Spinal

Back pain is very common, and about 95% of people have significant back pain at some point in their life. It is a frequent cause for taking time off work. Back pain is often due to age-related changes in the spinal discs, joints, ligaments or muscles, and can be termed “spondylosis”, “degenerative disc disease”, or “osteoarthritis of the spine”. Common back pain can often be treated with physiotherapy and non-operative measures. So called red-flag symptoms which should be reviewed by a doctor include non-mechanical back pain, elderly age, history of cancer, leg pain, weakness or numbness. Bowel, bladder or sexual problems require urgent assessment to exclude cauda equina syndrome, in which the sensitive nerves to these areas can be pinched by a disc prolapse, for example, and may require urgent surgical treatment.

Uncommon but potentially serious causes of back pain include spinal tumours, spinal infection, or abdominal problems such as aortic aneurysms, kidney stones, gall-stones, pancreatic problems, rheumatological conditions or auto-immune diseases. 

Neck pain is often due to age-related changes in the spinal discs, joints, ligaments or muscles, and can be termed “spondylosis”, “degenerative disc disease”, or “osteoarthritis of the spine”. Common neck pain can be due to muscle sprains or poor posture, and can often be treated with physiotherapy and non-operative measures. So called red-flag symptoms which should be reviewed by a doctor include non-mechanical pain, night-pain, elderly age, history of cancer, arm or leg pain, weakness or numbness.

Sometimes cervical nerve roots can become pinched by a disc prolapse, causing arm pain, or the spinal cord can become compressed causing “myelopathy” – pressure on the spinal cord affecting the arm and leg function. These conditions can be treated surgically, after assessment by a neurosurgeon and appropriate investigations which usually include MRI scans. 

Sciatica refers to pain radiating down the leg (the sciatic nerve runs down the back of the leg) and is most commonly due to disc bulges or age-related changes in the spine, causing nerve root pinching or irritation. It often co-exists with back pain and is very common. If there is no leg weakness or neurological problems in the the legs or bowel or bladder function, then it can be treated with medication and physical therapies, but if the sciatic pain continues then an MRI scan and neurosurgical assessment is warranted to look for the cause and advise on further treatment. Additional treatment may include spinal injections or spinal decompression surgery, depending on the scan results. 

Brachialgia literally means “arm pain”, but usually refers to a specific nerve pain which shoots down the arm when a nerve root is compressed in the neck, most commonly by a disc prolapse, or a boney spur called an osteophyte next to the nerve. An MRI scan is important to identify the exact cause. If there is no significant arm weakness or numbness, or significant cause found on the MRI scan, then physiotherapy, pain medication and non-surgical management is often appropriate.

Spine injections or surgery can be performed for select cases when the pain does not settle down, gets worse, or if there is a cause on the scan which is unlikely to resolve by itself. Other causes of arm pain include musculoskeletal causes, shoulder, elbow or wrist joint problems. 

Pain coming from the sacro-iliac joint (a stiff fibrous joint between the sacrum and the pelvis) can cause buttock pain, worse with movement and activity. It can be treated by physical therapies, medication, or steroid injections. Pain in this region can also be caused by lumbar or sacral nerve pinching, or inflammatory arthritis conditions of the joints.

Lumbar stenosis is an age-related condition whereby the spinal canal in the lower back (the channel down which the spinal cord and nerve roots descend down the spine to the legs) becomes narrow, causing pain in the legs, or sometimes heaviness or numbness, on walking or standing, relieved by resting. Surgery to decompress the lumbar stenosis can be performed to improve walking and pain, if necessary. 

Cervical stenosis is when the spinal canal in the neck (the boney channel within the neck bones, down which the spinal cord descends) becomes narrowed with age or due to a disc prolapse. This can sometimes cause spinal cord pinching and weakness, numbness or clumsiness in the hands or legs. It usually requires decompression by an operation to make the spinal canal bigger and take the pressure off the spinal cord, otherwise things are likely to get worse over the years. 

Cervical myelopathy is when the spinal cord is damaged, usually by a disc prolapse, but sometimes by a tumour in the neck, or infection, for example, compressing the spinal cord and causing problems with dexterity in the hands, or difficulty walking or balancing. It usually requires surgery, since the symptoms generally do not get better by themselves and tend to get worse over time. 

Cervical radiculopathy is when a nerve root is pinched, causing arm pain or “brachialgia”. The most common cause is due to disc prolapses in the neck, or bone spurs which can develop with age next to the nerve roots, called osteophytes. Cervical radiculopathy can be treated by physical therapies, medication, nerve root injections, or surgery. Your doctor can advise you on the best treatment for you, after assessing your symptoms and signs and reviewing your MRI scan. 

