Word explanations and possible therapeutic options
.. dealing with diseases of the spine
The spinal column is the central stabilizing organ for the upper body and hosts the spinal cord. The intervertebral disks allow for mobility of the spine and its single segments. Damages of the vertebral column can hence cause severe symptoms – often enough also in parts of the body which are not originally affected like the extremities. Underlying cause of these symptoms is mostly muscle tension or degeneration of spinal disks.
Back problems are one of the most frequent causes of missed work days in Germany. More than 80% of the population suffers from back pain at least once in their life.
One of our missions is to help patients understand the multiple technical terms around the spine and its diseases. For this purpose the APEX SPINE Center created the following guide to medical terms related to the vertebral column. It should help you also to find the solution that best fits your own back problems.
There are multiple causes of back pain. They may stem from the front part of the spine (intervertebral disks, vertebral bodies) and/or the rear part of the spine (osseous changes like arthrosis of the facet joints, stenosis, instability, etc.). Most common cause is degenerative change of spine structures (ca. 80%). As a matter of course also diseases like rheumatism, traumatic injuries (fractures of vertebral bodies), inflammatory disorders and tumors will be treated.
Pain causing structure
- Musculature (e.g. due to muscle tension or overwork)
- Spinal disc
- Facet joints
- Spinal nerves and spinal nerve roots
Underlying causes for pain
- degenerative changes of the spinal discs
- ligament insufficiency (=dysfunction of the ligaments)
- osseous changes
- dysfunction of the vertebral joints
- growth disturbances (e.g. scoliosis)
- congenital deformations
Generalized skeletal diseases
- Osteomalacia (=softening of the bones)
- infectious diseases
Tumors of the spine
- primary tumors
- whiplash associated disorders
There are four main segments
- The cervical spine, consisting of 7 vertebral bodies (this section is commonly called the neck)
- The thoracic spine, consisting of 12 vertebral bodies (this section is commonly called the upper back)
- The lumbar spine, consisting mostly of 5 (sometimes of 6) vertebral bodies (this section is commonly called the lower back)
- The sacrum and tailbone region (Os sacrum and os coccygeum) where there is generally little need for therapy
Each segment of the spine can be affected by different diseases – dependent on individual anatomy and typical undue stresses from modern working environment. Again a multitude of technical terms is being used.
Cardinal symptom of a herniated disc is pain.
It is sometimes associated with protective posture and a feeling of numbness (paresthesia) that can be allocated to the dermatome of the affected nerve root.
Severe symptoms that often make immediate intervention necessary are:
- Pareses (paralytic symptoms)
- Bladder or bowel dysfunction
- sudden loss of sexual function
Reasons for these symptoms are often degeneration of the spinal disks with consequential height loss of the intervertebral space (synonym: osteochondrosis) and constant overexpansion of the joint capsules and the development of concomitant arthroses of the small vertebral joints (synonym: facet joint arthrosis). This leads to increased tension of the adjacent muscles. Especially the paravertebral muscles that form the strands left and right of the spine, tend to shrink, to get tense and to shorten (synonym: hypertrophy, induration). The transversal abdominal muscles tend to weaken with constant back pain – even up to their complete disappearance (synonym: atrophy).
Different categories of pain:
- Pain can be local/punctual.
- Or pain can be non-local (mostly with momentous findings that lead to extensive muscle tension).
- Pain can be pseudoradicular (a pain that is transmitted along so-called muscle chains). It radiates into the arm or leg, without clear correlation to neurological findings. This form of pain is mostly dull and can often only be vaguely described.
- Pain can also be of a radicular character. Then cause of pain is damage of nerval structure. Radicular pain is sharp and can be assigned to so-called dermatomes (skin areas innervated by the sensory fibers of a single nerve root).
A special form of back problems is the “locking up” of vertebral joints. That locking is – similar to a stuck drawer – the almost entire inability of the joined in bones to move or slide in their anatomically designated way. This breakdown of joint function can happen to young patients without degenerative disease as well as to older patients with severe degeneration of spinal structures. Reasons for locking up are local undue stresses from unaccustomed physical strains. Sometimes also hypothermia plays a role. Some locked up backs can be traced back to sprain injuries of the spine.
