Dr. Dharmesh R Patel

1. Axial pain: 
   • Neck pain 
   • Back pain
2. Radicular pain(Brachialgia or sciatica)
   • pain origin from neck and spread toward elbow or hand is called BRACHIALGIA and
   • pain origin from back and spread toward foot is called SCIATICA

Numbness and altered sensation in limb

Pain /numbness/ heaviness in both lower-limb developed after walking of some distance OR on standing only

Hand function difficulty – decrease sharpness in hand function like,.. Difficulty in hand writing/difficulty in button and unbutton of shirt
Urinary function disturbance – loss of control on start or hold of urination

May developed in children or geriatric age group, side bending(SCOLIOSIS) spine forward bending(KYPHOSIS) of spine

Cervical spinal root or cord will be compressed with disc prolapse at cervical spinal canal. This compression leads to numbness and BRACHIALGIA – pain origin from neck and spread to hand / arm; may be associated with weakness in muscles of upper limb.

Management : acute cervical disc prolapse – if weakness is associated – early surgical decompression will have good outcome. If there is no neurological deficit we can wait for 4-6 week with medicine and other treatment like steroid injection etc. Chronic cervical disc prolapse – duration of symptom more than 4-6 week, is less likely to improve with medicine & nonsurgical treatment, so they require surgical decompression. After decompression of spinal root/cord, we can see improvement in pain – weakness – numbness over the time.
Surgery for Cervical Disc Prolapse :
1) Anterior cervical discectomy and fusion-fixation
2) Posterior cervical discectomy.

Stenosis suggest for narrowing of space available for spinal cord in vertebral canal. Stenosis in cervical region, resulted in compression of cervical spinal cord with or without spinal cord changes – myelomalacia and some times additional cervical root compression. Patient with cervical stenosis presented with neck pain, upper limb pain, difficulty in walking, hand function difficulty, urination difficulty and some time they developed all four limb weakness(quadriplegia) even after minor trauma.

Management : Usually this type of patient has natural progressive course of disease and less likely improve with conservative -medical treatment. Further as considering risk of sudden progression of weakness after minor trauma, we advice for surgical decompression for early presentation of cervical stenosis with cord compression. Depending on pre-operative neurological status and other factor, improvement after surgery will be noted over few months. Surgery can be- cervical posterior decompression with/without fusion, cervical laminoplasty, or anterior cervical decompression and fusion-fixation.

Spinal disc is made of central nucleus pulposus and peripheral annulus. Due to multiple reasons (most commonly degenerative age related changes and overload over disc,…) annulus become weak, resulted in disc prolapse of central part of nucleus pulposus come out toward to spinal canal which contain spinal root/cord. Now due to this disc prolapse in canal, space available for neural tissue decreased and compression(with inflammation and ischemia) over spinal root/cord developed. This leads to pain generation in typical nerve root which radiate to lower limb – foot/leg called SCITICA. Clinical examination and MRI add in diagnosis of Lumber disc prolapse. Management. In early case(before 4-6 week) without weakness in lower limb, trial of conservative treatment (other than operation) like, medicine, injection near nerve root and epidural space, physiotherapy etc, will work good.

Operative treatment is requirement if

1. Other than operative treatment (medicine, injection,..) failed
2. Weakness in lower limb, urinary difficulty etc (cauda equina syndrome)
3. Duration more than 6 week. There are multiple surgical treatment option is available(fig …. ).Out of this KEYHOLE (MINIMAL INVASIVE SURGERY) – MICRO/ENDOSCOPIC DISCECTOMY and PERCUTANEOUS ENDOSCOPIC DISCECTOMY is gold standard. After surgical decompression, sciatica – pain decrease significantly and patient is able to do daily activity in short duration after surgery.

Lumber stenosis and spondylolisthesis is developed due to age related degeneration. In Lumber canal stenosis, space available for spinal root and cord decreased and compression of neural tissue developed. Patient with lumber canal stenosis has NEUROLOGICAL CLAUDICATION -Pain /numbness/ heaviness in both lower-limb developed after walking of some distance OR on standing only. They may also associated with degenerative back pain. Spondylolisthesis means translation of one vertebra over other. This translation may developed with weakness of bone/facet joint resulted from congenital/developmental changes, degenerative changes, rarely traumatic. Patient with lumber spondylolisthesis has MECHANICAL back pain in addition to neurological claudication and radicular leg pain, weakness in foot.

Management : Conservative- non operative treatment(like medicine, injection, physiotherapy etc.) would give short duration of symptom relief and tried for early and non complicated cases. Common type of surgical option available for each as below.

For Lumber canal stenosis

1. Decompression laminectomy – decompression of neural tissue with removal of some part of lamina/bone.
2. Fixation and decompression – in sever spinal canal stenosis, fixation is required to avoid spinal instability in future and to avoid recurrence of pain/symptom

For Lumber spondylolisthesis SURGERY : REDUCTION–FIXATION–FUSION-DECOMPRESSION

1. POSTERIOR PEDICLE SCREW ROD FIXATION-FUSION, DECOMPRESSION
2. TLIF – TRANSFORAMINAL INTERBODY FUSION WITH PEDCLE SCREW FIXATION-FUSION,DECOMPRESSION (OPEN/MINIMALLY INVASIVE SURGERY)

Normal spine has physiological cervical and lumber lordosis and thoracic kyphosis and straight in coronal plane. Any change in coronal curve is called SCOLIOSIS and any change in curves of sagittal plane is called KYPHOSIS.

Common causes for change in curves are

• Idiopathic kyphoscoliosis
• congenital kyphoscoliosis
• neuromuscular or syndromic, etc

Usually this curve noted in 0-12 yr age group. Depending on cause, location and degree of curve etc., progression of kyphoscoliosis and its complication (cosmetic appearance, respiratory effect, neurological progression etc ) can be predicted. Progression of curve most rapidly developed in child’s growth sprut – 0-3 year