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Nationally recognized physicians, a dedication to research and development, and Mercy’s mission of compassionate, high-quality care make The Maryland Spine Center one of the leading spine centers in the region.
The Maryland Spine Center provides premier clinical expertise in treating: Spinal DeformitiesSpondylolisthesis
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Spondylolisthesis translated from Greek (spondylo = spine; listhesis = slippage) means ‘slippage of the spine’. This is a fairly common condition that typically arises from one of two sources: juvenile stress fracture (spondylolysis) or disk degeneration. Stress Fracture Approximately six percent of children develop a stress fracture within their low backs that never completely heals. This fracture is called spondylolysis (spondylo = spine; lysis = break). In most cases, this bone defect does not cause ongoing symptoms and is often unrecognized until later in life. The fracture produces weakness within the spinal column and in some cases leads to premature disk degeneration at the base of the spine. As the disk wears out, the fractured vertebra shifts forward out of alignment. The disk degeneration and associated arthritic changes often cause nerve compression and irritation. It is typically this nerve irritation, which manifests as buttock and leg pain, that leads an adolescent or adult patient with a spine stress fracture and spondylolisthesis to seek further evaluation and treatment. Typically, the slip occurs between the lowest lumbar vertebra (L5) and the sacrum, but can occur at other levels within the spine. In a small percentage of patients, often those with so-called “dysplastic” anatomy, the slip will progress to cause significant pain, hamstring tightness, and physical deformity. Rarely, bowel and bladder function is affected as well. In the worst cases, the lumbar spine dislocates over the front of the sacrum, a condition known as spondyloptosis (spine dislocation), causing patients to lose height between their rib cage and pelvis until their ribs rest upon their pelvis. Their rib cage projects in front of their pelvis, their buttocks are flattened, and they walk with a crouched posture. Treatment: All grades of spondylolisthesis in children and adults, including spondyloptosis, are treated at The Maryland Spine Center. Some patients with small amounts of slip respond to intermittent bracing, epidural steroid injections, anti-inflammatory medications, and rest. Others with persistent low back pain, nerve irritation and/or progression of the slip, require surgical intervention in order to provide a more lasting relief and return to normal activities. When symptoms persist in children and young adults with stress fractures without vertebra shifting, a fracture repair procedure alone is often possible. For more cases with nerve compression and spondylolisthesis, a minimally invasive fusion procedure provides relief of the nerve compression and stabilization of the shifted vertebrae. Dr. Charles Edwards has gained the largest experience in North America correcting major spondylolisthesis deformities, including spondyloptosis. He has numerous publications and authors most spine textbook chapters on the subject. Dr. Edwards and his associates have developed advanced surgical methods based upon stress relaxation to restore normal spinal alignment, trunk height, and body proportions. The preferred method of surgery is performed through one midline back incision. Anterior surgery (across the abdomen) is not required. Both fusion rates and spine biomechanics are enhanced by restoring the normal alignment of the spine. Clinical research with over 10-year follow-up has documented long-term clinical success with these procedures. Degenerative As disks in the spine age, they tend to lose some of their water content and become dehydrated. As this occurs, the disk height decreases resulting in mild loss of overall patient height. The narrowed disk bulges on the sides, much like a partially flat tire. The aging disk is less firm, allowing some shifting of the neighboring vertebra. The forward/backward shifting of the vertebra often irritates the spinal nerves and stimulates the development of bone spurs and enlarged spinal ligaments (ligamentum flavum). The combination of vertebral shifting (spondylolisthesis), disk bulging, bone spurs and enlarged ligaments produces a narrowed spinal canal (spinal stenosis). The resultant pressure on the nerves in the low back can cause a group of symptoms, including back pain, with radiation of discomfort or burning into the buttocks, thighs, legs, and feet. Numbness, weakness, and a forward hunched posture can occur in longstanding or severe cases. Typically individuals with degenerative spondylolisthesis and spinal stenosis will have difficulty walking more than short distances and feel better leaning forward or sitting down. Treatment: In most cases, the body is able to maintain stability to the spinal column and prevent the vertebra from actively shifting back and forth on each other through the accumulation of bone spurs. If this is the case, then symptoms are best treated with either medications, an epidural steroid injection, or decompression surgery. For short lived symptoms, anti-inflammatory medications or an epidural injection are usually sufficient to relieve the symptoms. For lasting symptoms and those that do not respond to appropriate non surgical treatment, a minimally invasive procedure to relieve the nerve pressure is often the best approach. Decompression surgery alone may not be possible if the slippage is in excess of 3 mm. In those specific cases, a decompression and fusion surgery would be necessary to maintain the stability of the spine after decompressing the nerves.
