Disc Arthroplasty > Cervical Arthroplasty

Replacement of intervertebral discs with artificial discs  is called discoplasty and is designed to maintain mobility of the cervical spine and to avoid shifting of loads to adjacent discs. Discoplasty  is not a technique that can be applied to all patients who undergo cervical microsurgical discectomy. Discoplasty can be applied in cases where the degenerative lesions of the level are not especially severe and there is no mechanical instability (spondylolisthesis) and the neurosurgeon wants to maintain the motion at this level.

In these cases, after discectomy and decompression, instead of  implanting a fixed plate and  cage to maintain the intervertebral disc space, an artificial disc is implanted which maintains both the intervertebral space and mobility. This modern method requires special training and familiarization with the necessary surgical instruments, but has the advantage  that  the maintenance of movement lessens the loads on adjacent discs in the long-term, which loads in the case of cage fixation are significantly increased  because the center of movement is transferred to the adjacent disc. Depending on the ability of the surgeon discoplasty can be applied even in more complex cases in selected patients. It is then combined with the placement of fixed cages in adjacent intervals, to achieve greater decompression and restoration of the anatomy of the cervical spine.

With the development of implants a  permanent solution has been provided  for the unwanted creation of osteophytes which up until now were a common finding in postoperative follow-up of cases treated with spinal fusion performed with fixed cages and plate.

This method allows the elimination of the danger of  pressure  being placed on the neural structures of the surgically treated level by the formation of osteophytes. Therefore the artificial disc gives a final and permanent solution without presenting this risk.

Minimal Invasive Surgery - Spondyloplasty (Verterbroplasty)

Is a minimally invasive, non-surgical method which is performed for the treatment of osteoporotic vertebral fractures or less common tumors of the vertebral bodies of the spine. It is also performed for painful hemangiomas  or traumatic fractures. Spondyloplasty is performed percutaneously  by introducing a thin needle into the vertebral body under the fluoroscopy or CT guidance. A special polymer (PMMA) is then injected through the needle, which hardens into an extremely durable solid material within a few minutes. The patient is immediately relieved of pain, the kyphosis is significantly improved and usually only a few hours of hospitalization are required. After two - three days the patient returns to his/her daily routine.

The diagnosis is usually made by radio-graphic control with computed tomography (CT) or nowadays with magnetic resonance imaging (MRI) but only after a detailed clinical examination has been performed.

After the procedure the patient does not need to be treated with painkillers. The success is immediately perceived by the patient and confirmed by CT imaging at the follow-up examination which is usually scheduled within the first month after the procedure.
The reduction or disappearance of pain helps patients regain lost mobility which further assists in the prevention of osteoporosis.

Minimal Invasive Surgery - Kyphoplasty

Kyphoplasty is the most advanced method for treating osteoporotic fractures of the spine. The word kyphoplasty is a compound word which means  plasty(repair) of kyphosis(hunchback).The purpose of the surgery is the restoration and strengthening of the vertebral body which is weakened and deformed because of fracture while simultaneously providing substantial pain relief. The method entails the correction of the shape of the vertebral body with the help of a special balloon and the injection of bone stabilization material (PMMA)into the vertebral body.

The method we apply is minimally invasive which uses modern technology for the therapy of Spine Compression Fractures(SCF) due to its ability to control the shape and volume of the void and to prevent the leakage of material used as a filler.

This is a method of reduction, and strengthening the "fractured" and "compressed" osteoporotic vertebral body through very small incisions in the skin. In this manner the incision does not exceed one centimeter, which as result does not cause muscle damage, the patient recovers immediately and is able to leave the hospital even on the same day in most cases.

The technique uses a non-stretch material PET (Polyethylene Terephthalate, a biocompatible material for artificial vessels and ligaments) which is filled with bone substitute mixed with PMMA to restore vertebral body height. This provides immediate stabilization of the spine, and pain relief. This cage(balloon) and the injector system control the volume and the shape of the material being injected without creating a void in the compressed vertebrae and they also allow contact due to the penetration of filling material through the pores of the PET cage( balloon) during the procedure. As the pore size and the number of layers of  the PET  cage (balloon) are  predetermined, the flow of the filling material through the pores is controlled.

The cage(balloon) used in this procedure acts as a dilator of the vertebral body, but also as a receptacle for filler  injected,  as it is inserted into the  fractured vertebra in "deflated" form. When placed inside , it is filled taking its final form, elevating the vertebral endplates with the filler.

In addition to osteoporotic fractures, the method has been applied with great success both on primary malignant tumors (multiple myeloma, plasmacytoma) or osteolytic metastatic tumors, as well as  benign tumors of the spine.

Minimal Invasive Surgery - Microdiscectomy

Nowadays the microscope can be used in almost all surgical procedures it is incorrect not to use it during surgery. In particular for the spine, use of the microscope allows minimally  invasive techniques. Techniques with minimal trauma, no injury to the tissues in order to access the surgical field and minimal destruction of healthy tissue.

The magnification of the plane are necessary to safely be able to separate the healthy structures and to remove the pathological tissues with maximum surgical precision without the need to repel the structures causing further affliction.

