Mr Neil Orpen

MBChB FRCS (Ed) TR & Orth

Consultant Spinal Surgeon

Scoliosis

Scoliosis is a sideways curvature of the spine, in which the spinal column can also twist, pulling the ribcage out of position. Although many people have not heard of the condition it is surprisingly common, with three to four children per 1000 needing specialist supervision. Scoliosis is not a disease. It just means that in an otherwise healthy person the spine is curved or twisted. It is not infectious or contagious and it does not develop as a result of anything the adult, child, or its parents did, or failed to do.

Scoliosis can affect people at different points in their lives. It can occur at birth (congenital), in infants (early onset), in juveniles and adolescents (late onset) and as adults (degenerative or de novo). In most cases the cause is unknown and the scoliosis is called idiopathic. In the remaining cases the causes can be attributed to neuromuscular conditions, such as muscular dystrophy or cerebral palsy, or scoliosis can result from syndromes, such as Marfan’s syndrome.

It can affect a person’s appearance because when the spine bends to the side the vertebrae (the individual bones that make up the spine) become twisted and pull the ribs round with them, which sometimes forms a characteristic lump on the back and can cause the shoulder blade to stick out. The spine can bend towards either side of the body at any place in the chest area (thoracic scoliosis), in the lower part of the back (lumbar), or above and below these areas (thoracolumbar). It can even bend twice, causing an S-shaped curve.

When the curve is S-shaped (a double curvature) it is generally not noticeable and the person can appear quite straight because the two curves counteract each other. If the curve is lower down in the spine, the ribs will not be affected but one hip might be higher than the other. The causes of scoliosis are many, and although we well understand the consequences, the origins of this condition remain complex and obscure.

There is contradictory evidence as to whether early discovery and treatment of a curve improves the long-term outcome, but we know that if curves are discovered late, when they are already severe, the results of treatment can be compromised. Therefore it is important that early referral to a scoliosis specialist is achieved. Treatment in a scoliosis centre will usually prevent unsatisfactory long-term results.

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Spondylolisthesis

The term spondylolisthesis refers to a slip of one vertebrae on another, either backward( retrolisthesis) or forward (anterolisthesis). Minor degrees of slip are common in the aging spine but occasionally these slips may be significant enough to cause symptoms typically of back or nerve root/ radicular pain.- sciatica

Due to the shape of the spine being like a long S when viewed from the side, in the standing position different forces act on the different regions of the spine so as to make a slip more likely to occur. The position in the spine will also determine whether the slip occurs forward or backward. For instance a significant amount of force acts on the spine in the lowest lumbar segments and this contributes to the fact that a slip may commonly occur at L5/S1 or L4/5. These slips are part of a number of indicators of spinal instability and causes of a spodylolisthesis include:

• Degenerative discs and facet joints- most common

• Developmental - Due to a pars defect or fracture

• Trauma and associated fractures - usually high velocity injuries

The two most common are degenerative which tend to seldom be more than 50% and those due to a pars defect which can be greater degrees of slip.

Pars defects (spondylolysis) and fractures/Lytic spondylolisthesis

Pars defects occur when parts of the spine fail to develop correctly. The pars interarticularis is the bony element that connects the facet joints to the main structural elements of the spine and so if this bony element is missing or only formed by scar tissue, the vertebrae may slip forward over time. There are a number of other elements that support the vertebrae so the slip usually takes many years to develop. The mechanism behind this is not always clear but symptoms seldom occur until at least the teenage years.

Certain sporting activities can lead to excessive force being placed across certain elements of the spine leading to stress fractures or even complete fractures. These don’t typically require surgery but may require changes to those activities that have led to stress. If a fracture has been present for some time and has not led to a slip but is symptomatic, we can considered repairing the fracture/defect before a slip occurs. Once the vertebrae have started to slip, there is commonly associated change to the disc and typically we would reduce the slip and fuse the disc rather than consider a form of repair.