Kyphosis (Hunchback)
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Several diseases can result in progressive forward bending of the spine, or “kyphosis”. In the neck, the head hangs forward and neck muscles become sore. In the upper back (thoracic spine), the spine bends forward to produce a hunchback deformity. In the lower back (lumbar spine), kyphosis (or flat back syndrome) forces the patient to lean forward when standing or walking. Significant kyphosis is usually associated with low back pain or back fatigue. Types and Causes • Osteoporotic Kyphosis – Osteoporosis most often occurs in women with advancing age when bone becomes less dense and more likely to break or collapse, often during everyday activities. Vertebral bodies near the bottom of the rib cage are especially susceptible to fracture and collapse. The vertebral bodies on the front side of the spine collapse while the back side of the vertebrae does not. As a result, the spine progressively bends forward placing even more pressure against adjacent vertebral bodies. Therefore, osteoporotic kyphosis usually does not stop with one or two vertebrae, but continues to progress over time. • Scheuermann’s Kyphosis – This condition results from an abnormality of the growth plates of the vertebral bodies. As a result, during adolescence, the front of the vertebrae do not grow as tall as the back side of the spine. This causes the spine to bend forward, as the stacked vertebra settle on each other in a non parallel manner. The spine may become very rigid and lead to pain in the remaining normal portion of the lower spine years later. • Ankylosing Spondylitis – This is an inflammatory condition that affects the sacro-iliac joints and spine. In the later stages of the disease, the spinal ligaments, which connect tissues between vertebra, contract and calcify. The spine steadily bends forward into severe kyphosis and becomes one rigid bony columnar structure appearing like a stalk of bamboo. • Kyphosis following Fractures or Tumor Collapse – The most common patterns of spinal injury (flexion-compression injuries) result in fracture of the vertebral body and rupture of the posterior spinal ligaments. Tumors often erode the vertebral body until it collapses. In either case, the spine bends forward over time into kyphosis. The condition is often painful and can cause pressure against the spinal cord. • Laminectomy, which is the procedure of surgically removing the posterior ligaments and bony structures from the back portion of the vertebra, is often performed in the process of decompressing the nerve roots or the spinal cord. This procedure can eliminate the ligamentous “check-reins” that prevent gravity from pulling the spine forward into kyphosis. This is often encountered after a laminectomy in the cervical spine (neck), and allows the head to fall forward to the chest. Treatment: The physicians at The Maryland Spine Center are able to fully correct the vast majority of kyphotic deformities and restore normal posture for most patients of all ages. By using the Kyphoreduction stress-relaxation methods developed by Dr. Charles Edwards, Mercy’s spine surgeons are able to correct the deformity through one midline back incision without the need to open the chest or abdomen. This surgery has been highly successful in patients of all ages. For elderly patients with kyphosis due to collapse of weak, osteoporotic vertebrae, “vertebroplasty” cement injection is available for patients with painful collapse of one or two vertebrae. More often, vertebral collapse afflicts many vertebrae and leads to a painful, hunchback deformity. In many of these patients the spine can be straightened and protected with an “internal brace” using spinal instrumentation with or without fusion.