Especially in microdiscectomy where it is necessary to create a minimal entry window in the lamina so that the micro instruments can facilitate access to expose the herniated disc. Minimal or no retraction of neural structures is necessary to distinguish the tissues and with the necessary safety to remove the herniated disc away from the pressed root or any adjacent channel structure. At the same time any intraoperative difficulty is addressed more easily seen as the safety of magnification and focus allow the safe and timely reaction of the neurosurgeon.

Minimal Invasive Surgery - Mini Interbody Lumbar Spinal Fusion with “stand alone” cages

The term minimally invasive surgery describes surgical procedures that cause less tissue damage, bleeding and complications in relation to the incisions of traditional surgery.

Minimally invasive surgical techniques are used to treat degenerative discs, spinal stenosis, spinal fusion, scoliosis, osteoporosis, compression fractures, as well kyphoplasty or the treatment of spinal tumors and spinal fractures. With the help of a computer, the surgeon is virtually guided by special imaging equipment (fluroscopy), and is able to identify the different areas of the spine with greater precision.
These types of surgical procedures in combination with the traditional surgical skills, know-how and experience allow the neurosurgeon to perform more precise movements within the surgical area, which reduces  the risk of damage to the nerves, muscles, bones and tissues in comparison to traditional surgical techniques.

 

Especially in cases of lumbar disc herniation relapse or first grade spondylolisthesis it has been shown that the mini Interbody fusion is the final solution. More specifically and with posterior lumbar access a bone window is created without requiring laminectomy to allow access for removal of the corpus ligament, fat and herniated disc and then two expandable cages  are implanted intervertebrally which ensure both stabilization - fusion  and prevent prolapse of disc  into the inner foramen or spinal canal. The outer surfaces of these cages are coated with hydroxyapatite material that promotes synostosis with the vertebral bodies. 

Minimal Invasive Surgery - Cranioplasty

Large deficits of the skull do not only cause aesthetic problems for the patient but also pose risks in particularly exposed areas and cause functional disorders with fluctuations of intracranial pressure(ICP) ,headaches, vertigo etc. Also, random direct percussion of the underlying brain cortex may result in irreparable damage and can also trigger epileptic seizures.

 Surgery is performed for deficits with a diameter smaller than 3cm only for aesthetic reasons, however in deficits larger than 3cm cranioplasty is almost always recommended.

 If there is no previous history of infection the cranioplasty is recommended as soon as possible, in other words immediately after surgery or within  3 months, whereas in the event of infection, the cranioplasty should not be performed in less than 6 months. Research has shown that cranioplasty performed within the first 6 weeks significantly improves the cerebral blood flow.

The new method of Cranioplasty is performed using a special implant which is custom made in the exact dimensions of the cranial deficit of the patient which means considerable ease and perfect fit in the implantation procedure.

International and personal experience has shown the immediate beneficial results of a cranioplasty can have in essentially helping a patient who already has serious cranial damage in their further rehabilitation.

Minimal Invasive Surgery > Microsurgery

Image guided surgery of the Brain and Spine

The trend in neurosurgery is characterized by minimizing of  surgical trauma and the improvement in  visibility of the surgical field. The use of neuroendoscopy  during neurosurgical procedures is the modern triumph.

Microsurgery with neuro Navigation

The endoscope is used during trans-nasal  transphenodial  removal of pituitary adenoma, during the insertion of drainage valves for hydrocephaly, to perform third ventriculostomy to remove skull base tumors in combination with microneurosurgery.

Another method for the precise location of the position of a tumor is stereotactic. Special equipment (special stereotactic frame and software) and with the guidance of CT or MRI offers the possibility of determining the damage to the millimeter.

Newer techniques however use special computer assisted equipment   and robotic arms or special microscopes to access and remove  respective tumors.

The abovementioned techniques can be applied to non-surgically accessible tumors which cannot be accessed and resected (eg tumors of brainstem and hypothalamus) to take a biopsy or brachytherapy with placement of microcatheter for radioisotope infusion, radiolabelled antibodies chemotherapeutic drugs or genetically engineered substances.

Over the past three decades, advances in surgical neuro oncology have been made in two sectors: the equipment which allows minimally invasive surgery and the quality and variety of imaging methods. The two sectors are now combined defining the beginning of image-assisted minimally invasive surgery.

Neuronavigation

Virtual imagery, or otherwise neuro navigation can be used before surgery to plan or even to carry out a test surgery. It can also be used for planning surgical approach. It can also be used in real time to record the progression of the surgery and to see beyond the visual field to protect the patient from the destruction of structures beneath the surface invisible to the surgical microscope.

There are two basic methods of using images to navigate in three dimensions. For micro millimeter accuracy an external stereotactic ring is used, which is fixed to the skull and used as a reference, this developed into a system without a ring, which allows recording on the patient's skin or bone and can perceive changes in real time. Therefore, a series of cameras continuously record the positions of the patient and surgical instruments and play them on screen in three dimensions in relation to the tumor of patient, the  blood vessels and the healthy structures of the brain with a delayed measurement of only a few milliseconds.

Intraoperative imaging

The construction of a virtual brain (and tumor) is a big step forward, but the brain is not a static organ. It begins to move as soon as the skull is opened and continues to move as cerebrospinal fluid (CSF) continues to decrease during surgery.

