BACK AND NECK PAIN 7/12/00 11:11 am Page 1

Back and neck pain

Spinal degenerative disease and related disorders

£3.00 (free to people affected by neurological disorders, their relatives and carers)

ISBN 1 901893 07 3
A BBSF Neurological Disorders Booklet
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Back and neck pain Contents

Spinal degenerative disease and related disorders

Published by the British Brain and Spine Foundation Page

©British Brain and Spine Foundation 1998
Reprinted (3) 2000 Acknowledgements 2
ISBN 1 901893 07 3 Introduction 2
British Library of Cataloguing in Publication Data What causes spinal pain? 3
A catalogue record for this book is available from the British Library Why do I experience different types of pain? 5
Editor, BBSF Neurological Disorders Series: M Alexander CBiol MIBiol What other symptoms can develop? 6
Photographs and images: Michael Nelson and Chris Priest How common are spinal problems? 7
Medical illustrations: Philip Wilson FMAA AIMI
Cover design: Carter Wong and Partners Could it be something serious? 8
Print: Clifford Martin Press What will happen if the pain is not treated? 9
What do the various words used by doctors mean? 10
British Brain and Spine Foundation What tests can be performed? 11
The British Brain and Spine Foundation aims to maximise the quality of life for How is spinal pain treated? 14
people with neurological disorders and to reduce neurological disability by
providing a national focus for research, education and information.
When is an operation necessary? 16
What do you recommend, doctor? 17
What does surgery involve? 17
Who should perform my operation? 19
British Brain and Spine Foundation What are the drawbacks of surgery? 19
7 Winchester House What is the recovery period? 20
Kennington Park
Cranmer Road What if surgery fails? 21
London SW9 6EJ What advances are likely in the future? 22
Telephone: 020 7793 5900
Fax: 020 7793 5939 Conclusions 23
Glossary 24
E-mail: info@bbsf.org.uk Other organisations that may be able to help 29
Registered charity no.1010067
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Acknowledgements
The British Brain and Spine Foundation would like to thank Mr Graham
Flint, Consultant Neurosurgeon, Neuroscience Centre, Queen Elizabeth
Hospital, Birmingham, who has written this booklet, and Mr R J C Laing,
Consultant Neurosurgeon, East Anglian Neurosurgery and Head Injury
Service, for his invaluable assistance with this project.
British Brain and Spine Foundation, 1998
Introduction
Lower back pain and neck pain are extremely common and occur more often as
people get older. They can affect not only the physical health of the individuals
concerned, but also their social and economic wellbeing. Although a source of
considerable anxiety, spinal pain and its related problems can usually be
managed successfully without surgery. With guidance, most people can learn to
cope with episodes of pain themselves and take measures to reduce the
likelihood of recurrences.
This booklet is for patients, employers and health care workers who need to
know more about the prevention and treatment of spinal pain.
Note: Words printed in bold are explained in the glossary on page 24.
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What causes spinal pain?
Muscular
In everyday life, many short-lived episodes of spinal pain, particularly lower
back pain, result from strains or other injuries to muscles and ligaments. These
may be caused by sports injuries or, not uncommonly, an unaccustomed
increase in an individual’s physical activity. Viral infections (’flu-like illnesses)
are often accompanied by muscular pain, including neck and back pain,
referred to medically as myalgia.
Degenerative changes
The spine is made up of individual bones or vertebrae which are joined
together by the intervertebral discs, as well as other joints and ligaments, to
form a strong but flexible structure (see figure 1). During middle age and
beyond, the commonest cause of spinal pain, besides purely muscular pain, is
wear and tear of the intervertebral discs and the associated joints of the spine.
These so called degenerative changes are caused by movement, and are
therefore more common in the neck (cervical) and in the lower (lumbar)
parts of the spine. The region between these areas, the thoracic spine, is
splinted by the rib cage and is relatively immobile.
Wear and tear affects the joints of the spine in a number of ways. Being
biological structures, they respond initially to any form of damage by trying to
repair themselves. Unfortunately, whilst nature is able to effect remarkable
repairs in many circumstances, the process is not too successful with the joints
of the spine. As a result, the regular, healthy structure of youth becomes more
irregular with age, as discs bulge, ligaments buckle and bony spurs form. The
spinal cord and the nerves issuing from it, which originally ran through smooth
canals and channels, may be nipped or compressed by the various irregular
surfaces that have developed.
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Injuries
People frequently link the start of their back or neck pain to an accident, often
one occurring at work, but the sort of accidents that cause this sort of pain are
equally likely to occur working in the garden or in the garage at home, or even
getting into or out of a car. In many cases a particular movement causes a
sudden onset of pain, but it is important to realise that, in most circumstances,
the ‘accident’ was merely the trigger which revealed the presence of an existing
degenerative problem affecting a segment of the spine. In other words, the
accident caused the problem to become symptomatic. In the case of neck
pain, for example, people often first experience symptoms when they wake up
one morning with a stiff and painful neck.

People sometimes ask whether heavy manual work can accelerate the natural
process of degeneration of the spine. This question is difficult to answer with
certainty, although the action of repeatedly loading and twisting the lumbar
spine may advance degenerative changes in lumbar discs. Weight lifters, for
example, are not particularly prone to disc problems, whereas gymnasts are.

One particular injury which can cause a good deal of distress is the so-called
‘whiplash’, or hyper-extension injury of the neck. This most commonly results
from rear-impact road traffic accidents. Affected people may experience
persisting neck pain, with or without symptoms in the arms, for many months
or even years after the accident. Often there is little to be found when the
person is examined, and even special investigations and scans may yield
negative results. This does not mean that the pain is unreal or imagined and
people usually complain of a consistent and recognisable pattern of symptoms.

Why do I experience different types of pain?

