We utilize the latest technology in physiotherapy & rehabilitation.   We use High End Low Level Laser and Ultrasound equipment for chronic pain patients. Flexion Distraction Table and 3-D Active Track Table for patients suffering from Herniated / Bulging Disc. Modalities commonly used: low level laser, ultrasound, electrotherapy & intermittent traction. Rehabilitative exercises are also integrated part of our therapy program: range of motion exercises, strengthening and balance training. Clinic Associates: Registered Physiotherapist (PT)
	Information about the most common causes of back pain.

 The intervertebral discs

They make up one fourth of the spinal column's length. There are no discs between the Atlas (C1), Axis (C2), and Coccyx. Discs are not vascular and therefore depend on the end plates to diffuse needed nutrients. The cartilaginous layers of the end plates anchor the discs in place.

The intervertebral discs are fibrocartilaginous cushions serving as the spine's shock absorbing system, which protect the vertebrae, brain, and other structures (i.e. nerves). The discs allow some vertebral motion: extension and flexion. Individual disc movement is very limited – however considerable motion is possible when several discs combine forces.

Annulus Fibrosus and Nucleus Pulposus
Intervertebral discs are composed of an annulus fibrosus and a nucleus pulposus.

The annulus fibrosus is a strong radial tire–like structure made up of lamellae; concentric sheets of collagen fibers connected to the vertebral end plates. The sheets are orientated at various angles. The annulus fibrosus encloses the nucleus pulposus.

Although both the annulus fibrosus and nucleus pulposus are composed of water, collagen, and proteoglycans (PGs), the amount of fluid (water and PGs) is greatest in the nucleus pulposus. PG molecules are important because they attract and retain water. The nucleus pulposus contains a hydrated gel–like matter that resists compression. The amount of water in the nucleus varies throughout the day depending on activity.  