Future applications

The sensitivity of magnetic resonance imaging (MRI) to changes in temperature is an important element in typesetting of new therapeutic methods for brain tumors. This capability allows the neurosurgeon to record thermal variations in microsurgical techniques, such as laser treatment, radiofrequency therapy, focused ultrasound techniques and cryosurgery. The focused ultrasound is a very attractive option because it does not need the surgeon to perform craniotomy, or to dissect the skin to thermally remove a tumor.

Our Medical Focus - Minimal Invasive Surgery

This is the application of minimally invasive methods either for conditions - injuries of the brain or for conditions - injuries of the spine.
This possibility was given to us by the widespread use of the microscope and their improved capabilities.

The focus and zoom of the surgical plane gives us the opportunity through a small incision 2-3 cm long to have access to a wide range of brain structures by changing the direction of view of the microscope in all axes.

 With this method the surgical trauma is minimal, postoperative recovery easier and ressections applied intraoperatively minimum.
Characteristically tumors of the skull base can be accessed in several cases  through a small incision in the eyebrow and a small craniotomy made in the underlying frontal bone.

The same technique of a small incision is applied in spine surgery to repair damage in all the degrees of the spine. Nowadays, microdiscectomy, decompression of  neural structures, disc replacement, spinal fusion, vertebroplasty – kyphoplasty, even  tumor extraction canin fact be performed through skin incisions of 2-3cm.

Cervical Spine

SURGICAL TREATMENT OF CERVICAL SPINE CONDITIONS

Introduction


Surgical treatment of conditions of the cervical spine is based on the correct preoperative evaluation of the nature and location of the lesion with the help of clinical, neurological, radiological, electrophysiological  and neurosurgical examination by a specialist neurosurgeon.

For discopathy, spinal stenosis and spondylosis the following should have particular evaluation and interpretation :

• the duration of radiculopathy (pain-findings peripheral nervous system) or myelopathy (findings in the  upper & lower extremities  ie the central nervous system or spinal cord)
• the age and
• the history of diseases that may contribute to the clinical picture (angiopathy, diabetes).

Neurosurgical intervention accordingly:

• for radiculopathy (neck-shoulder-brachial neuralgia with or without motor-radicular symptoms) is decided together with the patient,
• if the myelopathy and clinical symptoms are causing difficulty in fine movements of hands and gait (pronounced spasticity or instability) is imperative and immediate.

 

CONDITIONS OF THE CERVICAL SPINE

The cervical spine is the first segment of the spine. It consists of 7 cervical vertebrae which support the skull. The cervical spine is designed to allow movement of the head. It is surrounded by many muscles which contribute both to the support of the head and to mobility. The cervical nerves emerge from between the cervical vertebrae.

Degenerative lesions of the cervical spine appear in most people above the age of 40, however the type and extent vary considerably. The clinical severity of  degenerative lesions vary significantly, therefore the mild forms remain asymptomatic yet the more severe forms can even cause serious disability.

The main clinical manifestations of disease are stiffness, pain, radiculitis and myelopathy. Degenerative disease can affect all individual anatomical structures of the cervical spine such as: a) the intervertebral disc (discopathy), b) the small joints (osteoarthritis), c) the vertebral bodies (especially the epiphyseal plates), d) the ligaments mainly the ligamentum flavum and posterior longitudinal and e)paravertebral muscles.

Depending on which anatomical structure of the cervical spine is affected, degenerative disease is distinguished as degenerative disease of the small joints, degenerative disease of intervertebral discs, etc. Because the different anatomical structures function as a unified mechanical whole, the degenerative lesion of one anatomical structure  through interaction cause degeneration of adjacent anatomical structures, which result in practice to degenerative lesions occurring in more than one anatomical structure eg  reduction in height of the intervertebral disc increases the load and the mobility of articular apophysis, with result the development of osteoarthritis.
Conditions of the cervical spine cause a sensation of pain which is located basically in the neck area. Depending on the cause of the pain, it can reflect to other areas or be accompanied by other symptoms.

One condition of the cervical spine is discopathy. Between the cervical vertebrae are intervertebral discs which are responsible for the flexibility and mobility of the cervical spine. In case of intervertebral disk displacement, a phenomenon not at all uncommon due to the gradual deterioration induced is pressure on nerves resulting in pain and the onset of neurological disorders.

Another condition of the cervical spine is cervical syndrome. The cervical spine is surrounded by many muscles and there is a big risk of it being injured or for a muscle to stretch suddenly, only by weight of the head they support. In this case intense pain can also appear as a result of an accident and by whiplash injury.

The term cervicalgia  (sometimes rather incorrectly referred to as cervical syndrome) simply means pain in the area of the neck, although in several cases the pain may extend to the shoulder region, shoulder, arm or whole arm.

The most common cause of cervicalgia is of a mechanical nature, in other words it is caused by the various movements or  prolonged work in the office, bending and other activities. The most common cause is the deterioration of the intervertebral discs and joints of the cervical spine.(Of course, various injuries can cause pain in the neck, however these are not “cervicalgia”).

Regarding the extension of  pain(and also numbness and/or muscular weakness) into the areas of the shoulder, shoulder blades, arm and/or upper extremity, all of these problems can be caused by pressure, local irritation or inflammation of various nerves that are close to the affected intervertebral discs and joints.

