Print- Share
Email- A A A
PrintMinimally Invasive Spine Surgery
By Dr Fong Shee Yan
Surgery on the spine that once required large incisions, hours in the operating room and extensive blood loss, can, in some cases, be done through an incision less than an inch long.
After the common cold, back and neck pain are the second most frequent reason that Americans visit the doctor, according to the North American Spine Society. Treatment of low-back pain alone costs Americans at least $50 billion each year and is the most common cause of job-related disability and a leading contributor to missed work.
Minimally invasive spine surgery, for the right patient, can make the sometimes difficult decision of whether to undergo surgery a little easier. In traditional spine surgery, a surgeon has to make a large incision and dissect several layers of muscle to access the area of the spinal column he or she is trying to correct. The injury caused by cutting through this muscle and tissue significantly adds to a patient’s recovery time after surgery. In some cases, it can leave long-lasting weakness in the back muscles. Minimally invasive techniques limit injury to surrounding muscle and tissue without compromising results.
A vivid example is a procedure called endoscopic lumbar microdiscectomy, which is used to treat a ruptured or herniated disc in the lower back. The bulging disc compresses nerves in the spine, causing disabling leg pain. Traditional discectomy requires lengthy incisions and the stripping of several levels of muscle to give the surgeon a good view of the area where the disc material compressing the nerve needs to be removed. Now, microdiscectomy can be done through a two-cm incision. A tube is inserted through the incision, creating a tunnel for the surgeon to reach the affected disc with a microscope and surgical instruments with minimal blood loss (Huang 2004, J Orthop Res 23: 406-11). Patients typically can go home the same day or next. This is achieved as post-operative pain is significantly reduced and these often young working adult patients can return to work early. In fact, the average number of disability days was reduced from 49 to 27 days (Hermantin 1999, JBJS 81: 958-65).
 Dr. Fong Shee Yan | Qualifications
Professional Highlights
|
Other spine procedures that now may benefit from minimally invasive approaches include: lumbar fusion to correct back and radiating leg pain caused by spondylolysis, a defect or fracture of the wing-shaped parts of a vertebrae in the lumbar region or lower back. The fusion procedure, which traditionally required an incision that exposed the vertebrae, can now be done through incision an inch long. Similarly, the rods and screws that hold the spine in place while the fusion heals can be inserted via multiple small incisions even less than an inch. Thoracoscopic instruments — tools that aid in visualization and operation through portal holes in the chest — allow a surgeon to address part and, in some cases, the whole correction of a patient with scoliosis. During kyphoplasty to treat painful vertebrae fractures caused by osteoporosis, the surgeon makes two small incisions and inserts a tube in the centre of the vertebrae. Cement is injected into the weakened vertebrae, creating almost immediate pain relief.
Jessica Ellison
Jessica Ellison
Education
- Bachelor of Physiotherapy, Curtin University of Technology, Australia
Career Highlights
- Physiotherapist at Core Concepts Group
Quick Facts
Jessica is a Physiotherapist with Core Concepts. Her area of interest is the spine.
Heat or Ice? When to use which?
When should you use heat or ice therapy? The answer is – it depends. In general, heat therapy is for chronic conditions and ice is useful in acute situations.
If you recently sustained an injury or aggravated an old injury, ice should be applied for a period of 15mins each time for the first 3 days. If you feel your muscles are feeling tight and stiff, a hot pack on the muscles will help to relieve the tightness.
This spectrum of acute to chronic looks at the duration since injury. If the injury is sustained within 36 hours, it is considered to be in the acute stage. At this stage the inflammation process is ongoing. Ice will help to bring down the inflammation and swelling so that the injury can heal better. Note that applying heat to this stage will increase the blood circulation, inflammation and hence swelling.
There are 2 common scenarios that cause pain, making you reach for that heat/ice pack. One of them is the acute injury (for example a fall, twisting movement or direct blow that is immediately painful) and the other is the chronic injury (happened over a period of time or from an acute injury that failed to heal). Each scenario requires a different approach to reducing your pain and speeding up your recovery.
Acute Injuries
It might be that you have just sprained your ankle playing soccer, shut your fingers in the car door or fractured your hand. All these are examples of acute injuries and will show the following signs:
- Sharp, severe pain
- Swelling
- Redness
- Increased warmth
- Restricted joint movement
- Unable to put weight through the structure (e.g. leg, ankle, wrist etc).