Mostly simple locking up can be readily treated with chiro- or manual therapy.
For solving of locked up vertebral joints manipulation or mobilization techniques are possible options. With manipulations small, careful movement impulses are applied to the locked joint, with manipulations gentle stretching of the joints, muscles and connective tissue against the resistance from the locked joint will be carried out. The solving of the blockade may be accompanied by a crack. Persistently locked joints require several treatment sessions.
Manual therapy, chirotherapy and chiropractic are not all the same! Chiropractic therapists are no physicians and do not treat according to the current European guidelines for manual therapy. A locked up back may always be the clinical picture of a spinal disk disease or a stenosis that had not been diagnosed before. Hence the treating physician must conscientiously make his diagnosis – including a thorough physical examination, anamnesis and eventually the application of imaging techniques like MRI.
What segments of the spine are affected most often?
The region that is affected most often is the lumbar spine (lower back) especially with the two lowest intervertebral disk levels (L5/S1 and L4/L5). Second most common section is the neck (cervical spine) and least frequently the thoracic spine (upper back).
Due to modern lifestyle with its lack of movement and the resulting weakening of rump muscles a lot of people suffer from a lot of back problems. Many technical and “colloquial” terms are used with the development of degenerative diseases of spinal disks and vertebral joints or the narrowing of the spinal canal. They shall be explained in the following section.
Popular lore for “lumbago” is “lower back pain” or often also “sciatica“. The local pain is often associated with considerable movement restriction, locked up vertebral joints and concomitant muscle tension.
The true sciatica, however, is accompanied by leg pain – either as lumbosciatica when pain radiates from the lower back into the leg, or as sciatica when pain is merely in the leg.
Degenerative back disease starts mostly with degenerative changes of the spinal disks – they loose their function as shock-absorber and subsequent osseous changes of the upper and lower surfaces of the vertebral bodies (spondylosis) may occur. Your doctor may speak of an activated osteochondrosis if severe muscle tension and edemas at the upper and lower surfaces of the vertebral bodies (detectable in MRI images) coexist.
Spinal disc problems
If symptoms stem from the spinal disks (synonym: intervertebral disk, discus intervertebralis) this is called “discogenic” pain or disease and there are a lot of technical terms associated for the respective pathological states of the disk.
The disks consist of a fibrous ring (synonym: anulus fibrosus) and a gel-like nucleus (synonym: nucleus pulposus). The fibrous ring forms the firm outer wrapping and the nucleus provides the required elasticity.
Mostly degeneration starts with a loss of liquid of the nucleus pulposus and a subsequent height reduction of the intervertebral space (the space between the adjacent vertebral bodies). This is called osteochondrosis.
Shifting of disk material is mostly associated with osteochondrosis and there are again a couple of different technical terms.
Mostly the first thing that happens is a tearing of the fibrous ring (rupture of the anulus fibrosus). Subsequently more or less of the gel-like nucleus may make its way through this rupture into the spinal canal.
If only a small part “creeps” through the fissure your doctor will speak of a disk protrusion – he may also divide into different grades of severity. All protrusions have in common, that the rupture of the anulus is limited and great part of the function of the fibrous ring is still maintained.
If rupture is complete, more of the disk material will shift into the spinal canal and eventually pinch nerve roots. Your doctor will call this a slipped disk (synonyms: disk prolapse, herniated disk, disk herniation).
A special form of a herniated disk is the sequestered disk or disk sequestration. The nucleus pulposus shifts completely into the spinal canal without further connection to the original disk.
This condition may be an indication for disk surgery (nucleotomy or discectomy) if conservative care proved inefficient.
The term nucleotomy seems more appropriate than discectomy, as only the material from the nucleous pulposus that pinches the nerve root will be removed whereas the fibrous ring will remain untouched.
The most tissue-preserving surgical option for nucleotomy is the endoscopic technique that is successfully carried out in the APEX SPINE Center since many years. As opposed to other surgeons we are able to treat all herniated discs endoscopically!
Refer also to scientific publications.
Facet joint arthrosis
If symptoms stem from degenerative changes of the small pairs of vertebral joints (synonym: facet joints) your doctor will speak of spondylarthrosis, facet joint arthrosis, a facet syndrome or facet joint syndrome.
