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Spine Guide
LEARN ABOUT YOUR SPINE, COMMON SPINE
P RO B L E M S, A N D T H E C A R E YO U C A N E X PE C T
THE SPINE PROGR AM IS A
M U LT I D I S C I P L I N A RY, I N T EG R AT E D P R AC T I C E
that provides comprehensive spine care services, including
surgical and non-surgical treatment of all spinal conditions.
Our staff includes specialists in physical and occupational therapy,
physical medicine and rehabilitation, interventional and medical pain management,
behavioral medicine, radiology, neurosurgery, and orthopedic surgery.
AS AN INTERDISCIPLINARY TEAM, WE PARTNER WITH YOU
to assess your spine condition, weigh treatment options, and design a
personalized treatment plan. We combine clinical excellence with
research, education, and advocacy — and we strive always
to provide healing with a human touch.
What’s inside…
SPINE BASICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Your spine.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Common problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CARE AT THE SPINE PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Your spine care team. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Team-based approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ASSESSMENT AND TREATMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Treatment options.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
healing
with a
human
touch
SPINE GUIDE
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Spine Basics
Knowing about your spine — its parts, how they’re put together, and what can go wrong — can help you
understand your diagnosis and treatment options. It can also help you protect your spine in the future .
Your spine
Your spine is made up of vertebrae, discs, spinal cord and nerves, ligaments, and muscles.
Vertebrae
Your spine is a column of 33 bones (vertebrae) stacked up on top of each other. As shown below,
the spinal column is divided into four regions, and the vertebrae within each region are numbered.
Viewed from the side, the four regions all have natural curves
(curvatures). These curves help balance and distribute the weight
of your body.
Cervical. This is your neck area. The cervical
vertebrae are numbered from C1 to C7.
Thoracic. This is your upper- and mid-back, from
your chest to your waist. The thoracic vertebrae
attach to the ribs and are numbered from
T1 to T12.
Lumbar. This is your lower back area. The lumbar
vertebrae are numbered from L1 to L5.
Sacral. This region of your spine is your buttock
and “tailbone” area. It includes the sacrum
(5 vertebrae that are naturally fused to form a
triangular-shaped bone) and the four very small
coccygeal vertebrae below that.
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SPINE GUIDE
Vertebra and disc:
top view (cross-section)
FRONT
disc nucleus
disc annulus
the spine
spinal cord
nerve root
vertebra
DISCS
BACK
The vertebrae are separated by discs that cushion the vertebrae and
allow them to move properly. Each disc is a small, circular capsule
with a tough outer wall (the annulus) and a softer core (the nucleus).
In children, this core is gel-like, but with age, the core tends to harden
and become less elastic.
Spine and facet joints:
view from the back
facet joint
Facet joint:
side view
(cross section)
Spine section showing vertebrae,
discs, and facet joints:
side view
FACET JOINTS
Each vertebra has two pairs of facet joints. These joints link the
vertebrae together at the back of your spine. They stabilize the spine
and allow you to bend and twist. To help the joints glide smoothly
against each other as you move, the joint surfaces are covered by
cartilage and the whole joint is covered by a capsule containing fluid.
This joint capsule is made of ligaments and other connective tissue.
SPINE GUIDE
5
Spinal cord and nerves
MUSCLES
The entire spinal column is
stabilized by muscles in your
back, sides, and abdomen.
These muscles maintain your
posture and help you to bend,
twist, and move your back.
Besides supporting the weight of your body, the vertebrae also house and
protect your spinal cord. The spinal cord is a network of nerves that extends
from the base of your brain to your lower back. (The spinal cord passes
through a tubular space — the spinal canal — formed by the ring-shaped
openings of the vertebrae.) Smaller spinal nerves branch off of the spinal
cord, exiting through smaller spaces between your vertebrae to reach all
areas of your body.