The various methods of therapy can help relieve the acute, very painful problems, but the degeneration (mainly due to age) of the intervertebral discs and joints cannot be reversed.

DIAGNOSIS OF CERVICAL SPINE CONDITIONS

Pain in the neck is a warning of various problems but very rarely leads to severe disability, unless neglected for a long time. Simple  X-rays and computed tomography (CT scan) may help to clarify the cause or causes of the problem in some cases but are not usually useful as initial tests as soon as a problem in the neck appears.


 

Magnetic Resonance Imaging (MRI scan) of the cervical spine is the most useful test to lead to the diagnosis of  the source and nature of the problem, which is why it is considered as test of choice.

The MRI may reveal the following medical conditions with absolute clarity:

• Degeneration of the intervertebral disc: The first two findings of degeneration of the intervertebral disc are dehydration of the nucleus pulposus and the reduction in height of the intervertebral disc.
• Vacuum Phenomena: The term “Vacuum Phenomena” refers to the concentration of gas in the fissures which are created within the degenerated intervertebral disc.
• Calcification of the disc: Calcification is observed in the fibrous ring and secondarily in the nucleus pulposus.
• Osteophytes: Osteophytes are bony projections from ectopic osteogenesis which are formed as a result of   minor movements & injuries caused at the point of adhesion of the fibers of the fibrous ring with the vertebral body. 
• Degenerative lesions of epiphyseal plates: Degenerative lesions of the epiphyseal plates of the cervical vertebrae are found to a lesser extent compared to the lumbar vertebrae.
• Herniated disc: In the cervical spine, in order of frequency herniated discs are formed in the C5-C6 intervertebral disk (51%), the C6-C7 intervertebral disc (24%), the C4-C5 (17%) and less on the remaining disks. (types: bulging disc, focal protrusion, disc extrusion,  disc sequestration)
• Stenosis of the spinal canal: We refer to the reduction in the diameter of the spinal canal as stenosis

TREATMENT

The patient with a cervical condition must seek the help of a Neurosurgeon or Orthopedic Surgeon, always however to a spine specialist, when:

• The pain is so intense that it becomes intolerable,
• Pain worsens progressively (progressive)
• Simultaneous presence of various other symptoms (such as numbness, muscle weakness) of the upper or lower limbs.

The experience and specialization which every modern center for the treatment of spine conditions should have will help to determine which patients could benefit significantly from surgical treatment and which not. Patients with persistent neurological problems(in other words symptoms resulting from  pressure or inflammation of the nerves of the cervical spine) belong in the first category as well as patients with symptoms resulting from “reversible” conditions ,in other words conditions of the cervical spine which the specialist surgeon knows can have good results following surgical treatment (e.g. development of instability in specific levels of the cervical spine).
With modern diagnostic and technical developments the results of surgery of the cervical spine are very good, above 90% (for pain in the upper arm) and more than 60% (for neurological problems such as numbness or weakness in the limbs) when the treatment is not delayed more than 3 months from the appearance the  first complaints.

Recent studies have confirmed the necessity for intraoperative neurophysiological monitoring in order to minimize intraoperative complications.

Types of surgical treatment

The main criterion for selecting the type of surgical approach and technique is the correlation of clinical-imagery findings.
The surgical approach and technique has two objectives: the treatment(decompression) of the stenosis, which results in the release of the neural structures and the stabilization or spinal fusion in order to mobilize the patient rapidly.

Modern surgery of the cervical spine is  based on the experience of the specialist surgeon, the surgical microscope, the microsurgical techniques, the surgical equipment (bipolar diathermy, high-speed drill, micro instruments, special dilators), the implants and  stabilization / fusion materials, the intraoperative radiographic examination.

Radiculopathy. In cases of focal stenosis  -discopathy of the intervertebral foramina (by disc material with or without the presence of osteophytes) causing shoulder-brachialgia and dysesthesias with or without objective radicular findings, microdiscectomy – micro-osteophytectomy  with anterior cervical approach and stabilization with a special implant is preferred.

The  further screwing of a metal plate on the upper and lower vertebral bodies is decided mainly by the coexistence or not of preoperative instability-listhesis of the specific intervertebral space. In general and especially in the younger ages placement of a plate is not required, since the spinal fusion may cause future damage to the adjacent intervertebral disc due to uneven distribution of forces (the two  'fused'  vertebral bodies press against the  adjacent one).

Myelopathy . For patients suffering from myelopathy the criterion to choose the approach is associated with the direction of  the stenosis –compression of the spinal cord. The most common stenosis is caused by chronic dehydration and degeneration of the intervertebral disc and subsequent anterior pressure of the spinal cord. Thus the surgical approach of choice is the anterior cervical decompression-stabilization. The goal of this surgical approach and technique is excision of the bulging disc, the osteophytes and the posterior longitudinal ligament via anterior tracheal approach. In rarer cases the stenosis affects the posterior structures of the spinal canal (ligamentum flavum hypertrophy) and osteophytes are formed on the vertebral arch and pedicle.The appropriate surgery in these cases is posterior approach with laminectomy at the levels which require decompression.In very rare situations, the stenosis is concentric that a combination of anterior and posterior surgical treatment in one or two surgical sessions is required. By contrast, the coexistence of stenosis in more than one level causing radiculopathy or myelopathy is relatively common. In such cases a clinical-radiological correlation that allows the surgeon to decide whether to the decompress  more than one level is essential.