Degenerative Disc Disease (DDD) A gradual process that may compromise the spine. Although DDD is relatively common, its effects are usually not severe enough to warrant medical attention. In this discussion we address Degenerative Disc Disease in the lumbar spine. Degenerative Changes to a Disc Degenerative changes in the spine are often referred to those that cause the loss of normal structure and/or function. The intervertebral disc is one structure prone to the degenerative changes associated with wear and tear aging, even misuse (e.g. smoking). Long before Degenerative Disc Disease can be seen radiographically, biochemical and histologic (structural) changes occur. Some of these changes are not unlike those associated with osteoarthritis. Over time the collagen (protein) structure of the annulus fibrosus weakens and may become structurally unsound. Additionally, water and proteoglycan (PG) content decreases. PGs are molecules that attract water. These changes are linked and may lead to the disc’s inability to handle mechanical stress. Understanding the lumbar spine carries a large portion of the body’s weight; the stress from motion may result in a disc problem (e.g. herniation). Non-Operative Treatment: Yesterday vs. Today DDD is a disorder that may cause low back pain. It is interesting to note that although 80% of adults will experience back pain, only 1-2% will need lumbar spine surgery! In the past some physicians prescribed long courses of bedrest and/or lumbar traction for their patients with low back pain. However, that is not the attitude today. During the acute phase, bedrest may be recommended for a few days, but beyond that experts advocate stretching, flexion and extension exercises, and no/low impact aerobics. Of course, each patient is different and therefore so is their treatment plan. Therapeutic Exercise In some patients, the pain response may limit their flexibility. Prescribed stretching exercises can improve flexibility of the trunk muscles. Flexion exercises may help to widen the intervertebral foramen. The intervertebral (between the vertebrae) foramen are small canals through which the nerve roots exit the spinal cord. The intervertebral foramen are located on the left and right sides of the spinal column. Extension exercises, such as the McKenzie method, focuses on the muscles and ligaments. These exercises help maintain the spine’s natural lordotic curve, important to good . Aerobics (no/low impact) offers many benefits including improved muscular endurance, coordination, strength, strong abdominal muscles, and weight loss. Strong abdominal muscles work like a brace (or corset) to reduce the loads to the lumbar spine. It is also known that aerobics help to combat anxiety and depression. The loads on the discs during walking are only slightly greater than when lying down. Walking, bicycling, and swimming are forms of aerobic exercise a physician may suggest. Acupuncture Acupuncture, a type of alternative medicine, has been shown to control pain. It has been suggested that acupuncture stimulates the production of endorphins, acetylcholine, and serotonin. However, acupuncture should be combined with an exercise program for many of the reasons outlined in prior paragraphs. Drug Therapy During the acute phase of low back pain, drugs may be prescribed. Some of these may include narcotics, acetaminophen, anti-inflammatory agents, muscle relaxants, and anti-depressants. Narcotics are used on a short-term basis partially due to their addiction potential. When low back pain is caused by muscle spasm, a muscle relaxant may be prescribed. These drugs have sedative effects. Depression can be a factor in chronic low back pain. Anti-depressant drugs have analgesic properties and may improve sleep. Manipulation Today manipulation is performed by Chiropractors and Physical Therapists. For patients without radiculopathy (pain stemming from a spinal nerve root), manipulation may be effective during the first month. Thereafter, benefits are unproven. Manipulation is believed to be effective because of its effect on spinal mobility. Acute low back pain, chronic low back pain, and DDD without nerve compression may respond to manipulation. The First Six Weeks Usually during the first six weeks, acute low back pain is treated with a couple of days of bedrest (slightly longer with herniated disc) and appropriate medication. Muscle relaxants are seldom used for longer than one week. Early ambulation is encouraged to increase circulation (aids healing), improve flexibility, and build strength. Generally, during the first two to three weeks the acute symptoms subside. Aerobic (no/low impact) exercise may be started three times per week along with daily back exercises. Some patients may be referred to physical therapy or a supervised work-conditioning program. Beyond Six Weeks If the symptoms of DDD and low back pain persist despite non-operative treatment, further diagnostic tests may be necessary. These tests may include an MRI, CT Scan, Myelogram, or possibly Discography. Although most DDD patients with herniation respond well to non-operative treatments, a small percentage do not. Disc herniation is the most common indication for spinal surgery. In fact, 75% of all spinal surgeries are for a herniated disc. Red Flags Lumbar herniation causing loss of bowel or bladder control, or major lower extremity deficit, requires immediate surgery. These symptoms (Red Flags) are caused by nerve root compression. Cauda Equina Syndrome is a serious disorder that may be caused by a large central herniation. The cauda equina begins at the end of the spinal cord. The cauda sac is filled with nerves resembling the tail of a horse. When this sac is compressed the patient may present with the following symptoms: low back pain, bilateral lower extremity weakness, radiculopathy (pain from a nerve root), and incontinence. When these symptoms present, surgery is required immediately. Most herniated discs often do not require surgical intervention and respond quite nicely to non-surgical treatments (within 6 weeks). Surgical Procedures The type of surgical procedure(s) is dependent on the patient, the diagnosis, and the goals of surgery. Surgical removal of an inferior disc may involve a limited laminotomy and partial disc excision. The disc fragments are removed and the nerve is decompressed. Micro-discectomy is often a preferred procedure requiring smaller incisions resulting in reduced scarring and a more rapid recovery. If the entire disc is removed, spinal column instability may warrant fusion. Patients who are obese, smoke, or who have psychological problems exhibit lower rates of success. Smoking in particular negatively impacts the process of fusion and healing in general. Spinal fusion may be combined with spinal instrumentation, the use of medically designed hardware (e.g. screws, cages). In Conclusion Although degenerative disc disease is relatively common in aging adults, it seldom means a surgical sentence. When medical attention is warranted, the majority of patients respond well to non-operative forms of treatment. By eliminating tobacco and maintaining a fitness regiment along with a good diet, most people can enjoy the benefits of a healthy spine.