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Scoliosis is defined as a lateral (sideways) curvature of the spine. This may cause one shoulder to be higher than the other or one hip to be more prominent than the other. Scoliosis is usually associated with rotation (twisting) of the spine. Rotation may cause prominence of one side of the rib cage (rib hump). Most forms of scoliosis progress rapidly during adolescent growth years and then more slowly. Scoliosis can cause postural imbalance with the patient’s head to the right or left of the pelvis. Severe thoracic curves can even compromise the function of the heart and lungs. Types • Congenital – These deformities originate in utero. They are caused by formation of extra partial vertebrae or by vertebrae that fail to separate on one side as the fetus grows. • Adolescent – The most common form of scoliosis does not become noticeable until the growth spurt begins in adolescence. Its cause is unknown and so it is sometimes called idiopathic scoliosis. It most commonly occurs in females. • Degenerative – As the normal spine ages, disks soften and arthritis may develop in the facet joints (back side of the spine). If there is some curvature (scoliosis) in the lower back (lumber spine), it can greatly increase when the disks soften and facet joints erode due to arthritis. Increased curvature is often accompanied by increased instability and pain with activity. The facet joints form additional bone to help stabilize the failing spine. This extra bone can press upon nerves to cause leg pain. This process most often occurs in the low back of middle-aged adults and is known as degenerative lumbar scoliosis. Treatment: In the early 1900s, surgeons pioneered new bracing techniques for improving scoliotic deformities. Today, special spinal instrumentation is used that gradually applies corrective forces in all 3-dimensions to address all aspects of the deformity. It is rarely necessary to open the chest or abdomen. Using these methods, The Maryland Spine Center surgeons are able to achieve more correction of deformity than previously available.
Degenerative DisordersThe individual vertebrae that comprise the spine move through disks in the front and facet joints in the back part of the spine. The spinal cord and nerve roots occupy a canal in the center of the vertebrae. In young people, the disks are very elastic and have a high water content. As people age, they naturally loose the disk molecules responsible for its elasticity and water content. This process is known as disk degeneration. Genetic predisposition, overuse, or injury can accelerate the degenerative process. As disk elasticity wanes and the central disk becomes soft, more stress is transferred to the fibrous tissues surrounding the central disk (the annulus). With time, fibers in the overloaded annulus begin to fail, the annulus bulges, and the disk becomes narrower (shorter). The right and left facet joints on the back side of the spine are small versions of other synovial joints like those in the knee, hip, and fingers. Both sides of the joint are lined with articular cartilage. The cartilage is bathed in synovial fluid produced by synovial tissue which lines the joint. Arthritis can affect any joint in the body, including the facet joints in the spine. The synovium becomes inflamed and produces enzymes, which damage and digest the articular cartilage. Facet degeneration can also follow disk degeneration. When a disk becomes softer and shorter, more of the force crossing the spine must be borne by the facet joints. This can accelerate their rate of degeneration. When their articular cartilage is gone, the facet joints become loose and unstable. The bone adjacent to the joint edge then begins to grow in an attempt to stabilize the joint. These boney growths are known as osteophytes. Disk and facet degeneration can occur without major symptoms. If the process works according to nature’s plan, the instability that results from disk and facet degeneration is counterbalanced by increased stiffening from osteophyte formation. The osteophytes on either side of the disk and facet joints tend to grow together until very little motion occurs between the two vertebrae. Indeed, the majority of patients with degenerative disks or facets have no serious pain or nerve problems. Patients with a benign course of disk and facet degeneration may need only a regimen of intermittent anti-inflammatory medications, spine support and abdominal exercises to get them through brief exacerbations until their spine stabilizes. On the other hand, the combination of disk and facet degeneration can crowd the spinal canal and the openings through which nerve roots pass out of the spine. This crowding can irritate the spinal nerves, resulting in pain and weakness. If there is any imbalance in the spine, it can quickly accelerate if one side of the spine degenerates more rapidly than the other. This can lead to degenerative lumbar scoliosis, nerve impingement, progressive imbalance and deformity. Disc Herniation (Rupture)