Degenerative Spondylolishesis

This is the most common group and often leads to symptoms in patients later in life. Symptoms of back pain and sciatica may require surgical treatment, as the condition is often associated with spinal stenosis. Although injections with steroid may keep symptoms at bay, ultimately patients often require surgery and in the presence of spondylolisthesis, may require a fusion procedure. This is very dependent on the patient’s particular symptoms and findings on clinical examination and scanning which also may dictate what surgical techniques may be used to deal with these symptoms.

Summary

The presence of a spondylolisthesis on a scan or X-ray is not in itself an indication for any intervention. Often these deformities may be quite subtle and only a coincidental finding when evaluating for other problems. If symptomatic, however, then Mr Orpen will take this into consideration when making a diagnosis for a cause of pain and in planning the appropriate treatment.

This should be discussed carefully particularly in considering whether surgery may make the slip worse if not dealt with at the time of a decompression of the nerve roots. Also, an indication of movement of the spine and spondylolisthesis may only be evident on standing or bending X-rays rather than on an MRI scan so it is common for this investigations to be performed in conjunction with one another.

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Back Pain

Back pain is an extremely common symptom in adults and is considered a normal part of life. 90% of people will experience back pain at some time in their lives but fortunately for the vast majority of people, this is a self limiting rather than a concerning feature.

Back and neck pain is itself a symptom rather than a true diagnosis of what is the cause of the symptoms and in patients that are experiencing troublesome symptoms, it is the role of the spinal surgeon to assess and diagnose what may be the cause of these symptoms. It is during this assessment that the surgeon will assess the likely cause and consider the likely progression of symptoms and then suggest an appropriate approach to managing those symptoms. As each person is different it is important to assess each persons symptoms considering the best management plan and it is not uncommon for this to be different depending on an individuals circumstances.

Causes of back pain

It is important to stress that most people will not have a concerning cause for their symptoms and so a full assessment with special investigations such as scans may not be necessary in everyone. In fact many people will have full resolution to their symptoms before presenting to a spinal surgeon and it is very unlikely that the is a serious condition underlying if symptoms resolve fully without intervention. With that in mind, the following conditions often present with back or neck pain with or without associated leg or arm pain.

Degenerative pain.

The normal aging process of the spine includes “wear and tear” changes to the mobile elements (discs and joints) of the spine and this when associated with pain is often referred to as degenerative neck or back pain. This tends to be self limiting but may recur or progress and tends to respond well to interventions such as osteopathy, chiropractic treatment and physiotherapy. The aims of these therapies is to manage the acute flare up of pain using manipulative or manual therapy and then reduce the likelihood of recurrence by starting a program of self performing exercises to strengthen the spinal musculature to support the spine and maintain as much movement in the spinal joints. No one program of exercises fits all but often protocols overlap and it is suggested always to tailor a program to best suite each patient. Pilates has become popular as a generic safe way of exercising the spine and a number of other programs are also useful.

Occasionally the pain does not settle despite this approach and a spinal surgeon will investigate things further and ascertain if there is an alternative cause as well as if simple injection therapy can aid the rehabilitation process ( see facet joint injections, nerve root blocks and rhizolysis) There are surgical options to consider which as specifically tailored to each condition.

Deformity as a cause of pain

Spinal deformity as a term covers a number of conditions including scoliosis, spondylolisthesis and buy far the most common, degenerative scoliosis. Not all of these conditions will present with any pain and often as they are asymptomatic may not need treatment at all. But some patients do have progression of their symptoms and relapses of pain and surgery may be considered if their pain persists.

Very often simple injections of steroid will control the symptoms, but surgery can be aimed at correcting the deformity, relieving and nerve compression and preventing progression of the deformity. The surgery may be performed at a single level or may involve multiple levels and is always considered a major form of surgery. There are a number of minimally invasive surgical options to be considered which can be helpful in aiding recovery and reducing the time spent in hospital but Mr Orpen will be able to advise you if any or these procedures are suitable for your specific condition.