Results - Expectations

Surgical treatment of the cervical spine is generally considered a safe and successful operation with a very low risk of complications (<3%) and a high success rate (95%). The main objective is the treatment of pain (shoulder-brachialgia), the gradual restoration of muscular strength, balance and sensation, with a simultaneous decrease of spasticity. Rare complications of the surgery are hoarseness ("deepening" of the voice), or difficulty swallowing, implant displacement, contamination and hematoma of the wound, and lesion-injury , of the nerve root, the spinal cord, a large vessel (commonly the carotid or vertebral artery), esophagus or trachea or sympathetic plexus.

Lumbar Spine

The lumbar spine consists of 5 vertebrae. There are intervertebral discs between each vertebra which help absorb the force loads, the flexion and rotation of the spine.

The main diseases of the lumbar spine are: degeneration, disc herniation, discopathy, spondylolisthesis, neuritis, osteophytes, inflammation, radiculitis, lumbago.

Regarding  degeneration  one should emphasize that it is due to the deterioration of anatomical characteristics over time. This includes both the spinal joints as well as the ligaments and muscles, tendons and surrounding tissues.

The term hernia on the other hand means a bulge which is present on the surface of the intervertebral disc. When this condition occurs the patient complains of  severe pain in the lumbar spine. The condition is usually as a result of sudden movement and weight lifting.
Another condition of the lumbar spine is spondylolisthesis. This is the slipping or displacement of the upper vertebra on the lower. Spondylolisthesis is usually the result of a chronic degenerative condition of the lumbar spine.

Osteophytes are bony projections formed as a result of micro lesions of the vertebra caused by degenerative processes.
Another condition is  neuritis caused by local inflammation due to irritation of the nerve root. In this case as well  the neuritis is usually  the result of a chronic degenerative condition of the lumbar spine.

Back pain, sciatica, lumbar disc herniation

The main cause of sciatica is pressure on the nerve root of lumbar spine. However for displacement of disc substance into the spinal canal or intervertebral foramen to occur there must be certain preconditions such as partial or total rupture of the fibrous ring in the posterior part of the disc.

Pressure of the nucleus pulposus on the fibrous ring causes the weaker section of the fibrous ring succumbs to the pressures of nucleus pulposus, it gradually expands and eventually the disc tissue is projected into the spinal canal or inner foramen. When the rupture is only in the inner layers of the fibrous ring up to the posterior longitudinal ligament, then the lesion is characterized as a protrusion of the disc. However a total rupture of the fibrous ring creates a passage for the nucleus pulposus. This is then a genuine prolapse of the intervertebral disc. If the hernia which has extruded is still connected to the interior of the disc it is possible under certain conditions for it to return to its original position. His condition is described as a retrograde hernia. Central hernias are the exception, because the posterior longitudinal ligament in the middle of the fibrous ring protects the disc and thus prevents its exit. Most commonly the disc L5/S1 is affected followed by L4/L5 and L3/L4.


Clinical Picture

The clinical picture is characterized by : severe pain, reduced mobility to a large degree with  deformation of the spine (antalgic scoliosis), pain in the lumbar-sacral region when coughing and sneezing, pain when tapping and putting pressure at the position of the lesion and radicular leg pain. Deviations of reflexes, motor and sensory disorders of the lower limbs legs make it possible to locate the position of the lesion.

Conservative treatment  advised is bedrest in a raised position(hips and knees at a 90° angle by placing more pillows under the knees.)This position neutralizes the patient’s lumbar lordosis and relieves the rear of the intervertebral disc. Furthermore, analgesics, anti-inflammatory and muscle relaxant medication are prescribed. Also, blocking the nerve root with a suitable local anesthetic can have good results. After the acute pain has subsided treatment is continued with physiotherapy (electrical stimulation, massage, spas, chiropractic techniques).

When conservative treatment fails to bring results and the neurological lesions increase, then surgical removal of the protruding disc tissue is indicated(discectomy). After the surgery the patient is immediately relieved of the symptoms. Physiotherapy is needed however to restore mobility and muscular strength. Cauda equina syndrome is a definite indication for surgery. This is a special type of lumbar disc herniation, mostly a mass central disc prolapse. The presence of loss of bladder/bowel  control and bilateral perineal anesthesia help to make a quick diagnosis.

Diagnosis:

Initial diagnosis of lumbar disease is primarily obtained with simple x-ray and dynamic tests in extreme positions. With the x-rays we check the bony lesions, the intervertebral spaces, foramina, the alignment of the vertebrae.

We gain more information after a CT of the lumbar spine is performed. The bony lesions and soft tissues are imaged with greater clarity.
MRI is considered test of choice due its excellent enhancement of lumbar spine disorders. It highlights lesions of the discs, ligaments, muscles, joints, bones and the subcutaneous tissue and skin.

CT- myelography is used in cases where magnetic resonance (MRI) cannot be performed provided that it can be  carried out safely and with minimal complications.

It often seems useful to evaluate an electromyography (EMG) of the lower limbs especially when lesions are multilevel and difficult to examine clinically, so that the evaluation of electromyography can assist in the final preparation in the planning of the surgery and surgical decision.

