectomy (Ozone Nucleolysis)

Ozone discectomy is the application of ozone gas into the disk. It is also called ozone nucleolysis. In suitable cases, the success rate of this procedure is over 80%. It is an outpatient procedure so the patient can return home the same day after the procedure. Ozone discectomy is a method that can be applied in hernia cases without neurological deficits, that is, without significant weakness in the arms or legs. It is a method similar to other intra-disc methods, but here, ozone is injected into the disc. The indications for use of ozone nucleolysis are the same as the indications for intra-disc radiofrequency applications. Complication rates are almost nonexistent.

Ozone, nucleoplasty and cortisone injections can be used in combination in non-surgical herniated disc treatments in suitable patients.

Surgical Treatment

The goal of herniated disc surgery is to prevent the herniated disc from putting pressure on the nerves and irritating them, thus causing complaints such as pain and loss of strength. The most common method of herniated disc surgery is discectomy (or partial discectomy). This method involves the removal of a part of the herniated disc.

It may also be necessary to remove a small part of the bone formation behind the disc, called the lamina, in order to see the disc fully. The herniated disc tissue is removed with the help of special graspers. After the disc fragment pressing on the nerve is removed, the irritation on the nerve diminishes soon after for a full recovery. Currently, this procedure is commonly performed through small surgical incisions using an endoscope (endoscopic discectomy) or a microscope (microscopic discectomy). The technique and advantages of endoscopic discectomy are described in detail in the related section.

As a result of aging and various stresses put on the body, the disc between the vertebrae loses its water content, and the disc begins to deteriorate and becomes unable to function properly. As the disc continues to deteriorate, the outer layer, called the annulus, may tear and the nucleus of the disc may come out of a tear in the outer layer, compressing the nerves and spinal cord and causing a cervical herniated disc. This mechanism is similar to the mechanism of a herniated disc formation and is the cervical equivalent of a herniated disc.

The most common symptoms of cervical disc herniation are as follows:

• Pain in the neck, back, arms and shoulders
• Tingling sensation
• Loss of strength in arms and hands
• Loss of sensation (numbness)
• Weak reflexes in the arms
• Thinning of the arm

Diagnosis

In addition to a clinical examination, a careful physical examination of any loss of strength, loss of sensation and abnormal reflexes is usually sufficient to diagnose a cervical herniated disc.

The diagnosis is confirmed with X-rays and MRIs. X-rays can show bone spurs (osteophytes) and narrowing of the disc spaces as the spine deteriorates over time, but they do not show the herniated disc or the spinal cord and its nerves. MRIs provide detailed visualization of all parts of the spine (vertebrae, discs, spinal cord and nerves) and is the most trusted method for diagnosing cervical herniated discs. In addition, electro-diagnostic tests (EMGs) can also be performed to look for signs of nerve damage.

Non-surgical treatment

Most patients with cervical herniated discs can improve without any treatment. For patients with persistent or recurring pain, there are different options for treatment. There are many medications available to reduce the pain associated with a cervical herniated disc. Many patients will improve with drug treatment and other conservative treatment options, without requiring surgical intervention. Your doctor could recommend rest, use of neck collars, non-steroidal anti-inflammatory drugs (NSAIDs) to reduce edema and inflammation, painkillers for pain control, physical therapy programs, exercise or epidural cortisone injections, cervical root blocks all of which are viable treatment options for cervical disc herniations.

The main goal of these non-surgical treatments is to reduce the inflammation of the nerve caused by the herniated disc as well as to relieve pain. After the onset of pain due to a herniated disc, short periods of rest may be helpful. It is important to start moving again after this short rest in order to prevent joint stiffness and muscle weakness. Physical therapists or physiotherapists can recommend specific movements and exercises to patients.

If the patient has severe and persistent pain, narcotic analgesics may be added for a short period of time. In some cases, muscle relaxants may also be added to the patient’s treatment.

Corticosteroid drugs (in the form of tablets or injections) are sometimes prescribed for very severe arm and neck pain because of their strong anti-inflammatory effect. Like NSAIDs, corticosteroids can have side effects. Physicians should provide the patient with detailed information about the benefits and risks of these medications.

Spinal injection methods in the treatment of cervical disc herniations

Spinal injections or “blocks” can be used to relieve very severe arm pain due to a herniated disc in the neck. These are doses of cortisone (corticosteroids) injected by a technically trained doctor into the epidural space (the space around the spinal nerves) or into the holes (foramen) where the nerve roots exit. The first injection may be followed by one or two more injections at a later date depending on the patient’s specific case. These are usually done as part of a rehabilitation and treatment program. The goal of this injection is to reduce inflammation in the nerve and disc.

Intra-discal Radiofrequency (RF) and Laser Nucleoplasty in the treatment of cervical disc herniations

Similar to their use in the treatment of lumbar herniations, intra-discal radiofrequency and laser nucleoplasty are two separate procedures that could be applied to eliminate the compression caused by cervical hernias by using radiofrequency or laser energy. They are used in the treatment of small hernias that do not require surgery.

The patient is prepared under completely sterile conditions in the operating room and the area to be treated is confirmed by entering the disc tissue with a thin guide needle with the help of imaging devices. A probe with a movable tip is inserted through the guide needle to deliver “bipolar radiofrequency” energy or “laser” energy. Since the tip of this probe is movable, the targeted, herniated area can easily be reached using the operating room x-ray. The procedure lasts about 2 minutes. This painless and non-surgical application without anesthesia is an effective method and shrinkage and contraction of the disc is achieved with radiofrequency or laser energy. As the disc shrinks, the patients is relieved of pain.