Facet joint pain

This common condition responds well to physiotherapy/ osteopathy and chiropractic management. If these options fail, a set of facet joint injections of steroid may be performed as an outpatient or day case procedure under local anaesthetic. Denervation of the facet joints can be performed in a similar fashion for those that fail to have sustained benefit from facet joint injections

Discogenic back pain

This term refers to pain origination from the spinal discs and is a common source of both back pain and also associated leg pain/ radiculopathy. The pain from the disc commonly is worse on flexion and relieved by extension of the back and may be brought on by long periods of walking, standing or repeated lifting. Often it is relived by lying flat when all the stress is removed form the spine.

There are few injections that will improve these symptoms although nerve root blocks and epidural steroid injections are designed to place an anti-inflammatory around the disc and if there is an element of acute inflammation, these this will often improve symptoms. If symptoms are resistant to conservative options, surgery can be considered and this may involve a discectomy alone, and discectomy and stabilisation with a DIAM devise, fusion in the form of posterolateral fusion and interbody fusion, an anterior fusion ( ALIF) and Mr Orpen will also discuss if a disc replacement is an option to be considered.

The condition and cause of pain in these situations is very complex and surgery is seldom considered unless all other options have failed and symptoms are very disabling or severe.

Rare but concerning causes of back pain.

In a very small group of patients pain may be caused by fractures, infections and as a result of cancers. Each of these will be considered separately but as they are not common should not be the first thing to come to mind when evaluating back and neck pain. Doctors are trained to consider these conditons when evaluating back pian and so will usually have asked probing questions about the pain to evaluate whether the symptoms may suggest any of these conditions may be present.

Some of these questions are directed at so called red flag signs which are designed to remind practitioners and patients that don’t often treat spinal problems to be thinking about the possible underlying condition and even in themselves are not a clear indication that there is a problem. What they do suggest is that a second careful look is taken and appropriate investigations are performed to exclude more serious conditions.

These symptoms relating to back pain include:

• New onset back pain in children needs investigation as children seldom experience back pain and most of the conditions we commonly see occur exclusively in adults

• New onset pain in older patients particularly when occurring for the first time, after a stumble or fall, or that gives pain at night should be investigated further.

• Any patient that has a known history of a malignancy that develops back pain, should have this investigated

• If one feels unwell or has lost weight with the development of back pain, this should be investigated further

• Back pain that is associated with worsening neurology, should be investigated.

Most patients are better off initially seeing their family practitioner if any of these symptoms are present but if they feel further investigation is required should ask for a referral to a spinal surgeon. In the presence of these symptoms, Mr Orpen will ensure you are seen straight away.

Investigations in back pain evaluation

The most common investigation usually performed is an x-ray of the spine or neck taken in the position that brings on the most symptoms, this is usually therefore performed standing upright. X-rays are a useful way of assessing the spine as they can be performed in different positions such as standing, sitting, flexing forward or extending the neck or back. The are particularly aimed at looking at the bony elements of the spine and help to assess structure and mechanics which is useful as many of the causes of back pain are related to abnormalities of structure and how the bony elements relate to one another.

MRI scanning is an extremely useful investigation performed on the spine and is specifically aimed at looking at the neural elements and discs. It is typically performed lying flat and so does not give the best assessment of the spinal structure but can give some useful clues. MRI scanners are long tubes and therefore for scans of some parts of the body, the whole body enters the tube which may cause difficulty with patients that suffer from claustrophobia but this experience is typically less in an open scanner.

The Ridgeway Hospital has an open scanner which may be useful in these instances but image quality is not as good as a closed scanner and some scans cannot be performed in the open scanner. Mr Orpen will let you know if you scan can be performed in the open scanner or if a closed scan is recommended. If claustrophobia is a real difficulty, then we can prescribe sedative medication that some patients find very useful in making the scan more tolerable.

CT scans are sophisticated x-rays which involve computers to generate 3 dimensional views of the spine in great detail. They are also performed lying flat but also are useful in some conditions where very fine detailing is required. They are not requested in all patients but are used in some specific situations and in specific conditions.