Flickr: Kyle May
There are many ways of applying ice like using an ice pack; wrapping ice cubes in a wet towel or using a bag of frozen peas (sometimes that is the only thing on hand!). The cold agent should be in contact with the area for up to 20 minutes at a time and re-applied every 2-3 hours for around 3-5 days or until the swelling settles.
How does ice work?
1. Decreasing the pain
There are a few proposed theories regarding how ice decreases pain and it is possible that a combination of some of them can cause pain relief.
- Decreased nerve transmission in pain fibres
- Cold reduces the activity of free nerve endings
- Cold raises the pain threshold
- Cold causes a release in endorphins
- Cold sensations over-ride the pain sensations
2. Reducing swelling
Ice cools the surface of the skin and its underlying tissues, causing narrowing of the blood vessels. This narrowing leads to a decrease in the amount of blood delivered to the area and subsequently reduces the amount of swelling. After a few minutes, the blood vessels re-open allowing blood to return to the area. The narrowing and opening repeat in cycles.
The decrease in swelling also allows more movement in the area and lessens the loss of function associated with the injury. Pain is also reduced as pressure from the swelling lessens. Chemicals that intensify the pain are released into the bloodstream when tissues are injured, thus the narrowing of the vessels help to minimize this release and pain.
3. Decreasing metabolic rate
Ice reduces the metabolic rate and oxygen requirements of the cells. Thus, even with the decreased blood flow and oxygen delivery that comes with narrowing of the vessels, the risk of cell death will be lessened. This prevents further injury.
Sub-acute phase
A few days following an acute injury, the pain and swelling may have decreased so much that there may be no sign of the original injury. However, the tissues are still in the process of recovery and will still benefit from modifying your activities (less vigorous) as well as using both ice and heat alternatively. This means to apply ice for 10 minutes, followed immediately by 10 minutes of heat.
How does this work?
Doing this will cause massive increases in blood flow to the area as the narrowing caused by cooling is reversed when heat is applied, resulting in an influx of blood to the damaged tissues. The increased blood flow to the area provides proteins, nutrients and oxygen for better healing. It also helps remove the products of inflammation and reduce residual swelling.
An important point to note is to ensure that inflammation has stopped before applying this technique. That means that the area should not be red, and should not be warm to touch.
Chronic Injuries
Flickr: Capture Queen
In order to treat these, heat should be used to help relax tight, aching muscles and joints, increase the extensibility of ligaments and tendons and promote blood flow to the area. Heat can also be used before exercise in chronic injuries to warm the muscles and increase flexibility.
Heat can be applied to the area in the form of heat packs, a warm damp towel, hot water bottles or heat rubs. If using a heat pack or hot water bottle, ensure a suitable layer of protection is placed over the skin to prevent burns. The heat should be applied for 15-20 minutes.
How does heat work?
Heat applied on the skin increases the temperature of the skin and the underlying tissues. This in turn opens up the blood vessels like your ateries, allowing more blood to flow into the area. This increase flow helps to remove waste products from cells and deliver more nutrients, relaxing tissues. The increased temperature of the blood also warms up surrounding tissues. Heat also has an effect of increasing flexibility of the soft tissues.
Both heat and ice are cheap, easy to use and effective ways of speeding up recovery when used correctly. Besides managing your injuries with these modalities, it may be a good idea to consult a physiotherapist in helping you rehabilitate and/or prevent the same injuries from occurring.
When is Achilles Tendonitis not Achilles Tendonitis? When it is Retrocalcaneal Bursitis
Do you experience pain at the back of your heel? Is the back of your heel red and swollen? And you were told that it might Achilles Tendonitis? But so far treatment for Achilles Tendonitis does not seem to be working? You might be suffering instead from Retrocalcaneal Bursitis.
Background
www.merck.com
This condition is often mistaken for Achilles tendinitis but it can also occur in conjunction with Achilles tendinitis.
Signs and Symptoms
In retrocalcaneal bursitis, pain at the back of the heel is the main complaint from patients. Pain may worsen when tip-toeing, running uphill, jumping or hopping. Often, those who are accustomed to wearing high-heeled shoes on a long-term basis may also complain of pain at the back of the heel when switching to flat shoes. This is because when in high-heeled shoes, the calf muscle and the Achilles tendon are in a shortened position. Switching to flat shoes would cause an increased stretch to the calf muscle and Achilles tendon, irritating the Achilles tendon and the retrocalcaneal bursa. Other symptoms may include redness and swelling at the back of the heel.