 

Dr. hany has given an excellent description on the overall epidemiology natural history of degenerative disc disease and low back pain. As he so correctly mentioned, most back pain and degenerative symptoms do not require surgical intervention. Alternative treatments including medications, physical therapy and manipulation techniques improve symptoms tremendously over the first 6-weeks after the onset of symptoms. Beyond 6-weeks, more long term management may be required. If symptoms persist, then thorough diagnostic imaging studies would be required to adequately diagnose specific pain generators. If a disc herniation is identified and conservative care management does fail, then partial disc excision may be performed either through a small open or minimally invasive technique. When surgery is required on a degenerative disc, surgeons are currently trying to limit the morbidity of the surgical procedure by directly approaching the pathology. It makes little sense to remove a collapsing degenerative disc when that is isolated as a focal pain generator. Surgical reconstruction, including interbody fusion technique may be required either through an anterior or posterior approach. Disc replacement techniques including nuclear and total disc replacement may hold promise for failed degenerative disc treatment when intervention is required. Many of these techniques are undergoing FDA IDE clinical evaluation at this time.

 Lumbar Herniated Disc

Introduction
A common cause of low back and leg pain is a herniated or ruptured disc. Symptoms may include dull or sharp pain, muscle spasm or cramping, sciatica, and leg weakness or loss of leg functio. Sneezing, coughing, or bending usually intensifies the pain. Rarely bowel or bladder control is lost, and if this occurs, seek medical attention at once.

Sciatica is a symptom frequently associated with a lumbar herniated disc. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that extends from the buttock into the leg and sometimes into the foot. Usually one side (left or right) is affected.

Anatomy - Normal Lumbar Disc
In between each of the five lumbar vertebrae (bones) is a disc, a tough fibrous shock-absorbing pad. Endplates line the ends of each vertebra and help hold individual discs in place. Each disc contains a tire-like outer band (called the annulus fibrosus) that encases a gel-like substance (called the nucleus pulposus).

Nerve roots exit the spinal canal through small passageways between the vertebrae and discs. Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or nerve roots.

Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape. This is called a Herniated Nucleus Pulposus (HNP) or herniated disc.

Sciatic Nerve and Sciatica

The sciatic nerve is the longest and largest nerve in the body measuring three-quarters of an inch in diameter. The sciatic nerve originates in the sacral plexus; a network of nerves in the lumbosacral spine. The lumbosacral spine refers to the lumbar spine and the sacrum combined. The nerve and its nerve branches enable movement and feeling (motor and sensory functions) in the thigh, knee, calf, ankle, foot and toes.

The lumbosacral spine is pictured below. The sciatic nerve (1), sacrum (2) and hip bone (3) are labeled. In the center of the picture is the lumbar spine. The small yellow structures (unlabeled) are spinal nerves that branch off the spinal cord and pass through the neuroforamen and outward into the body. The neuroforamen are hollow passageways through which spinal nerves travel.

1 Sciatic Nerve (yellow) 2 Sacrum 3 Hip Bone
Yellow = Nerve Structures
Red Structures = Arteries
Blue Structures = Veins
Lumbosacral Spine - Posterior (Rear) View

The sciatic nerve exits the sacrum (pelvic area) through a special neuroforamen called the sciatic foramen. At the upper part of the sciatic nerve, two branches form; the articular and muscular branches. The articular branch supplies the hip joint. The muscular branch serves the leg flexor muscles; muscles that enable movement.

Other aspects of the sciatic nerve include nerves that supply motor (movement) and sensory (feeling) function to the thigh, knee, calf, ankle, foot and toes; the peroneal nerves and the tibial nerves. The peroneal nerves originate from the nerve roots at the fourth and fifth lumbar spine (L4-5) and first and second levels of the sacrum (S1-2). After the peroneal nerves leave the pelvis, they travel down the front and side of the leg, and along the outer side of the knee, to the foot. The tibial nerves originate from the nerve roots at L4-5 and S1-3. The tibial nerves pass in front of the knee and downward into the foot (heel, sole, toes).

Sciatica: Sciatic Nerve Compression
If the sciatic nerve is injured or becomes inflamed, it causes symptoms called sciatica. Sciatica can cause intense pain along any part of the sciatica nerve pathway - from the buttocks to the toes. If the nerve is compressed, caused by conditions such as a bulging or herniated disc or tumor (rare), symptoms may include a loss of reflexes, weakness and numbness besides severe pain. Sciatic nerve pain can make everyday activities such as walking, sitting and standing difficult.