The actual spinal pain or ‘local’ pain of spinal degenerative disease can stem
from a number of structures. The outer part of the intervertebral disc, the
annulus, has a nerve supply and is sensitive to injury. Minor splits or larger
tears in the annulus and the resultant bulging of the disc itself (herniation)
can all generate a good deal of local spinal pain. Furthermore, each
intervertebral disc is coupled with a pair of facet joints, which regulate
movement of the disc. When a disc bulges it loses height and the facet joints
become slightly displaced. They then become inflamed, producing a localised
Figure 1: Diagram showing a side view of the spine with a close-up of the
spine and spinal ligaments
form of arthritis. This also causes pain, experienced in the spine but often felt

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on one side or the other, rather than in the mid-line. Finally, when discs bulge
and facet joints displace, the muscles of the spine may go into spasm and
themselves become a source of pain.
In addition to local discomfort a person may experience what is called referred
pain. This is pain which is felt in a different part of the body than that from
which it actually originates. For example, pain arising in the facet joints may be
experienced in the shoulder and upper arm (in the case of neck disorders) or in
the bottom and the thigh (in the case of lumbar disease). The reason for this is
that some parts of the body are able to get clearer pain messages to the brain
than others. The skin, for example, is able to transmit very precise information
to the brain, whereas internal organs, including bones and joints, have poor
links with the brain. As a result, pain arising from internal structures may be
interpreted by the brain as coming from a site remote from its actual source.
The third type of pain is neuralgic or nerve pain, which is very different from
the other two sorts of pain described. It is usually sharp or shooting in nature
and is often likened to an electric shock, although it can also be a gnawing and
burning sensation. When this sort of pain occurs in the spine it results from
pressure on nerves and commonly spreads to the arm or the leg (from the neck
or lumbar regions respectively). This sort of pain has what doctors call
‘localising value’. This means that the distribution of the pain reveals its level
of origin in the spine.
What other symptoms can develop?
Abnormal sensations
Besides pain, an individual may experience numbness or tingling in an arm or a
leg, sometimes both. Such symptoms may be caused by compression of nerve
roots, and can also help doctors diagnose the source of a problem, particularly if
the abnormal sensation is confined to part of the limb or certain fingers or toes.
Muscle weakness
Occasionally a person will experience weakness in a muscle group in the arm or
leg, which may affect hand or foot movement. This too can have a localising
value for the doctor. It may also have implications for treatment, especially if
more widespread and disabling weakness develops. Sometimes a person may
feel as if a whole limb is weak when, in fact, muscle power is good. This is
6 7
usually due to pain inhibiting limb movement.
Bladder, bowel and sexual function
When nerves are trapped by slipped discs or bony spurs it is usually only one
nerve that is affected. Occasionally, however, a number of nerves are involved,
or the spinal cord is compressed. In these circumstances there may be
disturbance of normal bladder and bowel control or sexual function may be
affected. There may be other explanations for such symptoms, for example
women who have had children may often experience minor difficulties with
bladder control later in life. Older men may also have bladder problems due to
enlargement of the prostate gland. In general, however, doctors will prefer to
investigate such symptoms as a matter of urgency, particularly when they occur
together with other features suggesting trapped nerves.
Giddiness
There are many causes of giddiness which are unrelated to spinal problems, but
sometimes wear-and-tear changes in the vertebrae can result in compression of
one or both of a pair of arteries in the neck, known as the vertebral arteries.
The problem is usually managed simply by avoiding those neck movements
which bring on the giddiness.
How common are spinal problems?
Spinal degenerative disease is not a life-threatening condition and being part of
the normal ageing process, it is not curable. As a result it is extremely
widespread, becoming more common as people get older. It is estimated that
back pain alone affects about one in five of the population at any one time, and
that 80 per cent of people will experience back pain at some time in their lives.
The effect on economic activity is considerable, with back pain being
responsible for up to five per cent of all time off work. Neck problems,
although less common, also account for a good deal of suffering in the
community at large.
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Could it be something serious?
Most cases of spinal pain are the result of the wear-and-tear changes described
above, but there can be other causes. Doctors use the term differential
diagnosis to refer to the various disorders which may cause a particular
symptom to occur.
Internal organs
Disorders of internal organs can generate referred spinal pain (see page 6),
usually lower back pain. Ulcers, gall stones, kidney disease and disorders of the
uterus (womb) can all produce such pain. Sometimes disease of the major
blood vessels can cause back pain. It is rare for internal organs to cause neck
pain.
Nerves
Very occasionally, certain tumours, tumour-like structures or cysts may develop
in the spinal canal and compress the nerves within the canal. They may also
generate local spinal pain.
Bones and joints
Apart from degenerative changes, other conditions can affect the bones and
joints of the spine and are capable of producing back pain or neck pain.
• A person may be born with a structural abnormality of the bones or joints,
referred to as a congenital defect.
• A variety of arthritic conditions can affect the joints of the spine.
• The vertebrae can become infected by bacteria. This is rare.
• Tumours sometimes grow in the bones of the spine, a problem usually seen
in patients already known to have certain forms of cancer.
• In older people the vertebrae can be affected by osteoporosis, which
weakens the bones.
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What will happen if the pain is not treated?
People naturally worry about spinal disease getting steadily worse. In the case
of spinal degenerative changes, however, the natural history is for the wear-
and-tear changes to continue as we grow older. Fortunately, the symptoms don’t
directly mimic this progression, and most people experience only short-lived
episodes of discomfort. Even pain which persists over a long period will tend to
subside over the years.
The effect of symptoms on an individual is governed in part by his or her age
and level of activity. Spinal degenerative disease takes its greatest toll in the
working years of life. In retirement, when people are less active, the discomfort
is often less intrusive.
Even when we know that spinal pain arises from degenerative changes and not
from something more sinister, symptoms still produce a good deal of anxiety for
the affected person. The worry combined with the pain may generate an
overall level of distress which can at times become intolerable. Although in
most cases degenerative disease does not become ‘disabling’, the pain remains
unpleasant and it can certainly interfere with an individual’s ability to earn a
living, causing further concern and anxiety.
Whiplash
The neck pain associated with whiplash injuries, referred to medically as hyper-
extension injuries, can often persist and remain intrusive for many months or
even years after the injury - 20 per cent of people who sustain such an injury
continue to be troubled for two years or more. Often medical examination and
investigations reveal no abnormalities, and an affected person may feel that he
