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Spinal Treatment at the Bone & Joint Clinic of Houston

In any given year, more than 50% of adults in the United States will suffer from at least one episode of neck and/or back pain. While most of these complaints resolve without significant problems, almost all are very uncomfortable and some are indeed serious. The Bone and Joint Clinic of Houston offers Evidence-based Spinal Care to best serve the patient with spinal complaints. The utilization of Evidence-based Medicine techniques implies the consideration of each patient’s own special needs. The best research evidence available on spinal disease is then applied to the treatment needs of each patient and combined with the experience of your spinal specialist at the Bone & Joint Clinic. The over-lapping of these three areas, patient needs, best research evidence and physician experience is what defines the practice of Evidence-based Spinal Care:

Evidence-based Spinal Care

Conservative Care of Spinal Disease:

The cornerstone of good spinal care is based on conservative, non-operative treatment. The majority of spinal conditions ranging from simple sprains and strains to actual disc herniations (often referred to as a slipped disc or disc rupture) will usually respond to this type of care. Surgery of the spine, while available from your spinal specialists at the Bone & Joint Clinic, is used sparingly and only for surgical conditions that fail to respond to conservative care or in rare emergency situations where waiting might lead to serious neurological injury.

Evidence-based conservative care of the spine involves the use of education, medication and exercise-based spinal therapy. The best research evidence suggests that the more the patient knows about his condition, the better he is likely to respond to conservative care. Your physician will educate you on why you hurt, what you can do to feel better and how you should expect to respond to treatment. Questions will be welcomed and every attempt will be made to answer them by our staff and spinal specialists.
Most patients will require medications to help with their pain initially. Medications are chosen to treat the source of pain, rather than just to cover up pain. Back and neck pain is often a result of muscle spasm (like a “Charlie Horse” that occurs in the leg) and the use of a muscle relaxant is sometimes indicated. Back pain and pain going down an arm or a leg (sciatica) can also indicate a nerve is inflamed and an anti-inflammatory medication might be prescribed (such as Naprosyn, Mobic or Arthrotec). Many of these medications are available at your drug store without a prescription as well (Advil and Aleve) and often work just as well as the more expensive prescription medications. Finally, in cases of extreme pain, an actual pain medication might at first be added to the these medications to help control this extreme pain such as Ultram (tramadol) or even, for a short time, a narcotic such as Darvocet or Vicodin.

While a day or two of partial bed rest may initially be needed to treat your spinal condition, recent research in spinal care has indicated that prolonged bed rest only deconditions the patient’s spinal muscles and prolongs his or her recuperation. Your physician will suggest the use of exercises or prescribe a course of exercise-based physical therapy to help speed healing and rehabilitate your spine. You are able to do the therapy wherever it is convenient for you, but we recommend the Bone & Joint Clinic Physical Therapy Department as an excellent place to start this treatment. Our therapists are trained in the most recent, exercise-oriented spinal therapy programs.

Spine-related Pain Management

Some spinal conditions are more severe and involve severe nerve pain that fails to respond to medication. In such conditions the use of one or more spinal injections may be helpful. One type of injection that might be needed is an epidural steroid injection (ESI). In this pain management technique, a patient is sedated and a real-time X-ray device is used to help guide a needle close to the area of nerve inflammation.  When the needle is in the right position a combination of synthetic cortisone and a numbing medicine is injected. This type of treatment can be successful in avoiding surgery for conditions such as a herniated disc (slipped disc or disc rupture) or a condition known as spinal stenosis, often seen in older individuals that have not responded to the usual conservative care. Your spinal specialist at the Bone & Joint Clinic can tell you more about this technique and others that we provide for patients in need of such treatment. (Epidural steroid injection interactive video)     

Rarely, some patients have a condition in their spine that results in chronic and unremitting back pain, neck pain or sciatica. These rare conditions are considered chronic pain syndromes and are often related to scar tissue that has formed in the spinal canal from previous surgery. While rare, these conditions are difficult to treat. This kind of condition almost never responds to further spinal surgery and oral pain medication frequently is inadequate. In such conditions consideration may be made by you and your spinal specialist to use a spinal cord stimulator (Spinal cord stimulator implant interactive video) or implanted medication pump (Intrathecal pump implant interactive video) . These implantable devices, about the size of a cardiac pacemaker or pack of cigarettes, require your spinal specialist to perform a small surgical procedure to implant them. This procedure is done along with a pain management specialist who will then be responsible for managing your pain and monitoring the device after surgery.

Spinal Surgery

If conservative treatment including education, medication and physical therapy fails to resolve your spinal complaints, you and your spinal specialist may discuss further options for treatment including surgery. Prior to any surgical decision, an advanced imaging study such as Magnetic Resonance Imaging (MRI) or a myelogram/CT scan will be required. An MRI is a scan that gives your doctor important information on the inside of your body and, in this case, the inside of your spine. It is the test of choice for patients who do not have any contraindications to its use (such as a pacemaker, metallic clips in their brain or fragments of metal in their eye). (Spine MRI) Many patients who might have a contraindication to having an MRI can often have a myelogram/CT scan instead (Myelogram/CT Scan). If you cannot have an MRI and are allergic to iodine or some shell fish such as shrimp, you cannot receive myelogram dye and a simple CT scan can by used to help diagnose your spinal condition. (Computerized Tomography (CT or CAT Scan))

Even though the majority of lumbar or cervical disc herniations respond to conservative care and can resolve over time, lumbar and cervical disc herniations remain one of the most common reasons for spinal surgery. (Lumbar herniated disc interactive video). When the symptoms of a disc herniation do not resolve with appropriate conservative care or are associated with neurological symptoms beyond just pain, surgery may be considered by you and your spinal specialist at the Bone & Joint Clinic.