Bone scans or bone scintograms are a nuclear imaging study often used to assess for malignancy and infection in the spine. SPECT CT scans are a combination bone scan and CT scan which can be used when trying to isolate a specific cause or source of pain when a number of potential causes exist. This is often useful when trying to plan very limited surgery in the presence of a number of degenerative findings on MRI scans and x-rays. These scans are seldom a first line option in working up back pain and Mr Orpen will specifically advise if this si the case.

Diagnostic injection procedures:

When trying to identify a pain source, a very useful technique is to inject local anaesthetic around the pain source to temporarily block the pain signals from that area. Often the injection itself may also cause some pain due to stimulation of the painful area. This local anaesthetic may be short working ( lignocaine- 30 min – 1 hour ) or long working ( marcaine 8-12 hours). Often this is mixed with a steroid which has a potentially long working therapeutic action as a long working anti-inflammatory agent. Nerve root blocks, facet joint injections and discograms are used in similar circumstances to aid the diagnosis in evaluating pain.

Summary

Evaluation of the many causes of back pain is typically performed using a combination of the above mentioned. This therefore involves taking a clear history to guide the examination which is then supported by a group of key investigations which may then be supported by some further diagnostic procedures to ensure the best judgement may be made in choosing a particular treatment. There are some conditions where this process will be short as early on in the process, the diagnosis will be very clear and also in other situations, a complex diagnosis may need a number of investigations before a clear plan may be formulated.

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Spondylodiscitis/Infection

Spondylodiscitis is a combination of discitis (inflammation of one or more intervertebral disc spaces) and spondylitis (inflammation of one or more vertebrae), the latter generally involving the areas adjacent to the intervertebral disc space.

Spondylodiscitis is the most common complication of sepsis or local infection, usually in the form of an abscess. The main causative organisms are staphylococci and Mycobacterium tuberculosis, but potential organisms include a large number of bacteria, fungi, zoonoses. Spondylodiscitis frequently develops in immunocompromised individuals, such as by a cancer, infection, or by immunosuppressive drugs used for organ transplantations.

The main methods to diagnose a spondylodiscitis are magnetic resonance imaging (MRI), biopsy and microbiological tests such as PCR to determine an infectious cause.

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Spinal Tumours

Spinal cord tumours can be either benign or malignant. This website concentrates mainly on benign spinal cord tumours. Although benign tumours may not be particularly harmful in most parts of the body this differs where spinal tumours are concerned as damage to the spinal cord or nerves can cause many problems.

Symptoms

Initial symptoms can vary. They can include pain and sensory changes (eg numbness) and motor problems (eg muscle weakness and spasticity). The parts of the body which may be affected by these symptoms may vary according to the location of the tumour along the spinal canal.

Diagnosis

Several neurological tests will be performed. If necessary you will also have an MRI (magnetic resonance imaging) scan. This will show the spinal cord in detail.

Treatment

If a spinal cord tumour is diagnosed the most common form of treatment is for it to be removed by surgery. This will be carried out by a neurosurgeon. In some cases it isn’t possible to remove the whole tumour and the growth of the residual tumour is usually monitored by regular MRI scans. Sometimes surgery isn’t recommended because the damage it might do to the nervous system is considered too risky, and your consultant will discuss your options with you following your diagnosis.

Long term effects of benign spinal cord tumours

This can be very difficult to predict. Sometimes the nerves can recover to some extent but in other cases there may be some permanent nerve damage.

Further information can be found on the Patient.co.uk website.

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Consulting Rooms

The Ridgeway Hospital

Moormead Rd
Wroughton

Swindon
Wiltshire

SN4 9DD

 

NHS Secretary (Ridgeway)

Wendy Spencer

National BMI Spinal

MDT Co-ordinator

Tel: 01793 814848

Email Wendy here

Private Secretary (Ridgeway)

Geraldine Jackson

Tel: 01793 816006

Email Geraldine here

Private Secretary (Berkshire)

Andrew Capel

Tel: 0118 9028147

Email Andrew here

Berkshire Independent Hospital

Swallows Croft
Wensley Road
Reading
RG1 6UZ