or she is perceived by others, particularly doctors, as being a malingerer.
Fortunately, in most cases, the symptoms do not get any worse and, if anything,
will gradually improve with time.
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What do the various words used by doctors mean?
A glossary is provided at the end of this booklet to explain the medical terms
which are printed in bold type in the text, but a number of expressions are
worth special mention.
Spondylosis
Translated literally, this word means ‘disease of a vertebra’ and could include
any of the conditions discussed above. By convention, the term is reserved for
the degenerative (wear-and-tear) changes discussed in detail in this booklet.
Doctors themselves are not always very accurate with their terminology,
particularly when talking to patients. The word spondylitis is often used
instead of spondylosis, although strictly this word refers to inflammation of the
spine. Inflammation of the small joints between adjacent vertebrae does indeed
occur as part of the overall degenerative change, but is seldom the only
problem. For the same reason the term ‘arthritis’ is inappropriate for
describing spondylosis. Although doctors often mention arthritis in an attempt
to reassure patients that the disease is not sinister, this well-meant gesture can
backfire because the word often conjures up visions of a severe deformity
affecting all joints. The term ‘localised arthritis’, the result of intervertebral
disc disease, is perhaps more appropriate and reassuring.
Acute and chronic
In everyday use these words are often used to indicate that pain is severe and
unpleasant. In medical terminology they have a more specific meaning:
• Acute means that symptoms have developed fairly suddenly and last a
short time.
• Chronic means that a condition has been present for some time.
For example, degenerative changes in the spine may be chronic, having been
developing over several years. Symptoms caused by such changes may, on the
other hand, be acute, having been present for only a short time.
Slipped disc
This term produces visions of a disc having become displaced from its normal
position between two vertebrae. People sometimes assume that surgery, or
other forms of treatment such as manipulation, put the disc back in place.
They are often concerned that the disc will become displaced again. In fact
10
what happens is that only part of the disc bulges, but it may then trap a nerve.
In most cases this bulge gradually shrinks over a period of time, the nerve is
released and the problem resolves naturally. Surgery, when performed, removes
the bulging part of the disc, relieving the pressure on the trapped nerve.
Spinal stenosis
This term refers to a general narrowing of the spinal canal over several
segments causing pressure on the nerves in that region. The problem develops
gradually over several years. The structural changes which occur cause a
different pattern of symptoms from other forms of spinal degenerative disease.
Older people tend to be affected most often. They have little discomfort at
rest but problems develop when they begin to walk. This condition tends to
be progressive, rather than fluctuating.
What tests can be performed?
In the majority of cases an experienced doctor can diagnose the cause of spinal
pain by clinical features. By this we mean a person’s symptoms and the
physical signs noted during an examination. When there is doubt a variety of
special investigations can be carried out.
X-rays and blood tests
A combination of simple blood tests and plain radiographs - the proper name
for X-ray pictures - will usually rule out any serious diseases or other conditions
that require urgent treatment. Certain rare disorders affecting the nerves will
not show up and sometimes more detailed investigations are needed,
particularly if a person’s symptoms do not settle down in a reasonable period of
time.
MRI scanning
MRI or Magnetic Resonance Imaging is the most advanced way of producing a
picture of the spine, as well as other parts of the body. It relies upon high-
powered magnetic fields and radiowave energy, rather than X-rays or other
potentially harmful forms of radiation. As far as we know, the energy forms used
in MRI scanning have no harmful effects on body tissues.
MRI scanning produces high-quality images and can effectively be used to
diagnose most cases of spinal degenerative disease, as well as ruling out more
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serious disorders. The equipment is very expensive but it is gradually becoming
more widely available and in time will become the principal means of
investigating spinal pain after plain radiographs and blood tests.
Figure 2: A patient being prepared for an MRI scan
CT scanning
In units where MRI scanning is not available, CT scans still provide a useful
means of investigating spinal disorders. Equally valuable when introduced, CT
imaging is rapidly being replaced by MRI scanning in the diagnosis of spinal
disorders. CT scans do, however, still give better detail of bone and may be
preferred to MRI in some circumstances.
Myelography
For many years myelography was the only special investigation available to
doctors to investigate spinal disorders. It involves the injection of a contrast
medium (often referred to as a ‘dye’) into the spine. The patient is then
tipped up and down on an X-ray table while radiographic images are taken. The
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technique is invasive, which is why modern scanning techniques are now
preferred. Myelography nevertheless still has a role to play on occasions.
Media publicity about a condition known as arachnoiditis resulting from
myelography caused a good deal of concern at one time among patients who
had undergone this form of investigation. It is true that use in the past of a
contrast medium known as Myodil may have caused the later development of
unpleasant symptoms in a small proportion of people. Most patients who
received Myodil were, however, unaffected. Furthermore, modern contrast
materials, in use for the past 15 years, do not cause arachnoiditis.
Other investigations
Sometimes electrophysiological tests are used to investigate the functioning of
individual nerves. These tests involve low energy electrical stimulation of skin
and muscles. They cause only minor discomfort and are usually performed on
an out-patient basis.
The technique of discography involves injection of a contrast medium into
the intervertebral disc itself. X-ray images then show the structure of the disc.
The investigation is carried out on an in-patient basis. It is somewhat
uncomfortable at times but, by reproducing a patient’s pain, a doctor can often
gain useful information about its site of origin.
A simpler form of scanning, known as isotope scanning, is occasionally used to
look for generalised disease processes that can affect the spine as well as other
bones.
Sometimes various investigations are combined, for example CT scanning may
be performed after myelography or following discography.
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How is spinal pain treated?
Most episodes of spinal pain are short-lived and will settle down rapidly
without specific treatment. Doctors refer to such conditions as being self-
limiting. If the pain is particularly intense or persists then more specific
treatment may be needed.
Tablets
Many people are reluctant to take tablets for fear of becoming dependent upon
them, but simple pain killers such as aspirin or paracetamol, taken for short
periods, are often very helpful. Another group of pain killers known as non-
steroidal anti-inflammatory drugs, are particularly effective in dealing with
spinal and muscular pains. Some of these are available over the counter at
pharmacies, but others require a prescription from a doctor. You should be
careful when using this type of pain killer if you suffer from indigestion or
asthma.
Rest
In the past, prolonged periods of rest were prescribed for acute spinal pain.
The current approach is to limit this period, because it is now appreciated that
prolonged rest leads to stiffening of the facet joints and wasting of the muscles
