Herniated disc

The disc distributes and absorbs the load of our body between the vertebrae but when the protruding fragment of the disc compresses the spinal cord or spinal nerves, it can cause pains on the back, hips, and legs. About 80-90% of patients can be treated non-surgically, but in case of very severe herniation, surgical treatment is required.

Non-surgical disc therapy, such as medication, physical therapy, and spinal traction, can be helpful, and epidural steroid injection once a week can be an effective treatment for most cases.
However, despite these treatments, symptoms do not improve even after 6 weeks, surgical treatment is required to the patient with difficulties in everyday life due to severe pain, with leg muscle weakness, or with difficulties to urinate and defecate. Many patients are curious about after surgery, but most of them can return to their daily lives without any problems.

About surgery methods

Nucleoplasty, Percutaneous Epidural Neuroplasty. Percutaneous epidural Neuroplasty.

• To shrink the disc, the disc of interest is pierced by inserting the needle with high frequency.
  The operation takes about 20 minutes and is performed under local anesthesia, so you can leave the hospital the same day. Patients with mild disc herniation can immediately experience improvement in symptoms. Recently, it is possible to reach the target area along the neural tube through the sacral entrance above the anus. This operation requires a one-day hospitalization.

Endoscopic Spine Surgery

• Recently, endoscopic instruments and clinical skills have been further developed, and endoscopic surgery is performed only with local anesthesia without resection for most disc patients. It is possible to perform surgery while talking to the patient while checking the disc with a device containing a camera inserted through a small incision of 1 cm. It is possible to leave the hospital on the same day after surgery, and you can return to your daily life and work immediately.
  Unlike conventional disc surgery, which required extensive bone removal and screwing in due to instability, endoscopic spine surgery can reduce various surgical complications and does not require blood transfusion as there is little bleeding.
  The surgery is performed for patients with low back pain or pulling and numbness in the leg muscles have not improved despite various general treatments or have weakened leg strength due to nerves being pressed by the disc, or leg sensory and motor function.
  For about 2 weeks, it is recommended to avoid lifting heavy objects or sitting for a long time, and to walk or rest with your back straight. After 2 weeks, you can do light exercise such as swimming or hiking.

Microscopically Assisted Percutaneous Nucleotomy

• This operation is the most effective and has no sequelae or recurrence in the last 100 years. Recently, endoscopic surgery is mainly performed, but in the case of patients who cannot undergo endoscopic surgery, incisional surgery is performed. Since only about 3 cm of skin is incised and surgery is performed under a microscope, nerve damage and bleeding can be safely avoided through magnified microscopic images. Patients can walk from the day after the incisional surgery, and almost all patients can live a normal life without any complications or sequelae.

Spondylolisthesis

Cause

• There are five lumbar vertebrae in the waist, which is the center of the human body, and vertebrae called the sacrum below the lumbar vertebrae. This sacral vertebra is inclined at about 40 degrees, so the lumbar vertebrae located above the sacral vertebrae tend to slip forward. When the strength of the muscles supporting the spine decreases due to aging, the lumbar spine curves excessively.
  As the spine slips forward than the lower spine, the spinal joints are deformed or thickened along with the ligaments, compressing the nerves, which is called spondylolisthesis.
  When the spine starts to slip forward, it becomes unstable and presses on the nerves every time you bend and straighten the back, causing back pain. In addition, the surrounding ligaments, cartilage, and bones grow, stimulating the nerves that go down to the legs, causing numbness, pulling, and pain in the legs.

Therapy

• Spondylolisthesis caused by degenerative changes due to aging usually tends to no longer slip forward. In the case of patients with only back pain, the trend is observed while applying back muscle strengthening exercises, drug treatment, and vertebroplasty. If walking becomes difficult due to leg pull, leg pain, or hip pain, surgical treatment is required.
  If the slippage of the spine or the symptoms are mild, the patient should wear a brace while restricting vigorous exercise and observe the progress. However, if the slippage or symptoms are severe, surgical treatment is required to fix the spine so that the spine does not slip anymore.

Osteoporotic Vertebral Compression Fracture

Cause

• Osteoporosis is a condition in which the structure of the vertebrae weakens with age and loses the original strength of the spine due to loss of minerals.
  If an elderly person has osteoporosis, even if he or she does not experience minor shock or injury, compression fractures in which the shape of the spine is distorted may occur even during light daily activities such as waking up in the morning or washing the face.
  If there is a compression fracture without special trauma or if the symptoms do not improve easily, be sure to get a precise diagnosis at the hospital because there may be cancer in the spine.

