Spine Conditions San Francisco Bay Area
Bulging Disc Syndrome
Bulging Disc Syndrome is the most common cause of back pain in patients under 50. It is frequently mistaken for other problems and is misdiagnosed. Because of this, prescribed treatment may even be counterproductive, so it is important to recognize this very common problem. Contact your Bulging Disc Syndrome Specialist today if you are in the San Francisco Bay area.
Compression Fractures in the Spine
Vertebral compression fractures are common among post-menopausal women. Older men over age 65 can also develop such fractures.Drug-induced osteoporosis can cause compression fractures due to:
- Chronic use of steroids
- Aromatase inhibitors
- Gonadotrophin-releasing hormone antagonist
Tumors are a relatively uncommon cause of compression fractures. Lytic tumor or metastasis can cause bone resorption, resulting in fractures. Multiple myelomas frequently involve the spine, and compression fractures may be the initial finding.
Some compression fractures are symptomatic. Most patients become pain-free as the fractures heal. Symptomatic fractures may cause severe back pain, loss of mobility, and very limited function. Deformities such as kyphosis and/or scoliosis can result from multiple untreated compression fractures. In severe cases, these can lead to limited pulmonary function due to diminished lung volume. Untreated vertebral compression fractures can result in higher mortality. When pain is disabling and persistent in spite of appropriate noninvasive medical treatment, percutaneous vertebral augmentation should be considered. We have performed various percutaneous vertebral augmentation procedures for more than 15 years. We now use the most minimally invasive, least painful, and lowest-risk techniques to address this problem.
The first type of procedure for vertebral compression fracture is vertebroplasty, which involves fluoroscopically guided injection of polymethylmethacrylate bone cement into the affected vertebral body through a needle. Pain relief is usually immediate. To prevent cement leakage and to restore vertebral height, kyphoplasty was developed. This involves inflating a balloon in the collapsed vertebral body, creating a cavity before cement is injected. Vertebroplasty and kyphoplasty usually require entering the vertebral body through both right and left pedicles. We were involved in the IDE study of more advanced techniques.
We were the first spine center in the San Francisco Bay Area to perform Kiva vertebral augmentation. The Kiva procedure is even more minimally invasive than the previous techniques. It is performed through only one single pedicle, through a small incision. A small implant is first inserted to restore vertebral height and reduce the fracture. The coiled PEEK implant is designed to minimize cement leakage. Bone cement is then injected. This procedure can be performed in less than 30 minutes. The pain relief is usually immediate, and the patient can go home the same day.
The intervertebral disc is a complex structure with a rubbery outside and gelatinous center. One could think of it as a glazed jelly donut, with the bread being the rubbery part and the jelly being the gelatinous center. In the glaze on the outside are microscopic pain nerves. The jelly contains inflammatory chemicals that are meant to be isolated from the blood supply and kept away from the pain nerves. The jelly is made up of a special chemical composition that allows it to absorb water, and this contributes to the height of the intervertebral disc between the vertebrae and is important in the mechanism of transferring stress throughout the intervertebral joint. Unfortunately, as we all age, the jelly water-absorbing capacity diminishes, and the height of the disc decreases. This changes the force loading on the bread or rubbery part and beings the process of wear and tear that thins out its thickness.
When the inner two-thirds of the rubbery part is damaged, the gelatinous tissue begins to come in contact with the pain nerves and the blood supply, which is present only in the outer third. At this point, patients can develop symptoms and inflammatory reaction to the jelly itself. Although this damage can happen all at once, it usually is a slowly progressive problem and likely caused by body mechanics, the way in which we hold our back during various activities, and our genetic makeup, which has given our discs different rates of deterioration and resistance to stress, which is a hereditary factor. In the early stages of this very common problem, the symptoms can be controlled by proper body mechanics and exercises and recognizing the cause of the symptoms.
The hallmarks of bulging disc syndrome, which is essentially due to tears in the rubbery part (annulus fibrosis), are an onset of symptoms with positions that increase disc load. Sitting is often the main culprit (the sitting position) with the thighs at a 90° angle to the trunk. It pulls on the hamstring and buttock muscles, which tilts the pelvis forward, and this causes repositioning of the spine so that the load on the spine is concentrated on the discs in a way that tends to propel the gelatinous central area out toward the rubbery annulus part. With sustained time in this position, the force on the annulus part continues to grow until, because of its weakness, it stretches or new tears form in the wall, stimulating pain nerves and inflammatory reaction. This typically will cause a flare-up in back pain for several days to weeks, forcing a change to activities that do not irritate the damaged structure until it heals. If one recognizes the problem, reversing the initial mechanism of the injury can stop the injury quickly and accelerate its healing.
So the hallmarks of the clinical syndrome for bulging disc syndrome or annular tear are onset of pain when the spine is in a forward-flexed position—including:
- Bending over
If this is recognized, arching the back or hyperextending it in a slow, gradual manner will push the gelatinous material away from the damaged annulus and squeeze the damaged annulus together while reducing the load upon it, and this will usually result in greatly diminished symptoms. If the person then stays in this position, keeping the back arched most of the time, and does arching exercises, usually the symptoms will resolve within 72 hours. One can follow the pain pattern to get an idea whether the maneuvers are being effective. If they are, the pain should radiate less down the legs and centralize and then diminish in the center of the back. As long as the curve or hyperextended position in the back is maintained, symptoms will not become bad again.