which support the spine. Short periods of bed rest, perhaps four or five days,
are appropriate for severe episodes of lower back pain. Likewise, for acute neck
pain, a collar may be used for a few days. Note that it is unsafe to drive a car or
motorbike while wearing a collar and people doing this may have difficulties
with insurance claims in the event of an accident. The use of external supports
(corsets or collars) for long periods is undesirable.
As the acute pain subsides it is best to begin moving the affected parts again. If
this proves difficult or painful then specialist consultation or further
investigation may be required.
Physiotherapy
Physiotherapy has been the main way of treating spinal pain for many years,
despite occasional questions about its effectiveness. Most people feel much
more confident about managing their spinal pain if they first receive expert
tuition from a physiotherapist. Physiotherapists can also make very competent
clinical assessments and will refer people to specialists if necessary.
Physiotherapy exercise regimes, if followed regularly, can prevent an acute
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spinal problem from developing into a chronic and disabling condition.
Manipulation
Various manipulative techniques are used by physiotherapists, chiropractors and
osteopaths. Pain relief may be achieved by the small joints of the spine being
moved, but it is unlikely that these techniques will have any immediate or
direct effect upon disc prolapses. People often apologise to doctors about
having seen osteopaths or chiropractors. There is no need for this because
there is no doubt that such techniques can be valuable in treating acute spinal
pain. A responsible practitioner will know when manipulation is inappropriate
and will then refer a patient on to a medical specialist.
Injections
A number of injection techniques can be used to relieve spinal pain. Local
anaesthetics and anti-inflammatory agents (steroids) are injected, either into
the epidural space or around the spinal facet joints. These injections aim to
reduce inflammation and lessen acute pain while natural healing deals with the
underlying problem, which may be a torn annulus, a bulging disc or an inflamed
(arthritic) facet joint.
Do’s and don’ts
Once acute symptoms have subsided it is important that measures are taken to
reduce the likelihood of further episodes of pain and to prevent the acute
problem becoming a chronic one. Lifting excessive loads should be avoided,
particularly when the problem is lower back pain. Twisting and loading the
lumbar spine at the same time is particularly likely to cause problems. Any
awkward movements of the back or neck may bring on symptoms. Active
measures should also be taken to strengthen the muscles of the spine. Good
physiotherapy tuition will include a programme of specific exercises for the
back or neck, and maintaining strong spinal muscles will take some of the strain
off the discs, joints and ligaments, making them less vulnerable to physical
loads.
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When is an operation necessary?
The simple answer here is very infrequently, particularly when we consider how
many people suffer from spinal pain. On the other hand, some people reading
this booklet may have reached the point where they are wondering if an
operation could help them. Even then, surgery is rarely essential, but it may be
an option to consider. It is only essential in certain rare circumstances.
Multiple nerve compression
Surgery is seldom performed for lower back pain or neck pain alone. It is
occasionally needed when a single nerve is trapped (see below). When,
however, there is significant compression of several nerves, with resultant
disturbance of major functions - particularly control of the bladder, bowels or
sexual function - then an operation is essential to prevent long-term disability.
Such circumstances arise when the spinal cord is compressed in the neck or the
cauda equina is compressed in the lumbar spine.
Persisting acute pain
Most episodes of acute spinal pain, with or without limb pain, resolve naturally.
Sometimes, however, pain can persist at quite an intense level, sufficient to
prevent the person from carrying out any normal activity. Although there is no
immediate threat of serious physical disability, surgery may be performed to
decompress the nerve in order to relieve such severe symptoms.
Recurrent pain
Many people suffer recurrent episodes of pain, particularly if they have not had
expert physiotherapy tuition, and sometimes in spite of such assistance. In
such circumstances surgery is entirely optional but is a reasonable course to
consider. A person may decide to have surgery if the pain is sufficiently intense
or has been present for too long. In making a decision the individual needs to
balance the negative effect of the pain on work, recreation and normal daily
activities against the potential drawbacks of surgery (see below). The
alternative to surgery is continued conservative treatment and expectant
management. Such an approach will eventually lead to a resolution of the
problem but usually after several months.
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What do you recommend, doctor?
Patients sometimes put this question to their specialist. Unfortunately it
cannot really be answered meaningfully, even if the doctor has personal
experience of spinal pain. The reason is that one individual cannot experience
another person’s pain. In most cases it is the combined intensity and duration
of pain, and the effect upon an individual’s lifestyle, which determines whether
or not they take up the surgical option.
What does surgery involve?
The main aim of surgery is to relieve compression of trapped nerves.
Occasionally there may be associated problems with stability of the spine and
the surgeon may then have to undertake additional measures to deal with such
difficulties. Generally, however, there is a desire to minimise the extent of
surgery with advantages both to the patient, in terms of early discharge from
hospital, and to health authorities in the form of reduced costs.
Laminectomy
This operation involves the removal of the arches of bone at the back of the
spine, usually over a number of spinal segments. By doing this, the surgeon
gains wide access to the spinal canal and its contained nerves. The operation
can be performed in the neck or the lumbar region and is used when there is a
narrowing of the spinal canal over more than one level, the condition known as
spinal stenosis. This procedure creates a fairly long wound, with extensive
separation of the spinal muscles, causing a fair amount of discomfort for several
days after the surgery.
Discectomy
This term refers to the removal of an intervertebral disc, but the operation
never involves the extraction of an entire disc. Only part of the disc is taken
away, but this will include that part which is bulging and compressing the
nerve. Usually this consists of some of the annulus and a good deal of the
softer material from the inside of the disc, the nucleus. Remaining degenerate
nuclear material is also extracted from inside the disc to lessen the chances of
recurrent problems. Sometimes other structures, such as thickened ligaments
and bony ridges, contribute to the problem and it is important for the surgeon
to identify and remove these. Although usually referred to as ‘disc surgery’,
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this operation should really be thought of as the decompression of a trapped
nerve.
Discectomy can be performed in the neck as well as the lumbar spine. In the
lumbar region the operation is usually performed from the back but cervical
discectomy is most commonly performed from the front and is known as
anterior cervical discectomy.
Microdiscectomy
This term is used to describe a refinement of conventional discectomy where
an operating microscope is used and disruption of body tissues is reduced even
further.
Percutaneous surgery
Herniated intervertebral discs may bulge to varying degrees. Sometimes the