Lesions of the intervertebral disc

Chondrosis, Osteochondrosis, spondylosis
The process of degeneration of the intervertebral disc begins with the loss of water from the nucleus pulposis. This is followed by  loss of elasticity and tissue damage to the disc with early stenosis of the intervertebral space. This lesion is described as intervertebral chondrosis (chondrosis intervertebralis).

The degeneration of the quality of the intervertebral disc, which is included in the general concept of "lesions of the intervertebral disc" is closely linked to posture problems of humans. In an effort to maintain posture, the discs contribute as a means to help absorb load forces, flexion and rotation and the uniform transfer of powerful loads. Besides stabilizing the vertebrae, they provide the necessary mobility of the spine. Premature, lengthy and excessive mechanical stress  are causes of disc degeneration.

For the assessment of degenerative changes of the intervertebral disc, which can generally be checked radiographically, it is important for us to know if the body has been able  to stabilize the affected mobile disc. If the intervertebral space is surrounded by a strong  ring  of osteophytes, then this development of osteophytes can be defined as a type of  healing, which although it removes the mobility of the affected disc, it  relieves the patient from pain and makes it possible for it to accept loads.

Treatment

The treatment chosen depends on the cause.
Conservative treatment is consists of:

Bedrest:

Although the majority of patients with lumbar sciatica do not require bedrest, some patients with intense lumbar sciatica(radicular symptoms ie. pain travelling down the  limb is sciatica with or without  tingling -numbness, pins & needles and / or dysesthesias –burning sensations-  electric shock like sensation) can benefit from 5-7 days of bedrest. The benefit is that in a supine position the following are excluded: a) the factor of gravity which as a result  reduces the compression of the affected anatomical structures of the spine and B) painful movements which the patient is experiencing are restricted. It is now commonly accepted that the bedrest should not exceed 7 days, after which a gradual return to normal physical activity should begin. In a randomized clinical trial, bedrest for more than four days was accompanied by a longer period of recovery, increased muscle weakness and increased incidence of complications, mostly in the form of deep venous thrombosis.

Restriction of Normal Activities

The objective here is to maintain the everyday activities of the patient, with minimal discomfort from their condition. Limiting weight lifting, prolonged sitting or standing is recommended, and recommendations are given for correct posture in daily activities as well as sleeping. The majority of patients with lumbar sciatica regardless of the cause, will improve to some extent by adhering to a daily schedule of spine care.

Exercise:

Exercise, possibly as part of an integrated program of physiotherapy, may help not only the remission of symptoms but also prevent the recurrence of pain. Moderate aerobic exercise which places no strain on the spine (eg swimming) is recommended. After 2 weeks, the patient may begin strengthening exercises for back and abdominal muscle groups, with gradually increasing intensity. International studies recommend controlled exercise with gradually increasing intensity - from the early days of a lumbar sciatica crisis- allows  the patient to resume to normal activity sooner than the traditional limitation of any physical activity.

Analgesics :

The use of analgesics (paracetamol or NSAIDS) can help control the pain the first few days. In some cases of intense radiculopathy however  the use of opioids are required. In both cases, the use of analgesics is not accompanied by a reduction in  the total recovery time of patients with non-specific lumbar sciatica.

Muscle relaxants:

Despite popular belief, muscle spasms play a very small part in lumbar sciatica. However, it seems that the administration of muscle relaxants relieve pain more than placebo preparations. They should not be administered for longer than 3 weeks.

Patient Education

The briefing – training may be part of more comprehensive rehabilitation program and informing the patient on issues related to their condition, treatment and prognosis is recommended. The patient should be trained in the correct posture during physical activity and sleep, proper weight lifting techniques, other daily activities etc.

Local injection Therapy:

Epidural glucocorticoid injections  - local anesthetic are not recommended for the relief of lumbar sciatica, either in the acute or chronic phase. The epidural injections can be of benefit in the relief of acute sciatica (radicular pain) in cases where conservative treatments have failed or are unsuitable for surgery. For back pain without sciatica there are no indications that epidural glucocorticoid injections  - local anesthetic and/or opioids are effective.

Alternative Therapies:

Other types of physical therapies are included in the treatment of sciatica such as Transcutaneous electrical nerve stimulation- TENS,  ultrasound therapy, diathermy,  LASER, acupuncture and hypnotherapy, but their use is experimental and their effectiveness limited.

Not recommended:

Steroids have no benefit in the treatment of acute non-specific sciatica. An international study showed that oral administration of dexamethasone had no benefit in relieving pain. The same was shown in a corresponding study for anti-depression treatment.

Surgical treatment is indicated for cases which do not improve with conservative therapy as well as for the following:

Surgical Treatment:

From the above it is clear that acute non-specific sciatica is a benign disease, which has a good chance of cure even with minimal medical intervention.

The surgical indication arises only in cases where there is persistent lumbar sciatica with or without neurologic deficit when there is imaging correlation-confirmation (MRI) of  underlying structural damage, eg disc herniation, Synovial cyst, facet syndrome, tumor, hematoma, infection, osteoporotic fracture.