What leads to Retrocalcaneal bursitis?
There are several factors which can lead to a person developing retrocalcaneal bursitis. In athletes, especially runners, overtraining, sudden excessive increase in running mileage may lead to retrocalcaneal bursitis. Tight or ill-fitting shoes can be another causative factor as they can produce excessive pressure at the back of the heel due to restrictive heel counter. A person with an excessively prominent posterosuperior aspect of the heel bone (Haglund deformity) may also have a higher predisposition to retrocalcaneal bursitis. In such individuals, pain would be reproduced when the ankle goes into dorsiflexion.
How do we tell that it is not Achilles Tendonitis?
Careful examination by your physician or physiotherapist can determine if the inflammation is from the Achilles tendon or from the retrocalcaneal bursa. Tenderness due to insertional Achilles tendinitis is normally located slightly more distal where the tendon inserts into the back of the heel, whereas tenderness caused by the retrocalcaneal bursa is normally palpable at the sides of the distal Achilles tendon.
Diagnosis can be confirmed with an ultrasound investigation, MRI or CT scan.
Management
- During the initial acute phase of the condition, patients should apply ice to the back of the heel for 15 to 20 minutes and follow the R.I.C.E.R regime. Avoid activities that cause pain.
- Gradual progressive stretching of the calf muscle and Achilles tendon is also advocated.
- Changing the footwear. Wearing an open-backed shoe may help relieve pressure on the affected region. For those whose symptoms were caused by a sudden change from wearing high-heeled shoes to flat shoes, the temporary use of footwear with a heel height in between may be helpful.
- Inserting a heel cup in the shoe may help to raise the inflamed region slightly above the shoe’s restricting heel counter and relieve the pain. It is advisable to also insert the heel cup into the other shoe to avoid any leg-leg discrepancies that can lead to other problems.
- Training frequency and intensity should be gradually progressed with adequate rest between trainings.
Thawing Frozen Shoulders
In an earlier article, we look at what frozen shoulder was all about. In this article, we will look at some treatment options for frozen shoulders
What is the treatment for a frozen shoulder?
Flickr: nataliej
You can try taking over-the-counter painkillers such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDS) to help reduce pain and inflammation. If these do not provide sufficient relief, see your GP for a stronger prescription.
Applying heat the shoulder can also offer pain relief. This warms up the shoulder to make it easier to move, and easier to sleep at night.
Performing stretching exercises for the shoulder can also benefit in reducing stiffness in the shoulder. Diligent exercise can reduce the chance of severe restriction in the shoulder, which can aid in faster recovery from a frozen shoulder. These exercises will be taught by the physiotherapists.
Physiotherapy can help you in the recovery from a frozen shoulder. A physiotherapist can perform treatment techniques to increase movement in the shoulder joint, as well as reducing pain. They can also show you exercises that are specific to your condition and ensure you are performing them correctly.
Severe and unrelenting pain may require a cortisone injection. This is a steroid injection which may be effective in the reducing pain in the short term. Your GP or specialist will help you decide whether this treatment option is appropriate for your condition.
When conservative treatment fails, more invasive options can be considered. Shoulder distension is a technique where saline water is injected into the joint to stretch the shoulder joint to help allow it move more easily. Another option is manipulation, which can be performed to stretch out tightened tissues. This process is conducted under anaesthesia by an orthopaedic specialist to restore mobility in severely frozen shoulders. Surgery is the last resort for a frozen shoulder. During this procedure, scar tissue and adhesions are removed through arthroscopic surgery to allow the shoulder to move more freely.
What can I do to get better?
It is advised that you see your doctor or a physiotherapist to diagnose your shoulder pain if you are unsure of the cause. If you suspect it is a frozen shoulder, some simple exercises can be performed to help prevent your frozen shoulder from worsening. These should be performed 3 to 4 times a day and should be relatively pain-free, especially if your shoulder is quite painful. See your doctor if your condition does not improve within 3-4 weeks.