annulus of the disc is completely torn and nuclear material escapes into the
spinal canal. An open operation is then needed - that is one involving a
general anaesthetic and an incision of the body tissues. In a minority of cases
the disc bulge is contained, which means that the annulus is not completely
disrupted. In these circumstances it may be sufficient to pass fine instruments
into the disc via a steel tube which itself is passed through the skin. This can
be done under local anaesthetic. This procedure is far less traumatic to the
body tissues and, although it causes some discomfort, recovery is generally
rapid.
Chemonucleolysis
This may be used as an alternative to percutaneous surgery to treat a contained
disc bulge in the lumbar spine. A needle is passed through the skin into the
disc. A substance is then injected which chemically ‘digests’ the nucleus,
reducing the tension in the disc and thereby releasing the trapped nerve. The
technique is even simpler than percutaneous discectomy but can sometimes
produce a good deal of back pain lasting for up to two weeks after the injection.
Fusion
This operation involves fairly extensive surgery, more than for simple
discectomy or even laminectomy. The aim is to make two (or more) adjacent
vertebrae fuse together. Bone needs to be taken from one part of the body and
placed between the vertebrae involved. Natural healing processes - the same
processes that allow broken bones to heal - bring about fusion of the vertebrae.
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With surgery of such magnitude fusions have only limited use in the treatment
of degenerative disease of the lumbar spine. They may be called for when there
is clear evidence of instability of the spine, but are used only occasionally to
treat back pain in the absence of instability.
Fusions can be performed more readily in the neck, and results are more
reliable than in the lumbar spine. The operation also involves manoeuvres
which bring about the release of trapped nerves. Cervical fusions are therefore
performed more often, comparatively speaking, than lumbar fusions.
Who should perform my operation?
Patients are sometimes confused about whether they should see an orthopaedic
surgeon or a neurosurgeon. The spine is an area of ‘territorial overlap’ between
these two surgical disciplines. Some spinal operations fall entirely in the realm
of the orthopaedic surgeon, for example correction of major bony deformities.
Other conditions are solely the responsibility of neurosurgeons, for example
cysts or tumours within the spinal cord itself. Occasionally the combined skills
of both specialists are needed. There remain a number of conditions which
can be dealt with adequately by either specialist and uncomplicated disc
herniations form the commonest example. In general, degenerative disease of
the neck is more likely to be referred to a neurosurgeon while the more
complex disorders of the lumbar spine, particularly those requiring fusions, will
probably be dealt with by an orthopaedic surgeon.
What are the drawbacks of surgery?
Inevitably an operation involves a certain amount of inconvenience and
discomfort for a patient. There are also risks associated with any surgical
procedure. It is never possible to guarantee a successful outcome from surgery
and no operation can ever be made totally safe. Most people are aware of this,
even if they choose to put such thoughts from their mind at the time of their
operation. It is nevertheless important that a person considers these matters
carefully when deciding whether or not to submit to surgery. The risks of
surgery should, however, be kept in perspective, bearing in mind that many
human activities carry some risk, even crossing the road. Before making a
decision the individual should understand fully the reasons for the operation
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being performed and the potential benefits as well as the attendant risks, and
should discuss any concerns with their surgeon.
One ‘risk’ of surgery is that the pain may not diminish afterwards. Although the
discomfort might not be any more intense than it was before surgery, the sense
of disappointment may increase the overall level of distress.
Lumbar surgery
A common fear with lumbar surgery is that major paralysis or incontinence
could be caused. Statistically, the likelihood of such complications developing
is very small, but in a difficult case a patient may develop lesser problems,
particularly if surgery has been performed previously. There may, for example,
be a degree of weakness of one muscle group, or a patch of numbness may
develop. Difficulty with passing urine occurs very occasionally. Once again,
any anxieties about such complications need to be discussed with the surgeon
before an operation is performed.
Cervical surgery
The risks accompanying operations on the cervical spine are potentially more
serious. Indeed, there is the possibility of a total catastrophe in the form of
permanent paralysis affecting the arms and legs. For this reason surgeons do not
embark upon such operations without good reason. The risks are statistically
small, but again must be fully discussed prior to the proposed surgery.
What is the recovery period?
Wound healing
Any operation, however carefully performed, has an impact on the body as a
whole. The body does not distinguish between an accidental wound, a war
wound and a surgical wound. All of these injure tissues and cause complex
chemical alterations, called metabolic changes. The extent of these changes
and their effects upon the individual depend to some degree on the extent of
the surgery, but even relatively small wounds, such as microdiscectomy, may
disturb the body chemistry for up to a month. During this time an individual
will feel somewhat ‘washed out’ or ‘lacking in energy’. The old-fashioned term
convalescence describes this phase of recovery. After about four to six weeks
most people will begin to feel normal again.
20
Work
The time to return to work following surgery varies considerably from one
person to another and depends on a number of factors, including economic
circumstances and an individual’s level of motivation. It is usually acceptable
for somebody to be off duty for up to six weeks, but by three months most
people should be able carry out a normal day’s work. A job involving particularly
heavy physical work might need a longer period of recovery, perhaps six months.
Sports
Activities which do not load the spine, for example swimming, can be started
again at a relatively early stage, perhaps six weeks after surgery. More vigorous
sports, particularly those involving twisting and loading, for example tennis and
skiing, should only be started again when the body tissues have healed fully.
This will take up to six months in most cases. Remember that you should get
fit to play sports, not play sports to get fit.
What if surgery fails?
Occasionally, symptoms are simply no better after surgery. Sometimes, after
initial improvement, pain may recur. The surgeon will then re-evaluate
matters. There may have been an initial diagnostic error or a fragment of
herniated disc material may have been missed during surgery. On other
occasions, despite adequate decompression in the first place, further disc
material prolapses. This is known as a recurrent herniation. A number of
options are available if surgery is unsuccessful.
Repeat investigation
MRI imaging is the best means of re-investigation and is often accompanied by
an injection into a vein to help distinguish post-operative changes from other
features on the scan. Any of the other investigations described in the earlier
sections of this booklet may also be recommended on occasions.
Revisional surgery
An obvious missed or recurrent disc herniation may lead the surgeon to
recommend re-exploration of the spine. The decision to carry out further
surgery has to be considered carefully because, statistically, the chances of a
second operation succeeding when a first failed are not particularly high and
they decline with each successive operation.
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Pain relief clinics Artificial discs

