NECK
Cervical spondylosis (Testimonial 6, Healing hands Indranita D, 36 year old Jakarta):
This is a very common condition especially among Asians, with narrower spinal canals than Caucasians. It should be emphasized that degenerative changes on MRI scan in normal people without problems are very common. In one study, over 50% of normal population older than 50 year old have had degenerative changes in the neck. Obviously they do not need any treatment or surgery. In these patients it will be wrong and damaging to do surgery or injection on their spine.
On the other hand, severe cervical spondylosis can cause problems in 2 different ways:
a. Compression of a nerve root (radiculopathy, Figure 9), resulting in pain in neck, shoulder blade, arm, forearm or even in the fingers. This may be associated with numbness or pins and needles in the arm or fingers. In late stage there may be weakness of the limbs as well.
A patient with a disc prolapse at C5/6 level.
b. Compression of the main nerve, ie spinal cord (myelopathy, Figure 10), resulting in numbness of both hands, weakness of the arms and commonly weakness of the legs (walking unsteadily, problems in climbing stairs or even falling down). When severe, urination, bowel movement and sexual functions may be affected too.
The treatment is usually straightforward. When severe, removal of the compression (herniated disc, herniated
nucleus pulposis HNP or bone spur, osteophytes) frequently gives good relief and improvement. But if
significant damage is present before surgery, there may be some mild residual numbness. Overall, such surgery when performed with microscope, high speed drill and care is very safe and the risk is very low (See Testimonial 6, Healing hands, Indranita D, 36 year old, Jakarta)
After removal of the compression (discs or osteophytes), one can replace the empty disc space with one’s own bone, PEEK cage or artificial joint. Sometimes one may need to use plates and screws (pins) to fix the bone together (Figure 11).
LOW BACK PAIN
Lumbar spondylosis
Degeneration of the low back (Testimonial 7, Unexpected recovery, Mammik Sukijan 83 year old, Jakarta) can cause three different clinical problems:
a. Herniated Nucleus Pulposis (HNP):
Due to degeneration, injury or strain, a piece of cartilage disc is pushed out of place and presses on the nerve running down to the leg. This results in severe back and leg pain, and sometimes in a pulling sensation. The pain may be worse on coughing, sneezing or straining. Complete bed rest often relieves the pain. Physiotherapy should be the initial treatment, but if after several weeks of treatment the pain is still severe, a MRI scan should be done and consultation to neurosurgeon made. A microdiscectomy often solves the problem. Patients usually stay in hospital for only 1-2 days (Figure 12).
A Caucasian man complained of sudden leg pain from a huge disc prolapse (HNP) betweeen L4/5.
b. Spinal stenosis:
As one grows older, the ligaments in the spine become thicker. There are joint over-growth and bone spurs. These narrow the diameter of the spine and compress on the nerve roots. The patient often complains of pain or numbness mainly when they walk or stand. The symptoms improve once the patient sits down. For some patients, when they bend forward, they can walk further before the pain starts. Low back pain, when present, is often not severe. Simple decompression procedure may be enough to relieve the pressure on the nerves.
c. Spondylolithesis (alignment of the spine not straight).
Patients suffering from this problem have a lot of low back pain, especially during movement such as when getting out of bed in the morning. A simple x-ray of the spine from the side in bending forward and bending backward position (lateral lumbar spine x-ray in flexion and extension view) reveals this problem. For severe cases, a spinal fusion using pins (screws) and rods will fix this problem. Although this used to be a major operation, with modern instruments it is relatively simple and very safe now. There is no significant risk at all of getting paralyzed from this operation (See Testimonial 8, A delicate doctor, Pastor Budy Hidajat Jakarta and Figure 13,14).
Slipping of L4 over L5 (spondylolithesis) A 3-levels lumbar fusion was needed to solve this problem.
SPINAL TUMOUR (Newspaper 11)
The common types of spinal tumour are neurofibroma (Schwannoma), meningioma, ependymoma, astrocytoma and secondary tumouors. Neurofibroma is the commonest type and carries an excellent chance of complete recovery. Even a huge tumour may be completely removed (Testimony 8: A dedicated doctor, Pastor Budy Hidajat). In contrast to back pain due to degeneration, the pain from a spinal tumour often occurs and wakes patient up at night. It may be partially relieved by upright posture such as sitting or walking.
TETHERED CORD SYNDROME
If a patient has unexplained back or leg pain, numbness, urinary or sexual problems, tethered cord syndrome may be the reason. Below is a scientific paper I presented at World Federation of Neurological Surgery, Spine Section in Bali in 2018.
Tethered Cord Syndrome: True of False
Tethered Cord Syndrome (TCD) is a poorly understood and poorly known problem. Professor Shokei Yamada stated that 75% of ‘failed back surgery’ (persistent pain despite surgery) he came across in his practice in USA was due to TCS (Reference 1). When TCS is associated with a normal position of the conus medullaris (occult filum terminale syndrome), the diagnosis can be difficult and somewhat controversial.