Flexion
- In standing, hold a stick horizontally in front of you with hands shoulder-width apart
- With the arms straight, bring the stick from hip level towards the ceiling until you feel your pain come on
- Hold for 5 seconds and return to starting position
- Repeat 10 times
Extension
- In standing, hold a stick horizontally behind you with hands shoulder-width apart
- With the arms straight, bring the stick from hip level towards the ceiling until you feel your pain come on
- Hold for 5 seconds and return to starting position
- Repeat 10 times
External rotation
- Lie on your back and hold a stick horizontal in-front of you with your hands shoulder-width apart
- Bend the elbows to 90 degrees and keep them next to your body
- Using the hand on the pain-free shoulder, push the stick towards the affected side whilst still keeping your hands on the stick
- Hold the end position for 5 seconds and return to starting position
- Repeat 10 times
Internal rotation
- Stand holding a stick with the pain-free arm behind your head, and the affected hand behind your back holding the other end
- Using the pain-free arm, pull the stick up towards the ceiling until you feel the onset of pain in your affected shoulder
- Hold the position for 10 seconds and return to starting position • Repeat 10 times
What’s freezing up your shoulder?
There are many types of shoulder conditions, but one in particular can creep up on you without you remembering having hurt it. This condition is called Adhesive Capsulitis, or more commonly known as Frozen Shoulder.
What is a Frozen Shoulder?
Frozen shoulder is a condition where the shoulder joint becomes stiff and painful, often with no known cause. It usually comes on gradually, worsens over time, and then eventually resolves.
There are 3 stages in the development of a frozen shoulder which can take up to 2 years or more to complete.
Stage 1 – Freezing stage: During this stage, the affected shoulder gradually becomes more painful and starts to lose mobility. This stage can last from 6 weeks to 9 months.
Stage 2 – Frozen stage: Shoulder pain and stiffness is significantly noticeable during this stage. Daily tasks can be difficult to perform, and sleep disturbance is common as the pain is worse at night. This stage can last from 4 to 9 months.
Stage 3 – Thawing stage: The shoulder is not usually painful during this stage. The stiffness decreases as the shoulder starts to “thaw” out. This stage usually last between 5 months and 2 years.
How do you get a Frozen Shoulder?
The cause of frozen shoulder is poorly understood. It is thought that the joint capsule, the lining around the shoulder joint, becomes inflamed in a frozen shoulder. This inflammation causes adhesions and scarring to form within the capsule, resulting in pain and movement restriction. There is also a lack of fluid in the joint, further reducing joint mobility.
Research indicates that sometimes a frozen shoulder can develop after a trauma or injury to the shoulder. However, in many cases, there is no known cause. Apart from trauma, some other risk factors have been linked to frozen shoulder, including:
- Age and gender – frozen shoulder tends to affect people between the ages of 40 and 60 years old. It is also much more common in women than men
- Diabetes – diabetic people are more likely to develop a frozen shoulder, as well as take longer to recover due to poor blood circulation
- Other systemic diseases – heart disease and Parkinson’s disease are some examples of systemic diseases linked to developing a frozen shoulder.
How can I tell if I have a frozen shoulder?
Frozen shoulder is usually diagnosed by signs and symptoms which are assessed by a docotr or physiotherapist. People who have a frozen shoulder often complain of:
- Gradual worsening shoulder pain with no known cause
- Aching pain on top of the shoulder and often shooting into the upper arm
- Movement restriction without a loss of strength
- Inability to sleep on the affected shoulder and sleep disturbance when rolling on to it
- Difficulty with grooming and dressing as the condition progresses
A doctor or physiotherapist will also assess your movement and palpate the joint help confirm the diagnosis and rule out other shoulder conditions.
For treatment options of frozen shoulder, read our follow-up article on this topic, "Thawing Frozen Shoulders".
The Barefoot Professor: by Nature Video
This is a great video on bare-foot running by Nature. Harvard professor Daniel Lieberman has ditched his trainers and started running barefoot. His research shows that barefoot runners, who tend to land on their fore-foot, generate less impact shock than runners in sports shoes who land heel first. This makes barefoot running comfortable and could minimize running-related injuries. Read more here http://www.nature.com/news/2010/10012… and find the original research here: http://dx.doi.org/10.1038/nature08723
Heel Ergonomics – Part II
This interview continues from Handbag Ergonomics – Part I
MCR: Can high-heeled shoes change the way a person walks?
Flickr
MCR: Most shoes stores these days sell a lot of high-heeled shoes and wedges, what are the potential health dangers if they are worn for too long and too often?