When a surgeon recommends referral to a ‘pain clinic’ this will often seem like
an admission of failure. To some extent this is true, but a responsible surgeon
will not go on pursuing surgery if it’s unlikely to help the patient. Pain relief
clinics offer a variety of treatments which can help relieve symptoms in many
cases.
In an era of artificial joints and other forms of ‘replacement surgery’ it is
perhaps surprising that an artificial intervertebral disc has not been developed.
Some devices have been tried, but to date there is not an established and
effective substitute for the natural intervertebral disc. One reason, perhaps, is
that surgery, in most cases, aims mainly to decompress trapped nerves, and
there is really no need to replace the disc in such circumstances.

What advances are likely in the future?

Conclusions
Because it is part of the ageing process, spinal degenerative disease and the
symptoms it causes are likely to be with us for some time to come, even when Surgery is often regarded as a ‘last resort’ in the management of spinal
other common disorders become preventable. degenerative disease, but regarding it in this way can sometimes be
inappropriate. Surgery is usually not needed, even when a person feels that he
Causes or she has finally been driven to this point. On the other hand, timely surgery
We know something about causes already. Heredity plays a role, and smoking can relieve disabling symptoms and considerably improve an individual’s quality
probably aggravates matters in anyone who is prone to disc problems. of life. A person suffering from troublesome back pain, neck pain or related
symptoms should certainly see a doctor so that the source of the pain can be
Prevention diagnosed. Hopefully non-surgical treatment, principally physiotherapy, will
Employers are required by law to assess manual handling tasks in the workplace suffice. If not, referral to a specialist may be necessary to discuss other options.
and take steps to eliminate or reduce the attendant risk of injury to their
employees. Several measures should be adopted in the workplace to prevent
back pain. People asked to perform manual tasks should first be assessed with
regard to their general level of fitness for manual work. They should then be
given appropriate tuition in back care, particularly lifting techniques. Lifts and
hoists should be provided where appropriate. Whether at work or at home,
individuals who have suffered from back or neck pain would do well to learn
how to look after their spine to prevent chronic problems developing.

Service developments
The referral of patients to specialists does not always follow a logical plan. A
busy GP may seek assistance from any specialist who deals with spinal
disorders, including rheumatologists, neurologists and pain relief specialists, as
well as neurosurgeons and orthopaedic surgeons. All of these specialists have
cause to treat spinal degenerative disease at times but have different forms of
treatment. Hospital services and patient care will both benefit when referral
patterns are organised in such a way that patients are sent to the most
appropriate specialist in the first instance.