 

New Technologies for Treating Sciatica and Back Pain

Low back pain is one of the leading causes of lost work time, second only to the common cold. It affects 65-85% of the population of the United States at some point in their lives. The most common cause is a sprain, strain or spasm usually brought on by poor lifting technique, improper posture, bad back habits, or an unhealthy ergonomic environment. Another common cause is disc problems, brought on by injury, wear and tear, or age. Other causes include a narrowing of the spinal or nerve canals, arthritic or degenerative changes in the small joints of the back, osteoporotic fractures, and sometimes even infections or tumors.

The exciting new technology we will cover here refers to easing back pain and sciatica that is caused by disc problems. In the United States, it is estimated that about 7 million low back pain cases are related to disc problems. It is important to note that these new technologies are unproven, so it is imperative to use a healthy dose of caution. However, given that the treatment for disc problems are invasive surgeries, I felt it worthwhile to take a look at these new treatments because they are much less invasive, and they look quite promising.

What do spinal discs do?
Discs act as the shock absorbers between the vertebrae of the spine; they are tough, fibrous, outer-shelled discs (the annulus) that are filled with gel (the nucleus). In a healthy back, discs allow the spine to be flexible. Unfortunately, time, trauma, and inherent weakness in a disc can lead to degeneration of the annulus causing the nucleus of the disc to bulge out or even herniate (extrude) through the wall of the annulus.

These injuries can actually be verified by MRI or CT scans. Interestingly enough, scans can sometimes show such abnormalities in patients that report no back pain, but we have yet to understand why. At any rate, a degenerated disc can be the source of back pain, and if the bulging disc is pressing on a spinal nerve root, the pain can radiate into the leg causing sciatica.

Until now treatment options have been limited. Physical therapy can help to ease the painful muscles, which struggle to cope with the spine problem, and PT can also help to prevent abnormal stresses on the spine. Epidural steroid injections can reduce the inflammation in the area and are often helpful, but the pain tends to recur if the underlying problem is severe. For acute problems, the only remaining treatments have been to surgically remove part of the disc, or to surgically fuse the vertebrae to remove pressure on the disc.

Now, two as yet unproven minor procedures are available that may help with the treatment of back pain and sciatica: Intradiscal electrothermoplasty (IDET), and Radiofrequency Discal Nucleoplasty (Coblation Nucleoplasty).

Intradiscal Electrothermoplasty (IDET)
This procedure involves the insertion of a needle into the affected disc with the guidance of an x-ray machine. A wire is then threaded down through the needle and into the disc until it lies along the inner wall of the annulus. The wire is then heated which destroys the small nerve fibers that have grown into the cracks and have invaded the degenerating disc.

The heat also partially melts the annulus, which triggers the body to generate new reinforcing proteins in the fibers of the annulus. A study of fifty-three patients with discogenic back pain was published in the October issue of the journal, Spine. Depending on the stringency of criteria used, the success rate of IDET may be as low as 23% or as high as 60%.

Radiofrequency Discal Nucleoplasty (Coblation Nucleoplasty)
Nucleoplasty is even newer than IDET; it has been available for only a few months. Similar to the IDET procedure, a needle is inserted into the disc. Instead of a heating wire, a special radiofrequency probe is inserted through the needle into the disc. This probe generates a highly focused plasma field with enough energy to break up the molecular bonds of the gel in the nucleus, essentially vaporizing some of the nucleus. The result is that 10-20% of the nucleus is removed which decompresses the disc and reduces the pressure both on the disc and the surrounding nerve roots. This technique may be more beneficial for sciatica type of pain than the IDET, since nucleoplasty can actually reduce the disc bulge, which is pressing on a nerve root. The high-energy plasma field is actually generated at relatively low temperatures, so danger to surrounding tissues is minimized.

These new techniques are exciting. They offer the possibility of treating discogenic low back pain and sciatica with much less trauma and risk than surgery, but we must remember that these are still unproven technologies. I'll keep you posted on how research on these techniques develops, but it's great that we have some new tools to help people with this often debilitating problem.