Ligaments
The vertebrae are connected and supported by ligaments. The two main
spinal ligaments run the length of the spinal column.
spinal cord
Outer muscles
(shown on the left side)
and inner muscles
(shown on the right side)
nerve roots
ligaments
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SPINE GUIDE
Common Problems
Back or neck pain is common. Most pain is temporary, but it can reoccur.
It’s often caused by a strained muscle or sprained ligament — perhaps
from an activity you’re not used to, such as yard work, moving furniture,
or sitting for a long time.
Less often, pain comes from damage to part of your spine, or from
a condition you were born with. The pain may accompany other
symptoms such as stiffness, numbness, or weakness in your arms
and legs. Spine problems can even affect your bowels and bladder.
Some common problems are described in the following pages.
Who has back and neck pain?
Anyone can have back or neck pain. Still, some things increase
your chance of having pain, for example:
• Getting older. The older you are, the more likely you are to
have back or neck pain.
• Poor physical fitness. Lack of exercise and poor posture
increase your risk of back pain.
• Being overweight. Extra weight puts extra stress on your spine.
• Your job or your hobby. A job or activity that requires you
to lift, push, or pull can be risky. But desk work can also be hard
on your back — especially if you don’t sit up straight or don’t get
up very often.
Although your spine care
team will provide a thorough
assessment, it’s not always
possible to pinpoint the source
of symptoms. Studies show
many cases of back pain have
no identifiable cause.
• Smoking. Studies show that smokers have more back pain and
spinal conditions than non-smokers do.
• Previous injury. An injury you had months or years ago may
put you at risk for back problems later on.
• Diseases. Arthritis, osteoporosis, and other diseases can increase
your chance of having back pain.
• Family history and genetics. Some conditions run in families.
back and
neck pain
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Abnormal curvature
Your spine’s natural curves help balance your body. If the curves become too pronounced — or if your spine
develops a twist or an extra curve — it puts extra pressure on the vertebrae and discs. This can cause instability,
pain, and bulging or herniated discs. Abnormal curvatures include those shown below.
Scoliosis
Scoliosis
Scoliosis
Kyphosis
Kyphosis
Kyphosis
Scoliosis (in red)
Kyphosis (in red)
Lordosis (in red)
• A side-to-side curve
• increased curve (“hump”)
• increased curve in your in your back
in your upper back
(normal curvature shown in blue)
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SPINE GUIDE
Lordosis
Lordosis
Lordosis
lower back (“swayback”)
Fractures
Like any bones, your vertebrae can crack or break. Reasons for
a spine fracture include an injury, repeated stress, or a condition
like osteoporosis, which can make bones weak and brittle.
Fracture
Degenerated disc
Degenerative disc disease (DDD) is a catch-all term to describe
changes — usually thinning, hardening, and drying out — in
your spinal discs. Disc degeneration can result from normal
aging or wear-and-tear, but it’s sometimes begun or sped up
by injury, disease, or unusual stress. Degenerated discs can irritate
the spinal nerves and cause instability. They can be painful.
Healthy disc
Degenerated disc
Bulging disc
Bulging disc
If the outer wall of a spinal disc weakens, it may push out (bulge)
toward the nerves. This can cause painful nerve irritation.
Herniated disc
Herniated disc (also called ruptured disc)
If the outer wall of a spinal disc tears (ruptures), the soft
material inside the disc can squeeze out and press on nearby
nerves. This can cause pain, numbness, or weakness in your
legs or back.
Instability
Instability
Spinal instability is when adjoining vertebrae slip back and
forth, or have permanently shifted out of position. This
instability can be caused by a damaged spinal disc, a bone
injury, arthritis in the facet joints, or just something you were
born with. The slippage can irritate the bone, disc, spinal cord,
and nerves.
Herniated disc
pressing on spinal
cord and nerves
Bone spur
causing stenosis
Stenosis
Stenosis is a narrowing of the spinal canal. Stenosis can press on
the spinal cord and nerves and cause pain and other symptoms.
Stenosis can be caused by enlarged ligaments, facets, or other
abnormal bone growth such as bone spurs.