Intervertebral disc herniation(IDH):

• 75% of patients with acute lumbar sciatica due to IDH will improve with conservative methods. Nonetheless, the presence of sciatica (radiculopathy) with radiographically confirmed IDH may indicate surgery when it extremely persistent (it does not subside after 4-8 weeks of  analgesic treatment) and the patient wants immediate relief.
• The presence of progressive neurological disorder (mainly motion eg, foot drop) indicates surgery. The presence of paresis for more than 5-8 weeks is a relevant indication that the benefit of the surgery with respect to motor restoration is doubtful.
• The presence of cauda equina syndrome(bowel and bladder disturbances, muscle weakness in both extremities, multiradicular distributed numbness) is an indication for emergency surgical treatment (within 24 hours).

Synovial cyst

Synovial cysts are a rare benign entity that can cause  intense lumbar sciatica. Although conservative measures (facet injected corticosteroids) can bring  temporary relief, surgical has very good results in more than 80% of cases.

Facet syndrome

Facet syndrome is the irritation or degeneration in one or more joints between the vertebrae. The pain remains constant in a specific area of the waist and may radiate to the buttocks and back of the thigh, and rarely radiates beyond the knee. The pain worsens when stretching and walking. In the cases where there is radiographic confirmation of compression of the roots by elements of the ipsilateral joint and the pain is persistent – prolonged, percutaneous treatment (injection of corticosteroids or electrocoagulation) or surgical treatment is recommended.

Other Causes

Rare cases of lumbar sciatica which require further investigation and possible surgical treatment are:

• Tumors of the spine or spinal cord  (metastatic tumors or hematopoietic tumors, meningiomas, neurofibromas)
• Epidural hematoma (traumatic or automatic in patients with clotting disorders)
• Infection of bone and nerve tissue (tuberculosis, osteomyelitis, etc.)
• Implicit- minor trauma

 










CONCLUSIONS

The decision for conservative or surgical treatment must include the following parameters:

• Duration of lumbar sciatica
• Underlying nature of the anatomical lesion causing the lumbar sciatica
• Age, general health and psychological state, personality
• Lack of response to conservative treatment
• Selection of appropriate surgical treatment - experience of the surgeon

Surgical treatment is indicated only with a confirmed disc herniation, where the symptoms remain unaffected by conservative treatment and coexisting instability. Surgical treatment is recommended firstly to remove the hernia and secondly by the fusion of adjacent vertebrae.

Thoracic Spine

Conditions of the Thoracic Spine

Pathological conditions affecting the vertebrae and adjacent structures of the thoracic spine  are not uncommon. Spinal  injuries are the most common causes of impaired function of spinal cord due to compression of neural structures at these levels, ultimately resulting in permanent neurological disorders and secondary instability of the thoracic spine.

Some of the more common conditions of the Thoracic spine are: Osteoporisis, thoracic  herniated  disc, Kyphosis, Scoliosis. Traumatic injuries of the vertebra of the thoracic spine are the most common pathology of the thoracic spine neurosurgeons are required to treat. They often accompany a craniovertebral  injury as a result of a motor vehicle  accident or a fall from a height and are the second in order or frequency in the region of the spine, after the cervical spine which suffers  fracture or dislocation. Due to the anatomical characteristics of the thoracic spine, thoracic spine injuries are accompanied with serious neurological disorders.

Tumors that affect the thoracic spine can be primary or metastatic. The primary tumors emerge from the vertebrae, adjacent soft tissue, the meninges of the spinal cord, the cord itself and its roots. The extramedullary tumors are usually metastases affecting the  vertebral bodies which  can invade the soft tissues, the articular processes and pressure the dura & the spinal cord located within it. Intradural-extramedullary tumors (meningioma, neuroma) although they may not cause spinal instability,  can cause major neurological disorders due to direct pressure on the spinal cord.

Degenerative conditions of the thoracic spine (scoliosis, herniated intervertebral disk, thoraco-lumbar spinal canal stenosis) are less common in comparison to traumatic injuries  of this segment, as are tumors. The anatomical structures affected by degenerative spondyloarthropathy are the intervertebral disc, ligaments and articular processes and their membranes. Degeneration of these supportive structures transfers the center of gravity of the thoracic spine. The rotational movement axis is transferred from the gelatinous core to the articular processes of the vertebra, also the coupled motion forces are transferred to the articular processes which are already inadequate to cope with the increased loads. Simultaneous swelling of facet joints and the hypertrophy of the ligaments to maintain the limit in motion of the thoracic spine cause secondary scoliosis and spinal canal stenosis due to the usurpation of space in spinal canal. They show symptoms of root pressure with lumbar pain and intermittent neurogenic lameness.

Osteoporosis

Osteoporisis is a condition where the density of the bone is gradually reduced causing the bone to be thin, fragile and weak.
Risk factors for the development of  osteoporosis.

We all have a risk of developing osteoporosis as we age. Specific risk factors are summarized as follows:

• Hereditary
• Gender(women)
• Above 50 years of age
• Menopause / Hysterectomy
• Taking glucocorticoids (ie. cortisone)
• Various diseases: Hyperparathyroidism, rheumatoid arthritis, insulin dependent diabetes.
• Lack of exercise
• Diet low in calcium or vitamin D.
• Smoking
• High consumption of alcoholic beverages
• Excessive  coffee and tea

In its early stages Osteoporosis does not cause particular symptoms. As it progresses however, diffuse bone pain, progressive loss of height and more frequently fractures in various parts of the body are observed.