The basic simple exercise to address this problem involves lying on the stomach in a position as if to do a push-up, but leaving the pelvis on the ground and just arching the back by push-off of the arms. Especially after the initial injury, this has to be done gradually because the tissue needs time to shift. Therefore, when starting these maneuvers after the initial injury, one should place one or two pillows under the stomach and lie on the stomach. Every five to ten minutes, withdraw one of the pillows, and as long as the pain is not increasing down the lower extremities further, this maneuver would seem to be working. Once the patient is flat, they can do the press-up extension exercise described above, and this again should not be associated with pain radiating down the legs. If it does, the exercise should be stopped, and one should contact their healthcare practitioner in San Francisco Bay area. This treatment approach was invented and developed by Robin McKenzie, a physical therapist from New Zealand. More details regarding his technique can be found at the website noted in the references.
If the first maneuver seems to be effective in reducing and centralizing the pain, then the diagnosis is likely confirmed. The patient should perform ten of the press-up exercises every hour they are awake and try to rest in positions in which the back is arched—that is, on the stomach, or if lying on the side, keep one thigh in line with the trunk and not in the fetal position. The firmer the bed, the better. If symptoms are not improving in a rapid manner after the initial injury, patients should contact their licensed healthcare provider in the San Francisco Bay area for further instructions and treatment.
- mckenziemdt.org/robin.cfm (non-surgical treatment)
- chirogeek.com/003_idd-tutorial.htm (Internal Disc Disruption)
- orthoinfo.aaos.org/topic.cfm?topic-a00534 (gen information AAOS)
Low Back Pain and Lumbar Disc Degeneration
Lumbar disc degeneration is common. Most degenerative spine changes are seen on x-ray, CT scan and MRI are asymptomatic. However, as the condition becomes more advanced, lumbar disc degeneration can lead to:
- Loss of disc height
- Disc protrusion
- Disc herniation
- Spinal stenosis
Eventually, patients may develop more severe back pain, neck pain, numbness, and weakness associated with nerve compression.
Recent studies show strong evidence for genetic predisposition for disc degeneration. Other risk factors include:
- Environmental exposures
- Physical loading
- Whole-body vibration
- High body mass index
- Excessive height
We recommend evaluation of a patient with back pain and/or leg pain with a complete history and physical examination, followed by appropriate imaging studies—x-rays, MRI, or CT scan—to rule out serious disease. It is critical to be sure that there is no infection, tumor, spinal instability, or deformity.
In our Spine Center in the San Francisco bay area, we provide personal, thorough evaluation and treatment. We begin with non-invasive conservative treatment first. If spinal injection is indicated, we have a facility adjacent to our Spine Center to perform this in short order. If surgery is necessary, a minimally invasive procedure is considered first. Standard spinal operations can also be performed. When symptoms are very severe due to instability and/or deformity, spinal fusion may be necessary.
We were the first spine center to use pedicle screw fixation on the West Coast in 1984. The initial publications in the U.S. on pedicle screw fixation for spinal fusion came out of St. Mary’s Spine Center by the members of San Francisco Spine Surgeons (“Internal fixation with pedicle screws” by Ken Hsu, James Zucherman, Arthur White, Gar Wynne. Lumbar Spine Surgery. 1987. C.V. Mosby Company, pages 322-338. “Early results of spinal fusion using variable spine plating system” by James Zucherman, Ken Hsu, Arthur White, Gar Wynne. Spine. May 1988, J.P. Lippincott Company, pages 570-579.) So far, we have over 100 peer-reviewed journal articles and book chapters on these subjects.
Tumors involving the spine are diverse in their presentations and are challenging to treat. Primary spine tumors, which can be benign or malignant, are rare. Metastatic tumors are the most common type of tumor involving the spine. They are 25 to 40 times more common than primary spinal tumors. Cancer of the kidney, breast, thyroid, and prostate gland account for 80% of bony metastases, with the most common involvement in the spine. Progression of metastasis can lead to pathological fracture and instability, requiring surgical intervention. At St. Mary’s Medical Center in San Francisco, we have:
- Advanced diagnostic modalities
- The latest MRI and CT scans
- Expert oncologists
- Internal medicine specialists
- Paramedical personnel
- As well as very experienced spine surgeons to improve outcomes and quality of life and increase life expectancy
For primary spine tumors, surgical techniques have improved to the stage where en bloc resection for complete tumor removal is possible, although this should be performed selectively after thorough preoperative evaluation. In 1987, we performed the first complete removal of chordoma from L3 and L4 spinal segments in the world. (“Follow-up evaluation of resected lumbar vertebral chordoma over eleven years”r by Ken Hsu, James Zucherman, et al. Spine. October 1, 2000. Lippincott, Williams & Wilkins.) This patient is still alive after 29 years. In 1987, chordoma led to death in 63% of cases, with 50% survival rate at five years and 28% survival rate at ten years.