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Glossary
Acute A symptom is acute when it
has developed fairly rapidly and has
not been present for a long time.
Annulus This is the tough fibrous
outer capsule of an intervertebral
disc. In the healthy state it encloses
and retains the nucleus.
Anterior This refers to the front of
the body or one of its parts e.g. the
spine. It is the opposite of posterior.
Arachnoiditis This is active
inflammation of the membranes
which surround the spinal cord. By
common usage it has come to refer
to dense scar tissue that forms
around the nerves, inside the spine,
as a result of an earlier episode of
inflammation.
Cauda equina Literally translated
this means ‘horse’s tail’. It is a good
description of the appearance of the
leash of nerves which form the
continuation of the spinal cord in the
lower part of the spinal canal.
Cervical This term refers to the
neck. The cervical spine is that part
of the spine which supports the neck
and is made up of cervical vertebrae.
Chemonucleolysis This process
involves the injection of a digestive
24
enzyme into the disc nucleus to
make it soft, thereby releasing
tension in the annulus.
Chronic A condition is said to be
chronic if it has been present for a
relatively long time.
Clinical Exchanges between a
doctor and patient - history taking,
examination and some aspects of
treatment - constitute clinical
activity.
Congenital This term refers to a
condition which was present at birth,
even though it may not have become
apparent until later in life.
Conservative This word refers to
any non-surgical method of
treatment, for example rest, pain
killers or physiotherapy.
Contrast medium A substance
injected into the spine (or other
body part) so that certain structures,
e.g. nerves in the spinal canal, show
up on X-ray films.
CT scan CT stands for
Computerised Tomography. Beams
of X-rays are passed through the
body from various angles. The
amount of radiation energy absorbed
by the body is measured at each of
these angles. A computer then
calculates from these measurements
how much X-ray energy is absorbed
at individual points in the body.
These measurements are then
converted into dots, producing black
and white images of the internal
structures of the body.
Degenerative A degenerative
disease is one in which there is a
worsening of physical qualities
affecting particular tissues or parts of
the body, often leading to
impairment of function.
Dermatome An area of skin known
to be supplied by one particular
spinal nerve.
Differential diagnosis The term
used by doctors to refer to the
various possible causes of a patient’s
symptoms.
Discography The process of
injecting contrast medium into the
disc nucleus so that its structure will
show up on an X-ray film - the
discogram.
Electrophysiology A means of
testing the function of nerves by
electrical stimulation, recording
responses from the skin and the
muscles.
Epidural The name given to the
space just outside the membranes
which enclose the spinal cord and the
nerves in the spinal canal. Injections
into this space are sometimes used
to provide pain relief by numbing
nerves as they pass down the spine.
Expectant Expectant management
means that natural recovery is
anticipated without specific medical
treatment.
Facet joints The name given to a
pair of small joints, present at each
level of the spine, which are coupled
with an intervertebral disc. They
serve to regulate the movements of
that disc. They also provide a good
deal of stability for the spine.
Herniation Any abnormal bulge of a
body part may be referred to as a
hernia and the process of bulging is
called herniation.
Instability A term indicating
abnormally increased movement of a
vertebra in relation to its neighbour
immediately above or below.
Intervertebral disc The main
structure binding together individual
vertebrae of the spine. It provides
for a limited amount of movement at
each level, but acting together the
discs provide both strength and
mobility for the spine. The discs
degenerate as part of the normal
ageing process.
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Invasive An invasive procedure is
one which involves entry into the
body. This can be relatively simple,
as with an injection, or it can be
something complex such as an
operation. There are always some
risks with invasive procedures. Non-
invasive techniques, such as scanning
procedures, are preferred whenever
possible.
Isotope scan A method of
checking for disease processes
affecting the bones, including those
of the spine. A short-acting
radioactive substance is injected into
the blood stream a little while before
the scan. The radiation dose is low
and there is no significant risk of
radiation injury.
Laminectomy An operation to
remove the bony arches at the back
of the spine, either to decompress
nerves in the spine or to provide
access to these nerves so that more
involved procedures can take place,
e.g. removal of tumours.
Ligaments These are tough band-
like structures with slightly elastic
properties which help to hold bones
together at joints.
Lumbar The name given to the
lowest mobile portion of the spine,
sometimes referred to as the small of
the back.
26
Microdiscectomy An operation to
remove part of an intervertebral disc,
usually in order to release a trapped
nerve, but with minimal disruption
of the spinal muscles and other
tissues.
MRI scan Magnetic Resonance
Imaging involves sophisticated
technology, including high-powered
magnetic fields, microwave radiation
and computers, to generate images of
the inside of the body. The scanning
process, whilst painless, is a
somewhat claustrophobic experience
and the equipment is rather noisy.
Scans last some 20 minutes. Any
discomfort endured is rewarded by
impressive images of the internal
anatomy of the body, including the
spine and its component parts.
Myalgia A term referring to pain
generated in muscles.
Myelogram A method of imaging
the spine and the nerves inside the
spinal canal. It involves the injection
of a contrast medium which outlines
the position of the nerves.
Myodil The name given to a
contrast medium which was for
many years the sole agent available
for myelography. It has not been
used for many years, being replaced
by more modern substances.
Myotome A group of muscles
supplied by a single nerve root.
Natural history This term refers to
what will happen if a disease remains
untreated. It could become worse,
remain much the same or simply get
better on its own.
Nerve root The term used to
describe a main nerve trunk as it
arises from the spinal canal. It soon
divides into a number of branches,
some of which join with other nerve
roots and go on to supply various
parts of the body including muscle
groups (myotomes) and specific
areas of skin (dermatomes).
Neuralgic A term used to refer to
pain generated by direct stimulation
of a nerve. It has distinct qualities
and may be of use in diagnosing the
exact site of origin of the pain.
Nucleus The term used to refer to
the inner part of an intervertebral
disc. A high water content in youth
provides support for the spine, with
resistance to compression. With
advancing years the water content
declines, the nucleus becomes
compressible and the annulus of the
disc begins to bulge.
Osteoporosis With advancing age
the calcium content of bones tends
to decline, particularly in women
after the menopause. Bones of the
spine may then weaken and can
sometimes collapse, a cause of spinal
pain.
Percutaneous Any diagnostic or
surgical technique involving
penetration of the skin and body
tissues but without requiring an
incision or the cutting of tissues.
Physical signs Abnormalities
detected by a doctor when she or he
examines a patient.
Posterior The back of the body or
of a body part, e.g. the back of the
spinal column. The opposite of
anterior.
Prolapse The sinking down of a
part of the body.
Radiograph The correct name for
an image obtained by X-ray beams.
Commonly referred to as an X-ray,
the latter term really refers to the
beams of radiation which produce
the image, in the same way that light
produces the image on a
photographic print.
Referred pain Pain experienced
away from its site of origin. This
arises because of shared pathways for
transmission of pain impulses within
the nervous system.
Spasm A sudden, involuntary
contraction of one or more groups of
muscles.
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Spinal canal The cavity running
the length of the spinal column,
containing the spinal cord and the
nerves issuing from the cord.
Spinal cord The main nerve trunk
which connects the brain to the rest
of the body. It runs some two thirds
of the way down the spine, ending in
the upper lumbar region, where it is
replaced by nerves of the cauda
equina.
Spinal nerve As a nerve root exits
from the spinal canal it is sometimes
referred to as a spinal nerve, up to
the point, outside the spine, where
it divides into its various branches.
Spondyl- A prefix from which a
number of other terms are derived.
It means the same as vertebra.
Spondylitis Strictly speaking, this
term means inflammation of one of
the vertebrae, but it is commonly
misused as a synonym for
spondylosis.
Spondylolisthesis A condition
where one vertebra has slipped
forwards or backwards in relation to
the vertebra next to it. It is a
significant form of instability of the
spine.
Spondylolysis A condition where
there is a defect in part of a vertebra.
This makes an individual more likely
28
to develop spinal instability and may Other organisations that may be able to help
lead on to development of
spondylolisthesis. Arachnoiditis Trust
PO Box 27
Spondylosis Strictly speaking any Stoneycroft
condition affecting a vertebra. In Liverpool L13 5TZ
practice the term is reserved for Tel: 0151 259 0222
degenerative changes affecting the (Information on inflammation of the spinal canal)
spine.
BackCare
Symptomatic A patient is (Formerly National Back Pain Association)
symptomatic if he or she experiences 16 Elm Tree Road
symptoms. A condition becomes Teddington
symptomatic when it starts to Middlesex TW11 8FT
produce symptoms, even though the Tel: 020 8977 5474
condition itself may have been (Information and research)
present for some time beforehand.
Brain & Spine Helpline
Tendons Unlike ligaments, these British Brain and Spine Foundation
tough band-like structures are quite 7 Winchester House
inelastic and provide the means for Kennington Park
the attachment of muscles to bones. Cranmer Road
The full force of muscle contraction London SW9 6EJ
is transmitted via the tendon to the Tel: 0808 808 1000
bone, producing movement at a joint. (Information and support on neurological disorders for patients, carers and health
professionals)
Thoracic The name given to that
region of the spine between the neck Brain and Spinal Injury Charity (BASIC)
and the lumbar vertebrae. The ribs Neurocare Centre
are linked to the thoracic vertebrae. 554 Eccles New Road
Salford
Vertebrae Vertebrae are the Greater Manchester M5 2AL
individual bones which make up the Tel: 0870 750 0000
spinal column. Each vertebra has a (Information, research and support groups)
number of component parts which
have their own names. These Disability Sport England
include the body, pedicles, laminae, 13 Brunswick Place
spinous process, transverse process London N1 6DX
and facet joints. Tel: 020 7490 4919
(Information, support and counselling)
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Disabled Driver’s Association DVLA Drivers’ Medical Group