Herniated Disc of the Spine

Thoracic disc herniation is relatively rare as the disc is protected by the reduced mobility of the  thoracic cage as a whole.
Symptoms.

The herniated disc causes pain in the back, semi- thorax, shoulders which is accentuated  by movements of breathing, coughing, laughing and sneezing.

Depending on the size of the disc herniation and the existing pressure on the spinal cord numbness, movement disorders of the lower limbs and difficulty in urination and bowel function  appear.


Diagnosis

The initial diagnosis by simple x-ray reveals the stenosis in the space corresponding to the disc herniation.

Computed tomography clearly identifies the osteoporotic lesions while MRI is the examination of choice to reveal the anatomical lesions of soft tissue.

The electromyogram in many cases distinguishes  the level of the lesion .The somatosensory evoked potentials confirm lesions which are clinically manifested  but lack imagery confirmation.

The treatment of thoracic disc herniation is achieved by surgery with satisfactory results.


Surgery of the Thoracic Spine

The treatment of these disorders should be individualized and depends on the type, extent and level of the lesion, the presence of displacement, dislocation, or instability in the affected area of the vertebrae and finally the patient's neurological condition. The conservative treatment of a diagnosed thoracic herniated disc focuses on combating local aseptic inflammation and mechanical decompression and restoration of the herniated disc. Anti-inflammatory and painkillers are administered. Physiotherapy can contribute to the treatment of aseptic inflammation and partial restoration of the herniated disc.

Conservative treatment is insufficient and surgical intervention advised when neurological signs such as pressure on the spinal cord and/or symptoms of cauda equina syndrome appear or get worse.

Surgical decompression and discectomy through a lateral approach is the treatment of choice in patients with tumors and herniated discs in this area. Most thoracic spinal fractures may be treated conservatively, but surgical decompression and fusion is applied in some patients to improve the final outcome, particularly when there is a risk of  kyphosis of the thoracic spine.

When fractures are treated  the potential deterioration of the fracture is halted, the fracture is stabilized, the patient is relieved from the pain and in many cases kyphosis is corrected. Usually Kyphoplasty or Spondyloplasty (Vertebroplasty) is the chosen method or in difficult cases spinal fusion is carried out  with vertebral  screws and  support rods.


Kyphosis

When the curvature of the thoracic spine when exceeds 40°, it is called Kyphosis. There are  several causes.

Juvenile kyphosis occurs in children aged 12-16 years. It is more common in boys and is found in the thoracic spine. The symptoms are slight pain and a clinical appearance  in which the shoulders droop forward and downwards, the shoulder blades are raised backwards and the belly forward.

In mild cases correct posture is recommended and back muscle exercises lying on a hard mattress without a pillow in a supine or prone position. When exceeding the40° the most effective treatment is the application of a specially constructed orthopedic kyphosis brace for about 12 months.


Scoliosis

Scoliosis is a condition of the thoracic spine that causes deformity of the spine characterized by a lateral curvature and bending of the majority of vertebrae. It is an aesthetic problem, but be careful attention must be paid because in severe forms it affects the cardiovascular system.

There are functional and organic types of scoliosis, the most frequent type is idiopathic. Treatment of scoliosis is generally conservative and depends on the curvature. If the curvature is less than 40° surgery is not required, while between 20° and 40° special braces are worn. Patients are monitored regularly and the improvement is usually satisfactory.

Peripheral Nerves

CARPAL TUNNEL SYNDROME

By the term Carpal Tunnel Syndrome we mean the trapping - compression of the median nerve in the carpal tunnel. The Carpal tunnel is defined by bones, ligaments, muscles and tendons that move the fingers, wrist and hand.

Course of  the disease

Initially dysesthesia and/ or pain especially with strenuous activities are observed. The symptoms improve with rest. The symptoms intensify with increased pressure on the nerve. When the pressure increases significantly the symptoms,  predominantly pain are maximized reducing the ability of the hand to grasp objects.

Symptoms :

• Pain in the wrist which radiates to  the fingertips and even to  the shoulder and / or neck
• Worsening of pain during the night or early morning. The patient wakes up in pain.
• Abnormal sensations or tingling in the fingertips
• Impaired muscle strength of the hand
• Thenar Atrophy of  thumb muscles
• Dry skin, swelling and pallor of the skin.

Diagnosis:

The symptoms are usually suggestive and guide the diagnostic method. Tinel and Phalen sign tests are done where pressing the median nerve causes a feeling of dysesthesia and bending the wrist for at least a minute causes a feeling of dysesthesia or paresthesia, respectively.

Electrodiagnostic testing is done with electromyography.

In rare cases,  MRI  of the wrist is necessary.

Treatment:

Each condition can be treated either conservatively or if this is unsuccessful, surgically.

• A) Initially, patients will be given non-steroid anti-inflammatory medication and / or cortisone and painkillers. Cortisone may be injected percutaneously or locally by direct injection into the area of the wrist. At the same time a splint may be used during the night. Physiotherapy aimed at lengthening the ligament, electrotherapy and therapeutic ultrasound is often used in conservative treatment.
• B) The surgical treatment entails lengthwise bisection of the ligament to safely release the median nerve . This is done either by incision posteriorly on the palm of the hand approximately 3-4 cm in length or endoscopically.