Traditionally, a lumbar disc herniation that has failed to respond to conservative care has been treated surgically by a laminectomy and removal of the ruptured or herniated portion of the disc. (Laminectomy Procedure ). This type of procedure usually allows the patient to go home the day after surgery. In some cases, a newer, minimally invasive technique, the Lumbar Micro Endoscopic Discectomy can be performed. Patients frequently go home the same day when this type of surgery is performed. ( Lumbar micro endoscopic discectomy interactive video ). Your Bone and Joint Spinal Specialist will discuss with you which procedure might be best for your surgical condition.

When a disc ruptures or herniates in the cervical spine (neck) (  Herniated Cervical Disc, Cervical Radiculopathy - Spine-Health.com )and fails to improve with conservative measures of education, medication and therapy, there are several different surgical treatment alternatives. If the disc is in a certain position more toward the back of the spinal canal (not the most common type of disc herniation), an approach from the back (posterior approach) of the neck can be utilized to remove the ruptured disc material. More commonly, the disc is pressing on the spinal cord and nerve root from the front and this condition requires the surgeon to operate through the front of the neck (anterior approach). An approach from the front of the neck requires that the entire disc be removed, not just the ruptured part. Following this type of procedure, a piece of bone graft is placed in the empty disc space and a small titanium plate is attached to the spine to keep the bone graft in place.

In some cases of cervical disc herniation, the front approach can be made and  rather than placing a piece of bone in the empty disc space one of the new artificial discs can be used to replace the old disc that was removed. Your spinal specialist at the Bone and Joint Clinic with discuss with you the indications for and against artificial disc placement in your condition.

More extensive spinal fusion and reconstruction procedures are available for patients with serious spinal problems and special needs at the Bone and Joint Clinic. The need for these types of procedures is far less common than simple disc surgery. These types of procedures can be quite complex and require prolonged surgical time or even several different surgeries. If you are a patient in need of this type of surgery, you will be given time to understand and educate yourself on this type of surgery by your Bone and Joint spinal specialist before deciding on whether to undertake such an operation.

Osteoporosis and Spinal Compression Fractures

Osteoporosis is a condition in which the mass of a person’s bone, and hence the strength of that bone, decreases over time. One reason that this occurs is a change in bone metabolism as a person ages. While anyone can get osteoporosis as they age, there are risk factors that increase the chance of developing this condition. Some of these risk factors include being a female after menopause or with insufficient estrogen, being of western European descent, smoking, low body weight, certain medications (corticosteroids, anti-seizure or anti-anxiety drugs),drinking too many sodas or too much coffee or alcohol, lack of sufficient calcium in your diet and lack of exercise.

Because osteoporosis leads to decreased bone strength, certain fractures are more common in people who have osteoporosis. In the spine, the fractures associated with osteoporosis are called compression fractures. More than 700,000 compression fractures occur in the USA every year. Many of these fractures are quite painful and a person who sustains multiple compression fractures over time can develop a spinal deformity causing them to become shorter and bent forward.

It is very important to know if you have osteoporosis because this condition can be treated with medications and in some cases changes in life style. If you are at risk for osteoporosis, your physician at the Bone and Joint Clinic can obtain a DXA Scan in our radiology department.

If you do have osteoporosis or low bone density, your physician will discuss medical treatment with you. You may only require calcium with vitamin D supplements and a program of weight-bearing exercises. You may also need some of the newer medications that can actually stop osteoporosis and begin building bone mass and strength up again such as Fosamax, Actonel or Boniva. Your Bone & Joint physician will discuss with you the best treatment and potential side effects. He may also suggest changes in your life style. If you have severe osteoporosis and are risk for bone fractures, in addition to treatment, he may make recommendations about daily living such as installing night lights and removing throw rugs to reduce the risk of falling and causing a fracture.  Repeat DXA scans at one or two years are advised to monitor your bone density.

If you develop a painful compression fracture of the spine, it is important to note that most of these will heal in time. Usually just rest, pain medication and sometimes a brace are all that is require for the pain to go away over a period of days to several weeks. In a small number of cases, the pain does not go away over several weeks or sometimes the pain is so intense the patient becomes bed-ridden and cannot get to even go to the bathroom. In severe cases such as these, a procedure known as a Kyphoplasty (http://www.spine-health.com/dir/kyph.html) can be done to rid most patients of pain. In this procedure, the patient is taken to the operating room, given a short anesthesia and one or two balloons are placed through a small incision into the broken spinal bone. The balloons are inflated to help re-establish the height of the compressed spinal bone and then the balloons are removed and the bone is filled with bone cement to make it strong again and decrease the pain. If you have a spinal compression fracture, your Bone & Joint Spinal Specialist can discuss with you this technique and whether it is appropriate for you.