The symptoms may consist of low back pain which sometimes may involve thoracic or even neck pain. The pain in contrast to sciatic pain may radiate to the groins. Typical aggravating factors which stretch the filum include crossing the legs as in a Buddha pose, bending forward, lying supine during sleep (which decreases the lumbar lordosis). Carrying an object of about 10kg or more may also aggravate the pain. There may be unexplained paraesthesia or numbness.
There may be urinary symptoms or erectile dysfunction. Occasionally control of bowel may be affected. One must enquire about the presence of nocturia and frequency of micturition during daytime.
The classical sign on examination with TCS is weakness of toes extensors as stated by Yamada. During my examination of my patients, I found that hip flexors weakness is another cardinal sign of TCS. Its presence in the absence of other factors strongly suggests TCS. Reflexes in the legs if hyperactive or asymmetric is another possible suggestion of TCS.
The first investigation of back or legs symptoms involves MRI of the spine. If there is no pathology to explain the patient’s symptoms or signs, before concluding psychosomatic reasons, one should consider TCS. Sometimes MRI may show a thickened filum terminale as a white dot in T1 axial cut. I find there is an association of the presence of the white dot with TCS. Fine cut CT scan of the lumbo-sacral spine may reveal the presence of spina bifida. Sometimes this may be just a small discontinuity of the lamina and may take an experienced radiologist to spot this. There seems to be an association between the size of the defect and the presence of symptoms.
The third useful test is urodynamic study to assess the integrity of the sensory and motor nerves supply to the bladder.
The diagnosis of TCS cannot be made based on any single test but is based on the clinical pictures, presence of spina bifida and sometimes the presence of neurogenic bladder.
The treatment of mild or moderated TCS is conservative with avoidance of aggravating factors. Often such patients may not progress. But for severe case, division of the filum terminale offers good relief. Sometimes TCS coexists with other pathology such as spondylolithesis and treatment of the 2 pathologies can be carried out at the same time.
In my experience of about 100 such case the chance of good relief of the symptoms is about 90%.
Reference 1: S Yamada: Tethered Cord Syndrome in Children and Adults. AANS Thieme 2nd edition 2010
If a patient has unexplained back or leg pain, numbness, urinary or sexual problems, tethered cord syndrome may be the reason. Below is a scientific paper I presented at World Federation of Neurological Surgery, Spine Section in Bali in 2018.
Tethered Cord Syndrome: True of False
Tethered Cord Syndrome (TCD) is a poorly understood and poorly known problem. Professor Shokei Yamada stated that 75% of ‘failed back surgery’ (persistent pain despite surgery) he came across in his practice in USA was due to TCS (Reference 1). When TCS is associated with a normal position of the conus medullaris (occult filum terminale syndrome), the diagnosis can be difficult and somewhat controversial.
The symptoms may consist of low back pain which sometimes may involve thoracic or even neck pain. The pain in contrast to sciatic pain may radiate to the groins. Typical aggravating factors which stretch the filum include crossing the legs as in a Buddha pose, bending forward, lying supine during sleep (which decreases the lumbar lordosis). Carrying an object of about 10kg or more may also aggravate the pain. There may be unexplained paraesthesia or numbness.
There may be urinary symptoms or erectile dysfunction. Occasionally control of bowel may be affected. One must enquire about the presence of nocturia and frequency of micturition during daytime.
The classical sign on examination with TCS is weakness of toes extensors as stated by Yamada. During my examination of my patients, I found that hip flexors weakness is another cardinal sign of TCS. Its presence in the absence of other factors strongly suggests TCS. Reflexes in the legs if hyperactive or asymmetric is another possible suggestion of TCS.
The first investigation of back or legs symptoms involves MRI of the spine. If there is no pathology to explain the patient’s symptoms or signs, before concluding psychosomatic reasons, one should consider TCS. Sometimes MRI may show a thickened filum terminale as a white dot in T1 axial cut. I find there is an association of the presence of the white dot with TCS. Fine cut CT scan of the lumbo-sacral spine may reveal the presence of spina bifida. Sometimes this may be just a small discontinuity of the lamina and may take an experienced radiologist to spot this. There seems to be an association between the size of the defect and the presence of symptoms.
The third useful test is urodynamic study to assess the integrity of the sensory and motor nerves supply to the bladder.
The diagnosis of TCS cannot be made based on any single test but is based on the clinical pictures, presence of spina bifida and sometimes the presence of neurogenic bladder.
The treatment of mild or moderated TCS is conservative with avoidance of aggravating factors. Often such patients may not progress. But for severe case, division of the filum terminale offers good relief. Sometimes TCS coexists with other pathology such as spondylolithesis and treatment of the 2 pathologies can be carried out at the same time.
In my experience of about 100 such case the chance of good relief of the symptoms is about 90%. There were 2 cases of complication of CSF leakage (in early series) needing re-opening of the wound and dural repair.
Reference 1: S Yamada: Tethered Cord Syndrome in Children and Adults. AANS Thieme 2nd edition 2010
An example of such a patient can be found in My Alvernia Magazine issue #36/2018 page 16. Cover Story: Spreading Hope