Cheryl: Ankle and foot injuries while wearing high heels/ stiletto shoes are commonly reported. Commonly high-heel related injuries are calf sprains, twisted ankles and injuries from falls. Wearing high heels long term can seriously harm the feet by damaging the tendons in the heel and causing blisters, bunions, corns and calluses which some of them may even require surgery. Other conditions such as hammertoes, ingrown toenails and ankle and knee joint pains. Heel pains such as inflammation of the plantar fascia (bottom connective tissue of the foot) or plantar fasciitis are very common too.
MCR: What is the most serious scenario that can happen?
Cheryl: Fractures of the ankle or foot on falling and complete tear of ankle ligaments which requires a cast or ankle reconstruction operation to heal. Other more serious injuries that can be sustained on falling can be trauma to the head and shoulder fractures and strain. On a long term basis, research shows that wearing high heeled shoes regularly causes long-term health problems such as a distortion of the lower spine and arthritis in the knees which can lead to postural spinal stenosis and rapid degeneration of the lower spine (also known as lumbar spondylosis) leading to chronic low back pain and/or numbness or any other sensation changes in the legs.
MCR: What advice on choosing shoes?
Cheryl: There are no hard and fast rules about it, but it is recommended that high heel wearers take sensible precautions when going out in high heels or new and unfamiliar shoes in order to reduce injury. These include wearing shoes with ankle straps to help hold ankle and feet in place, making sure your shoes are properly fitted (size-wise), switching to flats during the day to give your calf muscles a break, and placing appropriate measures in shoes (i.e. heel pads, corn pads) to minimise the chance of blisters and painful friction.
MCR: How can physiotherapy help a person with heel pain?
Cheryl: Heel pain can be a result of bad walking posture/gait pattern, excessive walking and running (overtraining), wearing high heels frequently and/or muscle imbalance of the leg (hip, knee and ankle). Depending on the nature of the injury, be it a sprain or an accumulative stress related injury, physiotherapy help by applying various strategies in the reducing the stiffness, pain and discomfort in joints or muscles affected. Strategies include manual techniques, such as joint mobilization and manipulation, deep friction massage, stabilization exercises and electrotherapy i.e. ultrasound therapy. Should wearing heels be required on the job, the physiotherapist may make recommendations on the footwear, and advise on posture correction and specific muscle strengthening for injury prevention. Nevertheless, treatment is always more effective if the problem is detected and treated early as chronic problems (more than 3 months) have poorer treatment results. Therefore, if the pain does not resolve within 3-7 days and seems to get worse, it is time to make an appointment with your physiotherapist.
MCR: Besides heavy bags and high heels, what are the other potential fashion health hazards?
Cheryl:
Badly Fitting Bras
Studies have shown that as many as 90% of women are wearing the wrong bra size, many still hanging on to the same bra size they were fitted for years ago – irrespective of growing, losing weight or having children. Wearing the wrong bra could lead to shoulder tension, chest/ breathing restriction, headaches and chest and upper back pain. If the bra is too loose, it is not supportive enough and if too tight and restrictive, it can lead to restrictions in breathing normally, upper back pain and reduction of spinal movement.
Tight Pants/jeans
The trend for skinny jeans, hipsters/ low riding jeans tend to restrict movement and can also cause bad posture, changing the alignment of the spine. The tight, low riding jeans/ trousers can squeeze a sensory nerve under the hip bone, known as the femoral nerve, and cause a tingling sensation in the thighs (pins and needles) also called paresthesia.
Predicting Running Related Injuries in Male and Female Novice Runners
In a study of 532 novice runners (226 men, 306 women) preparing for a recreational 4-mile (6.7-km) running event. After completing a baseline questionnaire and undergoing an orthopaedic examination, they were followed during the training period of 13 weeks. Running Related Injuries (RRI) was defined as any self-reported running-related musculoskeletal pain of the lower extremity or back causing a restriction of running for at least 1 week.
Twenty-one percent of the novice runners had at least one RRI during follow-up. Male and female novice runners have different risk profiles
The model for male participants showed that body mass index (BMI) , previous injury in the past year , and previous participation in sports without axial load were associated with RRI.
In female participants, only navicular drop remained a significant predictor for RRI. Type A behavior and range of motion (ROM) of the hip and ankle did not affect risk.
Source:Am J Sports Med February 2010 38:273-280; doi:10.1177/0363546509347985
© 2003-2012 Core Concepts Pte Ltd, All rights reserved | Terms and Conditions | Policy
<
-
-
-
-
-