These arthroses of the vertebral joints are – with advanced state of disease – the most common cause for the development of a narrowing of the spinal canal (synonym: spinal stenosis, spinal canal stenosis)
In its pronounced form – where more than one segment is affected (definition according to Junghans: at least one pair of vertebral bodies with all its adjacent structures), it is also called a multisegmental bottleneck syndrome of the spinal canal.
Other causes for this quite frequent but often unrecognized condition are:
- undue stresses from sports activities or physical work
- an inherent narrowness of the spinal canal (synonym: congenital stenosis)
angeborene Enge des Wirbelkanals (-> Synonym: kongentiale Stenose).
A spinal stenosis can never be diagnosed merely from the evaluation of magnetic resonance images, but radiologic findings must always be directly correlated to prevailing symptoms.
It should be mentioned that the size of the spinal cord as well as the susceptibility of the dura differ individually.
Together this makes precise diagnosing a challenging task that requires extensive experience of a specialized physician.
Therapy of spinal stenosis:
Advanced stenosis with the clinical picture of a claudicatio spinalis (significant limitation of walking distance that is associated with pain) is often an indication for surgery. Conservative care with injections, physiotherapy and electrotherapy mostly fail.
With our tissue-preserving surgery technique (microscopic decompression of the spinal canal) we are able to discharge patients home a few days after the intervention and - after short out-patient rehabilitation - to reintegrate them into daily life very soon.
A special form of spinal stenosis is the slipped vertebra (spondylolisthesis or listhesis). This form of spine disease is also facultatively associated with a more or less pronounced segmental instability. This means that the affected vertebra tends to slip out of the proper position onto the bone below it.
It must be differentiated between
- a true spondylolisthesis which comes along with an inherent spondylolysis (defect in the connection between vertebrae)
This disease results from an inherent malposition and a concomitant degeneration of the vertebral joints.
There are different scales to quantify the degree of slippage. Most used is the Meyerding scale with a range from I to IV. The complete slippage of the vertebra out of its position is called spondyloptosis.
Therapy: If surgery is indicated we are often able to prevent so-called transpedicular reposition spondylodesis! This is a fusion surgery with simultaneous reposition of the slipped vertebra. With our special microscopic decompression of the spinal canal, the facet joints will mostly remain intact and the fusion hence not necessary.
Degenerative lumbar scoliosis
This degenerative sideways curvature of the spine with a concomitant twisting of the vertebrae is due to present stenoses and increasing static disturbances.
The development of a scoliosis may have different origins:
- degenerative (due to tear and wear )
- inherent or idiopathic (infantile or juvenile)
Progressive degenerative lumbar scoliosis is a common cause for severe back problems from the 4th or 5th decade of life on.
Second most often - apart from degenerative scoliosis - is the idiopathic form. That means scoliosis develops without apparent cause in early childhood (infantile form) or adolescence (juvenile form). Also congenital scoliosis is quite frequent.
Often scoliosis is quite well compensated for with good rump musculature and there may be only little symptoms over many years. Especially in the lumbar spine, scoliosis tends to worsen from the 4th or 5th decade of life on. The degree of curvature increases which can be quantified with the so-called Cobb angle.
If the apex of scoliosis is in the thoracic spine, disease progress is mostly slower and less severe as more stability is provided from the surrounding musculature.
Conventional treatment with electro- or physiotherapy and corsets often leads – if to any - to only insufficient symptom control.
Degenerative lumbar scoliosis can be treated etiologically only by elimination of the “bottlenecks” that are responsible for the prevailing symptoms.
The subtle minimally invasive and tissue-preserving microscopic decompression of the spinal canal allows in almost all cases for a safe and efficient treatment of stenosis. Facet joints will be preserved and a multisegmental fusion be prevented.
The standard procedure that is carried out in most clinics would be a laminectomy and a subsequent transpedicular distraction spondylodesis. That is a stiffening of several adjacent vertebrae and often leads to severe post-surgery syndromes. Our conviction is that we can provide our patients a considerable symptom relieve and significant increase in quality of life with our technique and save them from such a momentous stiffening surgery.