Treatment

• Vertebral compression fractures in patients with osteoporosis are treated for osteoporosis and compression fractures at the same time. For the treatment of compression fractures, it is usually recommended to wear a brace as early as possible after bed rest for 3 to 5 days and perform walking exercises.
  In most cases, symptoms improve only with bed rest, but about 25% of patients do not improve even with medication, physical therapy, or bed rest.
  If symptoms persist or compression deformation of the vertebral fracture site progresses, cement similar to human bone is inserted into the vertebral fracture site. This operation can be performed only under local anesthesia, and the patient can walk immediately after the operation as the pain disappears. You can receive outpatient treatment after being hospitalized for a day or two. If the pressure deformation is too severe, it can bend like a hunchback, so percutaneous balloon kyphoplasty is performed to correct kyphosis.
  If the proper treatment period for compression fractures due to osteoporosis is missed, there may be cases in which percutaneous balloon kyphoplasty cannot be performed due to severe collapse of the spine later. It is better to visit a hospital and receive treatment at the right time.

Back Arthritis

What is facet joint syndrome (lumbar arthritis)?

• It refers to a disease that causes back, hip, or leg pain due to degenerative changes or abnormalities in the back joint.
  Back pain due to back arthritis is severe in the morning, and the pain gets worse when you change posture, such as when you sit down and get up, or when you lie down and turn around. In addition to back pain, there are many cases where the pain extends to the buttock and outer thighs.

Lumbar facet joint block

• In 1976, Mooney et al reported that there was a positive effect by injecting saline into the lumbar joint to induce back pain and leg pain, and then performing lumbar facet joint block. Since then, various methods using high frequency or medication have been developed. Recently, the treatment effect is much better when intravertebral injection is performed together with medial branch block that controls the spinal joint.
  Lumbar facet joint block often improves back pain, and although the effect also varies from person to person, it lasts for an average of 6 weeks. This is a simple procedure that allows you to be discharged the same day.

Cervical myelopathy

Upper and lower limb numbness, gait disturbance may be mistaken for paralysis.

• Cervical myelopathy, which is often mistaken for paralysis, often misses the right time for treatment.
• Patients usually come to the hospital when they have numbness in their arms and legs and have difficulty walking due to loss of strength in their legs.
• In the beginning, the hand loses strength, the hand movement becomes unnatural, paresthesia occurs, and leg strength gradually disappears.
• The average person can cleanching the fists more than 20 times in 10 seconds, but not very quickly. Patients often complain that it is difficult to use chopsticks and to button up a shirt because they cannot perform detailed movements due to poor muscle strength in their hands. Patients with severe symptoms or who have had symptoms for a long time lose the ability to open or bring their fingers together.
• Unlike paralysis, this disease has no facial symptoms, such as the eyes or mouth. Paralysis stiffens and paralyzes the upper limbs, but this disease causes flaccid paralysis in the arms and stiffness and spastic paralysis in the legs.
• Surgical treatment is required because the symptoms are difficult to improve with conservative treatment.
• If the symptoms have just been discovered, the initial symptoms are mild, or if the neurological abnormality is recoverable based on the MRI results, and if you are under the age of 70, you can expect improvement through surgery.

Myofascial Pain Syndrome

What is myofascial pain syndrome?

• Myofascial pain syndrome is an inflammatory change in the membrane that surrounds the muscle, causing pain.
• When this disease occurs, chemicals are secreted from inflammation in the membrane surrounding the muscle, causing pain. Due to pain in one part, the patient often feels numbness or pain in the entire arm or leg. As time passes, it spreads to various areas, resulting in multiple lesions. The symptoms are similar enough to be thought of as having a herniated disc or disc stenosis, so many patients complain that there is no improvement in symptoms even after receiving all kinds of nerve procedures.
• The most common areas of pain are the back of the neck and both shoulders, muscles around the back, buttock muscles, chest, and flanks.
• Myofascial pain syndrome can be suspected if the patient feels sharp pain or cool pain relief when carefully pressing the painful area with a finger.

Therapy

• In general, medication and physical therapy are used.
• When the pain-causing location is found, the drug is injected (trigger point injection) and the target lesion is destroyed. Patients will see improvement in their symptoms about 2-3 days after the procedure. When these procedures are performed about 3 to 5 times a week, most patients experience improvement in symptoms.