The patient can return home 1 hour after having this procedure. It is a very effective method of treatment if the patient is a good candidate and the success rates are high in patients who are solely suffering from a neck hernia that does not require surgery.

Ozone Discectomy (Ozone Nucleolysis) in the treatment of neck hernia

Ozone discectomy is the application of ozone gas in varying doses to the neck for the treatment of neck hernias. It is also called ozone nucleolysis. There is over a 80% success rate when applied in appropriate cases. The patient can return home soon after the procedure on the same day. Ozone discectomy is a method that can be applied in hernia cases where there is no neurological deficit present, that is, without significant weakness in the arms. Although it is a similar method to other intra-disc treatment methods, in this procedure, ozone is injected into the disc. The indications for use of ozone nucleolysis are the same as those for intra-disc radiofrequency (RF) and laser applications. Complication rates are almost negligible.

Surgical treatment methods for cervical hernia

Surgical treatment is usually recommended for patients who are diagnosed with a cervical hernia but do not benefit from other, non-surgical treatment methods. The goal of cervical herniated disc surgery is to remove the part of the disc that is compressing the nerve. This is done by a procedure called discectomy. Depending on the location of the herniated disc, the surgeon makes an incision in the front or back of the neck to reach the spine.

The decision of whether to perform the operation from the front or back of the neck is determined by many factors including the location of the herniated disc and the surgical experience of the surgeon. In both the front and back approaches, the part of the disc pressing on the nerve is usually removed successfully. In the anterior approach, since the entire disc is removed in order to reach the herniated disc, a fusion procedure is usually necessary in the same session. With recent advancements in medicine, it is also possible to perform this procedure endoscopically using the minimally invasive technique that only requires a 7 mm incision. This method can also be applied from both the front and back of the spine. Determining the more appropriate method depends mainly on the patient’s condition. Detailed information about this method is described in the “Endoscopic Cervical Discectomy” section on our website.

Spinal fusion with cage in cervical disc herniation – Cervical Disc Prosthesis surgery

The most important disadvantage of spinal fusion surgery is the loss of movement in the treated area. However, fusion surgery performed at a single level does not create a loss of movement in the neck as the movement of this segment is tolerated by adjacent intact segments. However, it overlaps these intact areas. For this reason, it may cause wear and tear of these areas as well as neck hernia and pain in the future. With advancements in technology, removable prostheses can be placed where the disc has been removed. This can also be an alternative treatment option instead of applying fusion. However, prosthesis application is not suitable for every patient. Young patients who do not have calcification in the facet joints located behind the spine and whose disc space height is relatively preserved are the most suitable patients for disc prosthesis.

Spondylolisthesis is when a vertebra slips forward on the vertebra below it, while retrolisthesis is when it slips backwards, for any reason. In patients over the age of 50, spondylolisthesis can often be accompanied by canal narrowing. Slipped vertebrae are usually seen in children and middle-aged people.

Patients with slipped vertebrae usually have pain in the lower back and hips. The intensity of these pains increases when bending forward and decreases when bending backwards. Cramps in the legs after standing for a long time or in the evening may also be among the symptoms of a slipped vertebra. In cases where the amount of slippage is more intense, a hollowing and stepping behind the lower back can be seen.

In the diagnosis of spondylolisthesis, tests with MRI and mobile X-rays are used. MRI scans in various positions can be used to determine whether or how much the vertebrae have slipped.

Patients diagnosed with slipped vertebrae receive medical treatment before surgery. The severity of the pain and how much the vertebra has slipped are important factors for treatment. The doctor may ask the patient to reduce daily activities. If necessary, the doctor may also recommend a lumbar brace. A lumbar brace can help reduce pain and relieve spasm. Epidural cortisone injections may also help with pain management.

Physical Therapy and Rehabilitation Methods

The goal of a rehabilitation program is to strengthen the muscles in the area. With physical therapy and rehabilitation, the short muscles and tense muscles around your hips are lengthened and the slipped vertebrae are expected to become more durable and stable.

When is surgical treatment necessary for slipped vertebrae?

Surgery may be necessary depending on the severity of the slipped vertebra and the patient’s complaints. However, it is important to remember that surgery is recommended if the pain and symptoms are beyond the scope of non-surgical medical treatment. Difficulties in walking, functional disorders of the bowel and bladder, and significant compression of the nerves may also require surgery.

Indications for surgical treatment are as follows:

• Persistent pain that does not respond to non-surgical treatment
• Development of neurological lesions
• Displacement of more than 50% of one vertebra on the other vertebra
• Progression of slippage
• Associated instability of the spine
• Development of a pronounced posture disorder

Surgical treatment options vary according to the type and degree of spondylolisthesis. The presence of neurological involvement may also change the surgical technique to be used. In surgical treatment, the vertebrae are fixed together to prevent the progression of slippage. If there are neurological symptoms, the nerves in the slipped area are decompressed. Surgery can be performed from the front or back or from both sides. Postoperative rehabilitation programs support the healing process. Modern medical advancements also allow for surgical treatment to be performed with minimally invasive or endoscopic methods.