One of the drawbacks of standing on two legs is back pain. Physicians and surgeons at the Hospital of Saint Raphael are investigating new ways to alleviate the discomfort without major surgery.
Currently the hospital is turning to new devices, one for the neck, the other for the lower back, that ease nerve pain by repositioning vertebrae.
The alternatives include removing parts of vertebrae or fusing adjacent vertebrae together.
Both require a longer hospitalization, lengthier recovery and heavier cost.
This is important because back problems are widespread and expected to multiply as the population ages.
The spine supports the rest of the body like a cantilever, or a truss and sometimes like a suspension bridge. The 33 vertebrae, separated by cushioning disks of cartilage, are involved in almost all activities.
Keeping it healthy can be a challenge.
About 80 percent of Americans experience a back problem at some time. Aches arise from a burst of occasional exertion, like shoveling snow or moving furniture. Other pains, tingling, numbness and weakness can be symptoms of chronic conditions that descend on us slowly as we grow old.
One of the most common is called spinal stenosis, or a narrowing of the channel that normally protects the lower spinal cord. Another, degenerative cervical disk disease, is literally a pain in the neck.
St. Raphael’s is opening a consolidated spine program, incorporating 13 neurological and orthopedic surgeons, along with physicians, nurses, therapists and other specialists to coordinate and standardize spinal care.
The program will bring complementary disciplines together to work on the same cases, said Anne R. Moore, director of the spine program.
Moore, who has graduate degrees in nursing, was previously the manager of the Orthopedic/Neurosurgical Unit at Saint Vincent’s Medical Center in Bridgeport, as well as an adjunct faculty member at Saint Vincent’s College. Moore also conducted clinical studies.
St. Raphael’s performed about 900 spinal surgeries last year, Moore said.
Treating spine problems can be perplexing. “Sometimes the pain goes away by itself. Sometimes, even with lots of treatment, you don’t get better,” she said.
The spine itself is part of the problem. Without an extensive set of ligaments, tendons, and muscles supporting the structure, the spine would have the stability of a stack of stale doughnuts.
Instead, evolution has left us with complex vertebrae. The vertebral column holds up the head, and provides an anchor for arms, legs, and ribcage. Running down the “back” of the back is the spinal column, which has a smaller diameter than the vertebrae and which has a “Y”- shaped cross-section.
This ligament-lined canal is home to nerves that run down from the brain to the most distant fingers and toes.
The vertebrae also have projections that are connected by ligaments. All of this soft tissue provides extra mobility and strength. The structure also allows us to walk, bend, twist, look around, crawl, climb, juggle and ride unicycles.
As we age, the ligaments age and swell, said Dr. John M. Beiner, an orthopedic spine surgeon at St. Raphael’s and in private practice. Speaking at a recent lecture on spinal stenosis at the hospital, Beiner said the enlarged ligaments squeeze on branches of nerves that lead to the buttocks and legs.
This bothersome narrowing is called lumbar stenosis and is “very common,” Beiner said. The condition develops slowly over decades. Sometimes the condition occurs unnoticed. More frequently, the squeezed nerves eventually begin to swell and become inflamed.
The body perceives this as a tingling or painful feeling that extends from the hips and rear end and down the legs. This is often called sciatica, although the sciatic nerve that runs down the leg is often not to blame, Beiner said.
The pinched nerve can also cause weakness and trouble walking. Injured nerves also release chemicals that damage other nerves, decreasing blood flow, and nutrition to the limbs, he said. Insufficient blood adds to the leg pain.
Typically, leaning forward spreads the affected vertebrae apart, alleviating the unpleasant feelings. This is one reason that older people are sometimes seen walking hunched over, or bent forward over a shopping cart.
Distinguishing spinal stenosis from other causes of leg pain can be complicated. Circulatory problems, and “mechanical” problems, such as arthritis in the hip or leg can cause pain that is difficult to distinguish.
Often exams fail to disclose an obvious problem, Beiner said.
One way to distinguish neurogenic pain from local pain is to inject a small amount of a steroid into the suspected pinch-point.
If the pain continues, than the problem is in the legs. On the other hand, if the discomfort is immediately alleviated, the diagnosis of spinal stenosis is confirmed.
Dr. Patrick R. Tomak, a neurosurgeon at St. Raphael’s who often works with Beiner, said surgery is generally the final option.
Patients may experience relief with prescribed exercises, non-steroidal anti-inflammatory drugs like ibuprofen, and physical therapy. Periodic epidural steroid injections also often offer relief. Narcotics can also be useful.
Finding a comfortable position and staying frozen like that is one of the worst approaches, the doctors said. “Motion is life,” Tomak said.
Just a few days of complete inactivity can stiffen and weaken muscles, he said.
So — the non-surgical measures have not worked, and you want relief from the pins, needles, pains, and loss of mobility. Now what?
One of the most common surgeries for spinal stenosis is intended to decompress the squeezed and inflamed nerve.
A straightforward way of doing this is a procedure called a laminectomy, otherwise known as “unroofing” the spine. As the name suggests, a section of the lamina, one of the bony processes on the back of the spine is removed. This releases pressure on impinged nerves, but leaves the spinal cord more exposed.
There is one way to relieve pressure without cutting through bone, rupturing ligaments, or slicing tendons. Medtronic Spine LLC of Sunnyvale, Calif., manufactures the “X‑Stop,” a metal assembly that is installed between the vertebral processes, pushing them apart, and giving more space to the nerves.
It is shaped like an “H.” The cross bar fits between the lamina, preventing the two vertebrae from squeezing together, and thus, sparing the spinal cord. The “uprights” of the H keep the device in place.
The X‑Stop can be repositioned as required or removed in the event that more involved surgery is necessary. In effect, the X‑Stop produces the same relief as bending forward, which also decompressed the lumbar vertebrae and disks.
The X‑Stop is being used at both St. Raphael’s and Yale-New Haven Hospital.
The Prestige Surgical Disc, also made by Medtronic, is an artificial disk replacement for a cartilage disk in the neck. When a cervical disk shrinks or disintegrates, nerves running through the vertebrae of the neck can become pinched, leading to problems superficially similar to spinal stenosis, including pain, tingling and loss of motion.
The device bolts onto the two vertebrae on either side of the degenerated disk, which is removed. In place of the disk are a convex piece of stainless steel on the end of the one vertebra that fits into a concave piece of steel mounted carefully on the other vertebra.
This procedure can be performed on outpatients. Like the X‑Stop, no bone or tissue is removed, so further surgery can be undertaken if necessary, Moore said.
St. Raphael’s is also studying a synthetic cage that can be placed between vertebrae and makes room for bone to grow, as an alternative to bone grafting. The hospital is also evaluating a new biological bone-grafting material that encourages vertebral bone to grow around it.
All of these techniques avoid fusing vertebrae, or removing the disk and allowing the bones to grow together, with help from screws, rods and other hardware.
Although the procedure is often necessary, it often transfers stress from one area on the spine to another, Moore said.
Moore is preparing a lecture series for the staff, and public, on spinal issues, as well as a pre-op class for patients, to decrease their anxiety.