Areas where myofascial pain syndrome occurs easily

Spinal stenosis

Cause

Instability occurs in the spine due to aging-induced degenerative changes and muscle weakness around the spine, which narrows the spinal canal, nerve root canal, or intervertebral foramen in the center of the lumbar region, and invades the spinal nerve membrane or nerve root, causing symptoms.

Symptoms

• Back pain and intermittent claudication (symptoms in which it is difficult to walk steadily because of pain in the back or hips and legs and you have to walk after resting) cause pain that seems to tighten the lower extremities when walking, but the symptoms are relieved by bending over and sitting for a while. In severe cases, muscle weakness or paralysis may occur.
• As shown in the picture, normal spinal nerves (within the white circle) are round, but spinal stenosis is caused by compression of the nerves in a triangular shape due to pressure from discs or ligaments.

• When the patient is at rest, there is no leg pull or back and hip pain, but when he starts walking, leg pain, numbness, back pain, and hip pain occur, so he cannot walk continuously and must rest.
• This is because when the patient bends down or squats to rest, the narrowed spinal canal widens and the symptoms improve.

Therapy

• Drugs that improve blood circulation in the nerves and drugs that help relieve symptoms by calming down inflammation can be used, and other treatments such as epidural injections and physical therapy can be used. In particular, exercises that bend and straighten the waist are very helpful in alleviating symptoms. About 70% of patients are able to get by without the symptoms progressing any further, but surgical treatment is required if the symptoms worsen over time or if the symptoms do not improve even after non-surgical treatment for a sufficient period of time. Stenosis surgery results are successful and patient satisfaction is very high.

Internal disc disruption

What is the definition and function of intervertebral disc?

• Disc (intervertebral disc) is a cushion of fibrocartilage between two vertebrae in the spinal column and is composed of proteoglycan, collagen and water. Each disc absorbs the stress and shock the body incurs during movement.

  • 

• Internal disc disruption is a syndrome in which there is almost no change in the shape of the disc, but an abnormality in the internal structure or metabolic function occurs, causing continuous and severe back pain. In other words, internal disc disruption refers to problems occurring inside the disc.
• Pain-causing chemicals in the nucleus pulposus that have ruptured from the inside stimulate the micro-nerves that distribute the membrane surrounding the disc; stimulate the back pain-causing nerve called the sinu-vertebral nerve behind the disc; or trigger an immune response in the body, which causes back pain.
• Internal disc disruption often occurs when moisture or protein inside the disc is lost, so it cannot withstand the constant load and the membrane (annulus fibrosus) surrounding the disc is often ruptured.
• There is a problem with these shock absorption, so it does not smoothly perform the role of absorbing the load, resulting in pain.

What are the symptoms of internal disc disruption?

• Persistent back pain that worsens when sitting or bending over may be accompanied by pain in the hip or lower extremities. If the pain is located deep in the back, it does not improve well even with rest, and the condition gets worse as time passes, and it gets worse when you work or exercise.
• In particular, it is characterized by difficulty sitting for a long time, difficulty straightening the back when standing up, and worsening symptoms when bending the back. In addition, patients suffer from depression or lose weight due to stress because back pain persists without knowing the cause.

What causes internal disc disruption?

• It is known that it can occur mainly after trauma, but it can occur even without trauma.

How is internal disc disruption diagnosed? Can it be diagnosed with MRI?

• First of all, taking the patient's history is important. If the patient has been injured in the past (may not be), has chronic back pain that does not improve, and the symptoms worsen when sitting or bending the back, internal disc disruption is suspected and MRI is recommended.
• As shown in the image below, elasticity decreases as the moisture or protein content inside the disc decreases, and depending on the degree of loss, the disc appears black in the MRI image.

  • 

• If the disc has turned black on the MRI and the ruptured membrane surrounding the disc is white on the MRI (arrow), internal disc disruption can be suspected, but this alone is difficult to diagnose.
• Therefore, discography is performed.

What is a discography and how is it diagnosed?

• If you get an injection into the disc through a needle, you can check the degree of rupture inside the disc with an image.