Spinal tumours are rare, and of many different types, ranging from benign tumours through to malignant tumours or cancers which have spread from other parts of the body called “metastases”. Even though a tumour may be benign, it could still press on the spinal cord or spinal nerves and therefore it is important to seek medical assessment and advice to determine the best treatment. 

Meningiomas of the spine are usually benign tumours which originate from the “dura” which is the fibrous covering of the spinal cord. They are very slowly growing, if at all, but may require removal if they press on the spinal cord or nerves and cause symptoms. 

These rare blood vessel abnormalities are usually present from birth, but can cause abnormal blood flow and neurological symptoms which develop in adulthood. They can produce spinal pain, or leg weakness or numbness and difficulty walking. Treatment includes occlusion of abnormal blood vessels or blood flow by endovascular techniques performed in the x-ray department, or by spinal microsurgery.

Chordomas are rare tumours which grow slowly and can rarely spread. They are usually found in the skull base (the part of the skull which is hidden behind the nose), spine, or sacrum (bottom end of the spine where it joins the pelvis). They can present with pain or neurological symptoms, and a biopsy can be taken to confirm the diagnosis. Treatment can include surgical excision, proton beam radiation or other forms of radiation treatment. Due to their rarity, these treatments are usually performed in specialist centres.

Spondylolisthesis means slippage of the spinal vertebrae, either due to age-related wear-and-tear changes in the discs and joints of the spine, or due to conditions that are present from birth when the joints of the spine haven’t formed correctly. This can result in back pain and nerve pain, with shooting pains down the legs. Treatment can include medication, physical therapies, spinal injections, surgery to decompress the nerves, or spinal fusion surgery.

Sometimes the spinal cord can become swollen with fluid in the middle, causing neurological symptoms such as arm or leg pain, numbness, weakness or bowel/bladder problems. There are many causes for syringomyelia including Chiari abnormalities around the skull base, previous neurological infections, bleeding, trauma, tumours, spina bifida or lumbar spine defects, or hydrocephalus (fluid pressure build up in the brain).

Arachnoiditis is due to adhesions or stickiness around the spinal cord or nerve roots, from previous infection, or bleeding, surgery, Myodil myelograms, CSF leak, or sometimes it can be spontaneous. Treatment depends on the cause and extent of the arachnoiditis, but usually involves medical management, and surgery has a limited role in the treatment of arachnoiditis.  

These are cysts around the lumbar spine nerve roots, usually in the sacrum from around the S1, S2 or S3 nerve roots. They are common and usually do not cause any symptoms or require any treatment. Occasionally a cyst can become very large and cause symptoms of nerve root irritation, bladder or bowel disturbance, or low-pressure headaches but this is very rare, and they are usually an incidental finding seen on an MRI scan.

A birth defect or variation, where the lower part of the spine is not formed completely. A common example is spinal bifida, and can cause leg weakness or numbness, pain or bowel and bladder problems. 

This is a rare tumour in the spinal cord which is benign, but can bleed and cause neurological symptoms of arm or leg weakness, numbness or pain. 

See spinal arteriorvenous malformations, above.

A pars defect is a condition usually present at birth where some of the elements of the lumbar spinal vertebrae have not formed completely, leading to some laxity in the lumbar spine joints and this can give rise to spondylolisthesis and symptoms of back pain or leg pain (see spondylolisthesis, above).

This is a rare condition when the spinal cord in the middle of the back can become stuck on a hole in the dura (the fibrous sheath around the spinal cord) causing tethering of the spinal cord. The restricted movement of the spinal cord can produce progressive damage to the spinal cord, and leg weakness and numbness. Treatment is usually by microsurgery, to release the spinal cord from the hole in the dura.

This is a rare tumour of the skull base or spine which is slowly growing. Surgery and radiation treatments are options for management. 

Chiari malformations are conditions which are usually present at birth, whereby the skull volume is too small for the developing brain, which then protrudes through the hole at the base of the skull called the “foramen magnum”. The cerebellum at the bottom of the brain can protrude through the foramen magnum and restrict the flow of cerebrospinal fluid, producing symptoms.

Chiari malformations are quite common and don’t always produce symptoms, but if there is sufficient blockage to CSF flow then this can cause headaches, and in rare instances, can compress the nerves in the spinal cord to the arms and legs, or cause build-up of fluid in the cervical spinal cord and neurological symptoms (syringomyelia). Treatment can include surgery to widen the foramen magnum if there are significant symptoms, scans and correlating MRI findings.