Nerve problems
All of the conditions described above can irritate or press on
(“pinch”) the spinal cord or nerves. This can cause pain,
numbness, weakness, and other problems throughout your body.
Common examples are lumbar radiculopathy or sciatica (nerve
problems in your lower spine, causing leg pain) and cervical
radiculopathy (nerve problems in your neck, causing arm pain).
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9
Care at the Spine Program
Spine treatment isn’t one size fits all. At the Spine Program,
we work closely with you and with each other to understand
your condition and create a treatment plan that matches your
needs and lifestyle.
Your spine care team
care and
healing
The Spine Program includes people from different specialties working
together to help diagnose and treat you. Here are a few of the people
who may be on your spine care team:
• Nurses, Nurse Practitioners, Physician Assistants. These experts
can help assess your condition and coordinate your care. Working with
the rest of your team, they can also directly provide much of the care
you’ll receive at the Program.
• Doctors. Your team may include doctors specializing in physical
medicine and rehabilitation, radiology, interventional and medical pain
management, or behavioral medicine. If surgery looks like it may be an
option for you, your team will include a neurosurgeon or orthopedic
surgeon. Your spine team will also consult with your primary care doctor
as needed.
• Physical therapists. The treatment of spine and pain conditions often
includes physical and occupational therapists. These experts help create
individualized programs to improve or restore strength, flexibility,
movement, and function.
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SPINE GUIDE
Team-based approach
At the Spine Program, our experts work as a team on each phase and aspect
of your care. Here’s what you can expect:
• An initial assessment. When you first come to the Spine Program, a
provider will work with you (and with your primary care provider as
needed) to understand your previous care and your reasons for coming.
The provider will consult with others at the Spine Program to evaluate
your case and assemble a team suited to your needs.
• Interdisciplinary care. We may recommend that you see more than one
provider at the Spine Program. There are several reasons for this. First,
we may need a range of medical perspectives to build a complete picture
of your problem and treatment options. Second, you may need to see
different providers at different stages of your care. Or, your care may
require more than one type of treatment at a time — and thus more than
one specialist.
• Care management. A nurse or other provider will coordinate all your
care at the Spine Program. Thanks to this coordination, everyone on
your spine care team — including you — will have the full story of your
problem. They’ll also know the treatment plan you’ve agreed to, and
be able to do their part efficiently and effectively.
• Communication. You are the most important person on your spine care
team. Throughout your treatment at the Spine Program, we’ll do our best
to explain our processes and give you the information you need to make
decisions and help care for yourself. We welcome your questions and
suggestions — in fact, we depend on them to help us work well with
you and your family.
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11
Assessment and Treatment
This section describes the common techniques used for
diagnosis and treatment of spinal conditions.
Assessment
To learn about you and your condition, your spine team will discuss your
symptoms with you, examine you, and obtain relevant diagnostic tests.
Over the course of your care, these evaluations and tests may be repeated as
part of follow-up care, or as other clinicians become involved in your care.
Here are some of the evaluations and tests your team may use.
Patient history
Your care team will ask questions as part of their assessment. Possible
topics are listed below.
• Pain and other symptoms, for example: Where is your pain? How bad
is it? How long have you had it? When did you first notice it? What makes
it better, or worse? How is your life affected by your symptoms — have
they changed your sleep habits, your work life, your recreation?
• Previous medical care, for example: What tests or treatments have
you already had? What were the results? What medications do you take?
Please bring prior imaging and medical records to your first appointment.
The place where your studies were performed can help you obtain copies.
“Taking a patient history”
simply means asking
questions. Besides talking with
you, your providers may use
a questionnaire (like the one
shown at left). This will help
them continue to personalize
your care over the course of
your treatment.
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SPINE GUIDE
• Lifestyle and daily habits, for example: Do you smoke? Exercise?
What kind of work do you do? How do you usually sleep, sit, stand?