What if I just let my back pain go? About the treatment of internal disc disruption

• Acute back pain tends to recover within 2 weeks. However, about 7% of them can become chronic, and about 3/1 of chronic patients may have pain that makes it difficult to do daily life or work.
• There are cases in which symptoms naturally improve over time in patients after middle age, but the natural improvement in young people is not well known.
• It can be treated by taking painkillers, anti-inflammatory drugs to block chemicals coming out of a ruptured disc, getting an epidural injection, or combining physical therapy and exercise. If symptoms do not improve with these methods, you can simply try procedures such as nucleoplasty (Fig. 1) or radiofrequency thermal coagulation (Fig. 2), and if there is no improvement even after long-term treatment, surgery may be considered.

  • 

  • 

Which patients need surgery?

• Patients can consider to undergo surgery if they have back pain lasted for more than 1 year, worsened more than once a month, were unable to work for more than 4 months, did not improve despite non-surgical methods for at least 6 weeks, and have found back pain in discography. However, the diagnosis of this disease must be made carefully and there is room for controversy, so it is necessary to differentiate it from general back pain. Therefore, nonsurgical treatment and observation for a sufficient period of time are recommended.

What are the surgical methods for internal disc disruption?

• The key to surgery is to pinpoint the disc causing the pain and repair or remove it.
• There is a minimally invasive method of making a minimal skin incision and a surgical method of performing a skin incision.
• Radiofrequency thermal coagulation (Fig. 3) can be considered, but the success rate has been reported to be around 40-60%, so it is very important to perform it after an accurate diagnosis.
• <Figure 3> is a case in which a male patient in his late 60s who suffered from back pain for several years was successfully treated after performing radiofrequency thermal coagulation through MRI and discography.

  

• After removing the problematic disk, a CAGE, the latest fusion instrument, can be inserted to fix the spine in the space occupied by the disk.
• After removing the problematic disk, a CAGE, the latest fusion instrument, can be inserted to fix the spine in the space occupied by the disk. The success rate of this surgical method has been reported variously, ranging from 65 to 95%.

  • 

  • 

  • 

  • 

What are some exercises or lifestyle habits to help prevent back pain?

• It's good to be in a good and comfortable position. It is not good to stay in one position for a long time even if it is comfortable. It's hard to say which posture is good, but it's good to lie down with a cushion under your legs when lying down, or with a pillow between your legs when lying on your side. When lifting objects, bend your hips and knees and use a posture that puts less strain on your lower back. Frequent exercises such as bending at the waist, exercising on the side, and stretching seem to be very helpful.

What is scoliosis?

• Scoliosis is a sideways curvature of the spine. It is common to think that the spine is bent due to poor posture or carrying a heavy bag on one shoulder for a long time. This is called functional scoliosis and can be treated by correcting posture.
• When there is a problem with the structure of the spine itself, it is called structural scoliosis.
• Unlike functional scoliosis, there are not a few cases where the curvature gets worse, and if left untreated, the curvature of the spine can become severe, resulting in a decrease in cardiopulmonary function and, in severe cases, a shortened lifespan. Therefore, early diagnosis, professional consultation and treatment is most important.

• In most cases, no cause is found, and this is diagnosed as idiopathic scoliosis. Most (80 -85%) of scoliosis cases belong to this category.
• Most cases of scoliosis are painless and can be detected late.
• Scoliosis is a sideways curvature of the spine, which is accompanied by rotational deformation of the spine in the head and pelvis.
• If the scoliosis is severe, it is difficult to bend the back well and the flexibility of the spine is reduced.
• If scoliosis develops from an early age, abnormal development of the thorax can occur and affect lung and heart functions.
• Congenital scoliosis often accompanies deformities in other organs of the body. Urinary malformations (20-40%), cardiac malformations (10-20%), and spinal nerve abnormalities (10-40%) are often accompanied, so detailed examinations such as MRI, ultrasonography, and kidney tests are necessary.

Why does scoliosis occur?

• If the curvature of the spine is mild, it does not interfere with daily life, exercise, or social activities. In the case of idiopathic scoliosis, which is the most common scoliosis, there are not many cases that require active treatment. However, when scoliosis is discovered, it is most important to accurately diagnose and determine the current condition and to select an appropriate treatment method.
• As adolescent patients (middle and high school students) grow up, the curvature of the spine may increase. If the angle exceeds 20 degrees, scoliosis is likely to worsen, so regular treatment and observation are required.
• It is known to date that when scoliosis becomes severe, the heart and lungs are compressed by the curved spine, resulting in decreased function and an increased probability of death.