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Although disk degeneration is most common in older patients, it can occur in young adults as well. It is most common in the lowest two joints of the lumbar spine and near the base of the neck. As mentioned earlier, when the central disk material becomes soft, more stress is transferred to the surrounding annulus. A sudden exertion or extreme turn can tear the weakened annulus and allow some of the central disk material to squeeze through the tear into the spinal canal. This is known as a disk rupture or disk herniation. Disk rupture or herniation usually causes pain in the low back or base of the neck. If the disk herniation occurs in the vicinity of a spinal nerve root, the root is either irritated by the presence of the disk material or, worse yet, the disk material presses upon the nerve. In this case, the patient feels pain down the arm or leg along the course of the affected nerve. Treatment: The great majority of disk herniations resolve without medical treatment. After an initial inflammation, scar tissue forms and contracts about the disk fragment. At the same time, the nerve adjusts its shape to share the space with the remaining disk fragment. Hence, most patients require only anti-inflammatory and muscle relaxation medications combined with a cervical collar for neck disk ruptures and restricted activity for lumbar disk ruptures. When pain is intolerable or does not steadily decline over the first few weeks, more potent anti-inflammatory medications or injections may be indicated. Surgery is only needed when there is progressive loss of nerve function or when the level of pain is too severe or its duration too long to tolerate despite use of anti-inflammatories. Surgery to remove the herniated disk fragment and relieve pressure against a nerve has a very high rate of success. The smallest incision that reveals all relevant local anatomy enabling the surgeon to locate and completely remove the offending fragment is preferred. Most patients are able to go home the same day as surgery. Degenerative Disc Disease
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The early form of this condition also can be referred to as an “internal disk derangement”. Disk degeneration is part of the normal aging process. It usually causes little pain unless followed by disk herniation, facet arthritis, or spinal stenosis. However, there are a few patients who do appear to have significant pain associated with early disk degeneration. Treatment: Many patients with pain from spinal arthritis and/or degenerative disk disease will obtain satisfactory relief with a combination of short-term bracing, medications, and then physical therapy. For patients who do not find adequate relief or suffer recurring problems, a great emphasis is placed on finding the precise source of pain before considering surgery. If surgery is indicated, the surgeons must then determine the least amount of surgery necessary to solve each patient’s problem. When surgery is truly indicated, the most frequently performed operation for disk disease in the neck is disk removal, expansion of the space for the spinal cord and nerve roots (decompression) and fusion of the painful segment. The surgery is performed through a short horizontal incision on the left side of the neck. The incision is placed within a natural skin crease in order to minimize any scaring. Thin metal plates are used to hold the bones stable during the 2-3 month bone healing process. Most patients experience rapid relief of pain and are kept in the hospital overnight for observation. At The Maryland Spine Center, the most common surgery for painful disk degeneration in the lumbar spine is a one or two level posterior surgical fusion. Although this is not a small procedure, it is well established and safe; success rates are high, and the results are permanent. The physicians are careful to select the smallest and safest procedure to relieve the patient’s source of pain. Patients typically spend 2-4 days in the hospital after which some go home and others stay on the rehabilitation floor for additional therapy. Once home, patients are able to walk up and down stairs, take a shower, and walk about the house. A cane or walker and a soft brace are often helpful for the first few weeks while the soreness of the surgery subsides.
Spinal Stenosis
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When the combination of disk degeneration and facet arthritis narrow the spinal canal or openings (foramen) for exiting nerve roots enough to irritate or compress the nerves, the condition is known as spinal stenosis. Typically, the nerves are caught between the disk annulus in the front and expanded facets on the back side of the spinal canal. When the disk loses height, the surrounding annulus bulges back into the canal, much like a tire without sufficient air pressure. The arthritic facet joint capsules thicken due to chronic inflammation. Facet osteophytes grow ever larger in their attempt to stabilize the spine. The space left for the nerves continues to get smaller. If this occurs gradually, the nerves can accommodate to a surprising extent. However, eventually the space gets so small that normal nerve function is no longer possible. Patients with spinal stenosis often experience increased leg pain with perhaps numbness, weakness or clumsiness when walking or when lying or standing in one position too long. Their leg symptoms are often worse than their back symptoms. They find relief by resting or changing position. Treatment: Since physical narrowing of the spinal canal causes spinal stenosis, the only treatment with lasting effectiveness is to remove those overgrown tissues pressing upon the nerves. Prior to surgery, an MRI or a CT-myelogram is obtained to accurately visualize the course of each spinal nerve and the structures pressing upon them. For the surgical decompression, The Maryland Spine Center surgeons have perfected a “diagonal decompression” technique that provides complete decompression of the nerves, but preserves all major spinal ligaments and facet joint capsules. Although more tedious and time-consuming, this technique diminishes subsequent spine instability and saves many patients from much more extensive fusion operations.