National Headquarters DVLA
Ashwell Thorpe Longview Road
Norwich NR16 1EX Swansea SA99 1TU
Tel: 01508 489449 Tel: 01792 783 686
(Representation, information and advice on mobility issues) (Fitness to drive)

Disabled Living Foundation Health Information Service

380-384 Harrow Road Tel: 0800 66 55 44
London W9 2HU (General health information and advice)
Tel: 0870 603 9177
(Advice on equipment for daily living) National Ankylosing Spondylitis Society
PO Box 179
Driving Assessment Service Mayfield
Astley Ainslie Hospital East Sussex TN20 6ZL
133 Grange Loan Tel: 01435 873527
Edinburgh EH9 2HL (Advice, information, publications, physiotherapy and hydrotherapy)
Tel: 0131 537 9192
(Assessment and advice on driving with a disability) Scoliosis Association UK
2 Ivebury Court
Disablement Income Group (DIG) 323-327 Latimer Road
Unit 5 London W10 6RA
19-23 Wedmore Street Tel: 020 8964 1166 helpline
London N19 4RR (Advice, information and support)
Tel: 020 7263 3981
(Welfare benefits advisory service)

Disablement Income Group Scotland

5 Quayside Street
Edinburgh EH6 6EJ
Tel: 0131 555 2811
(Welfare benefits advisory service)

Disability Scotland
Princes House
5 Shandwick Place
Edinburgh EH2 4RG
Tel: 0131 229 8632
(Information on disability)

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Notes Supporting the work of the British Brain and Spine

Foundation
In order for the British Brain and Spine Foundation to continue to fund its
vital research and education work in brain and spine disorders, we need your
help.
YES! I would like to help.
Please find enclosed a gift of £10 £15 £25
£ other Please accept this as a Gift Aid donation
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Note: All donations now qualify for Gift Aid if you are a tax payer. Please sign and date this form in the
box below as confirmation.

Signature

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or you may donate by Visa/Mastercard/CAF card by filling in the details
below or calling our donation line on 020 7793 5900
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I am also interested in:

■ Making a Bequest to the Foundation in my will
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British Brain and Spine Foundation, 7 Winchester House, Kennington Park,
Cranmer Road, London SW9 6EJ Telephone: 020 7793 5900
Fax: 020 7793 5939 Registered charity no.1010067

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Notes
Publications from British Brain and Spine Foundation
We can supply one copy of each relevant publication free to patients and carers
affected by neurological disorders. However, if you are able to pay for them, it
will help us to cover our costs. Additional copies cost £4 each for booklets and
£3 each for leaflets. (Price includes £1.00 post and packing). Please make your
cheque payable to the British Brain and Spine Foundation.

Please complete your name and address below, tick the appropriate box/es, and
post your order to us at:
British Brain and Spine Foundation, FREEPOST, London SW9 6BR.

Name (Mr/Mrs/Miss/Ms)

Address

Postcode
Please tick as appropriate:

Aids and the brain ■ MRI Scan (leaflet) ■

Angiogram (leaflet) ■ Multiple sclerosis ■
Back & neck pain ■ Neurophysiology ■
Brain tumour ■ Paralysis – the loss of muscle power ■
CT Scan (leaflet) ■ Parkinson’s disease ■
Dizziness & Speech, language and
balance problems ■ communication difficulties ■
Epilepsy ■ Stroke ■
Face Pain ■ Sub-arachnoid
Headache ■ haemorrhage ■
Head injury & concussion ■ Transient ischaemic attacks
Meningitis & Encephalitis ■ and mild strokes ■
Motor neurone disease ■ Transverse myelitis ■
British Brain and Spine Foundation, 7 Winchester House, Kennington Park, Cranmer Road, London SW9 6EJ
Telephone: 020 7793 5900 Fax: 020 7793 5939

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Notes Notes

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