What to do when scoliosis is discovered?

• Usually, examination and general x-ray imaging can reveal the type of scoliosis and the degree of skeletal maturation.
• If the degree of scoliosis is between 20 and 40 degrees, it is usually necessary to wear a brace for treatment, and for scoliosis of more than 40 degrees, surgical treatment is carefully considered.

About orthosis (brace)

Types of Orthosis

• Orthosis can be largely divided into soft orthosis, such as a corset, and rigid orthosis, which restricts the spine motion and provides passive trunk stiffness. Corsets support posture and provide psychological stability, but do not limit the movement of the spine. Rigid braces can be divided into three types according to their shape.
• First, thoracolumbosacral orthosis (TLSO)
• Second, cervicothoracolumbosacral orthosis (TLSO or Milwaukee brace)
• Third, dynamic corrective brace (DCB)

Thoracolumbosacral orthosis (TLSO)

• Boston brace, Dupont Jacket, Miami TLSO, Newington brace, etc. are the most commonly used braces, and they are made of plastic after modeling the upper body with plaster to fit the body. These braces are used when the vertebrae most distant from the central axis of the body (apical vertibra) are below the 7th or 8th thoracic vertebrae. In Thoracolumbosacral orthosis, the patient corrects his/her posture inside the brace and is treated with the pressure of the pad, so the position of the pad is important, and the position must be adjusted by taking a radiograph after wearing the brace.

Milwaukee brace

• The Milwaukee brace was originally made for fixation after scoliosis surgery, but is now used when the apical vertibra is above the 7th or 8th thoracic vertebrae. Because there is a metal ring around the neck and there are molds and pads on the front and back of the body, it is visible even when wearing clothes. The patient is treated through compression by pads and traction by metal rods. These braces can be divided into active braces (Boston brace, Milwaukee brace), which make the patient actively try to correct the posture, and passive braces (general thoracolumbosacral orthosis).

Dynamic corrective brace

• Dynamic corrective brace is a band-type orthosis developed after long research. It does not appear to be worn regardless of the position of the apical vertibra, and it is not metal or plastic, so it is convenient for patients to move.
  
  Developers say that unlike conventional braces, it is possible to correct posture if adolescent patients wear it several years before they finish growing (before 1st or 2nd grade of middle school). The derotational force of the band corrects the curved and rotated spine. The price is high, and it is only suitable for patients who are younger than the first or second year of middle school and have much left to grow.

Use of orthosis

Use of orthosis in idiopathic scoliosis

• In idiopathic scoliosis, patients with a scoliosis angle between 20 degrees and 40 degrees and who have not completed their growth, and those whose scoliosis is less than 35 degrees and have worsened by more than 5 degrees (regardless of the time taken for deterioration) on regular radiography.

Use of orthosis in other scoliosis

• In cases of congenital, neurofibroma, or neuromuscular scoliosis, braces are not as effective as in idiopathic scoliosis. Because it only temporarily balances the body, the surgery can be delayed.

The effectiveness of orthosis

• Orthosis can correct 10-15%. In some cases, it just maintains the original angle, and sometimes it gets worse even with braces.

How to wear an orthosis

• Scoliosis specialists at home and abroad recommend wearing it for 20-23 hours a day, and adolescents wear braces until they grow up.
• The risser grade, which shows the growth of the pelvic growth plate in the pelvic picture, determines when to stop the orthosis. If the Risser grade is 4 or higher, it is considered that growth is almost complete, and the time of wearing the brace can be gradually reduced over 10 to 12 months.

About surgery

When should I have surgery?

• In the case of idiopathic scoliosis, surgery is required if it is more than 40 degrees when first discovered or if it worsens to more than 40 degrees while wearing a brace.
• Age is an important factor when deciding on surgery. For adolescent patients with high growth potential, this 40-degree rule can be adapted.
• However, it is considered that patients who have completed growth do not need surgery even if they have scoliosis of more than 40 degrees. If an adult patient's spine is bent more than 50 degrees, surgery is recommended because it can be aggravated and the body imbalance is severe.

Surgical method

• Recently, pedicle screw fixation is known to be effective, and several world-class companies are developing screws for spinal fixation.

Activity after surgery

• Many people ask whether the spine does not move after surgery. Scoliosis surgery using pedicle screw fixation is very solid and the patient's pelvis is flexible, so the movement of the spine is not difficult for daily life.