Spinal InjurySpine Trauma
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Spinal trauma may rupture ligaments or fracture vertebrae in the neck or back. More severe injuries can damage the spinal cord or nerve roots to cause paralysis or regional pain and weakness. Some injury patterns do not initially appear to be alarming, but can leave the spinal column unstable and subject to progressive deformity and/or chronic pain. Treatment: Dr. Charles Edwards was co-founder and director of the Spinal Injury Service for the Maryland Shock Trauma Center. He has developed new and improved operations for reconstructing the injured spine and published over 50 papers on spinal injury. The Maryland Spine Center has round-the-clock spine surgeon coverage to provide immediate evaluation and treatment for patients with spinal injury. Once the spine is stabilized with bracing or surgery, intensive occupational and/or physical therapy helps speed recovery. Spinal Tumors
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Cancerous tumors can arise within the vertebral column. Many can be cured if diagnosed early and completely removed before they spread. Dr. Charles Edwards and his associates have successfully removed some of the largest spinal tumors ever recorded. They have published articles and chapters on the diagnosis and surgical treatment of spinal tumors. Metastatic tumors arising from other organs commonly lodge in the spinal vertebrae. As these tumors grow, they erode bone resulting in vertebral collapse and pain. Metastatic tumors are often best treated with a combination of radiation or chemotherapy to shrink the tumors and spinal surgery to straighten and stabilize the spine. Treatment: The Maryland Spine Center surgeons have had excellent results using both spinal injury instrumentation and the same Kyphoreduction instrumentation and methods as are used for Kyphosis. These procedures straighten and stabilize the spine. This typically eliminates most of the pain, restores patient mobility, and protects the spinal cord from injury due to fractures from weakened vertebrae. When it is necessary to remove large portions of the spine, our surgeons have extensive experience in reconstructing one or more vertebrae with custom artificial spinal segments. Surgeons at The Maryland Spine Center work together with oncologists and numerous other specialists for management of cancerous conditions. Extended rehabilitation is available.
Complex ConditionsMany patients are afflicted with neck or back pain and/or arm or leg weakness without a clear explanation. Some have had unsuccessful surgical procedures. Chronic back pain or weakness may result from continued nerve root compression after disk or decompression surgery, early degenerative changes that do not show up on x-ray, or unsuspected nonunion after fusions that were thought to be successful but were not. The Maryland Spine Center physicians utilize a systematic approach that may include MRI, myelography, CT scans, facet injections, nerve root blocks, and quantitative motion studies. A careful history and exam combined with one or more of the listed studies often yield a clear explanation for the previously unexplained pain or weakness. If a cause can be identified and verified, treatment is usually successful. Correction of Previously Failed Fusions (Nonunions)
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The purpose of a spinal fusion is to stop motion between painful vertebrae. A fusion between two spinal vertebrae is similar to a weld between two pieces of metal. In a good weld, one piece of metal is left. After a successful spinal fusion, the two vertebrae are united into one immovable piece of bone. Hence, any painful joints or disks in between no longer move and are, therefore, no longer painful. It can be very difficult to determine if a spinal fusion is successful. The x-ray can show substantial new fusion bone, but that does not mean the two vertebrae actually have fused into one piece of bone. As a result, a surgeon can believe that a solid fusion has been achieved, when, in fact, motion remains and can explain the patient’s persistent pain. The surgeons at The Maryland Spine Center recently described and presented a novel technique of identifying nonunions using CT scans. Described as the “Vacuum Disk Sign”, the presence of air between the vertebrae was found to be 100 percent specific in the diagnosis of a lumbar nonunion. Treatment: Nonunions are treated by improving the biology and biomechanics of the healing environment. Bone morphogenic protein (Infuse) is commonly used in an off-label manner to stimulate the local bone cells to rapidly produce new bridging bone. While the bones are healing, it is important that they be restricted from moving. Modern pedicle screw implants are used as a form of internal brace to hold the vertebra still while the bone healing takes place. Solid fusion typically occurs within three months and is monitored with monthly post-operative x-rays. While the screw implants may be removed after bone healing, this is rarely performed as the implants are generally painless and pose no risk. The Maryland Spine Center provides compassionate patient care as well as focuses on research to enhance the capabilities of treating complex spinal deformities and injuries.
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