• Family history, for example: Does anyone else in your family have
back problems or chronic pain?
• Overall physical and emotional health, for example: Do you have
any chronic conditions such as arthritis or osteoporosis? Have you had
cancer, depression, or an infection? How would you rate your recent
and current stress level? What do you do for fun and relaxation?
Physical exam
As part of a physical exam, your doctor will check your body and its
movement. Below are some things your doctor may note.
• Weakness: Simple exercises can help test your strength.
• Range of motion: Your doctor may check your flexibility or watch you
bend and twist.
• Tenderness: Your doctor may assess areas of soreness by touching parts
of your body.
• Sensation and sensitivity: Your doctor may check to see that you can
feel heat, cold, or a pin prick on parts of your body.
• Reflexes and motor skills: Your doctor may ask you to walk on your
heels or toes, or do tests to check your body’s reactions.
• Shape, tone, and position of the spinal bones, muscles, and so on.
PAIN IS NOT THE
ONLY SYMPTOM WE
CARE ABOUT....
Your medical assessment
should cover a range of
symptoms — not just pain —
such as the following:
• Numbness, tingling, “pins
and needles”
• Bowel or bladder problems
• Stress or emotional issues
• Fever, chills, sweating
• Weakness, slow reflexes
• Dizziness, headaches
Laboratory tests
• Sexual dysfunction
Sometimes back and neck symptoms can be caused — or made worse —
by a systemic illness (an illness throughout your body, not just in your spine).
To check for illness, your doctor may request a test of a sample of your blood
or urine. In addition, if surgery or other interventions will be part of your
treatment, routine laboratory tests are usually ordered first.
• Unusual weight gain or loss
Imaging studies
There are several technologies that allow your spine team to take pictures
of the inside of your body. Depending on what they need to see, they may
suggest one of the imaging studies listed below.
Mention these or any other
unusual changes or symptoms
to your care team. Even if it
seems unrelated to your spine
or doesn’t bother you, it will
help your providers get a
more complete picture of
your health.
• X-ray: Beams of low-dose radiation create pictures of tissues, bones, and
organs on film.
• MRI: Magnetic Resonance Imaging (MRI) uses a magnetic field and
radio waves to create images. MRI is very useful for evaluating details
of soft-tissue structures, like nerves, in and around your spine. • CT scan: Computed tomography (CT) uses a computer and x-rays to
create cross-section views (“slices”) of areas of the body. It’s especially
useful for highlighting abnormal tissue and clearly showing bone detail.
• Bone density scan: This scan uses x-ray or ultrasound to measure the
amount of bone in a particular area. It can detect and assess osteoporosis
(thinning bones).
Electrodiagnostic testing
The term “electrodiagnostic testing” covers a range of tests that measure
electrical activity in nerves and muscles. Two common electrodiagnostic
tests are the electromyogram (EMG) and the nerve conduction study (NCS).
Results from these tests help your doctor assess nerve and muscle function
and locate any damage.
Other procedures
Other procedures, such as spinal injections and discography, may be useful in
evaluating sources of back pain that cannot be seen on other common imaging
studies. Your care team will provide information on these procedures if needed.
If assessment shows a problem
in your spine, it doesn’t
necessarily mean that you won’t
get better. Many people with
arthritis, disc degeneration,
and other problems can live
with little or no pain when
treated effectively.
SPINE GUIDE
13
Treatment options
Your care may include one or more of the treatments
described below.
Education and activity
Your care team can teach you what you can do on your own to relieve pain,
regain strength, and increase flexibility. For example, they may advise you on
proper body mechanics (how to sit, sleep, lift, and so on) or how to use ice
and heat to ease inflammation. Much of this important education can help
you prevent spine pain in the future — as well as treat it today.
Oral medication (pills)
Your doctor may prescribe medication to reduce inflammation, relax muscles,
and ease pain. Take the medication exactly as your doctor or pharmacist
advises — and let your doctor know about other medications, herbs, or
supplements you take.
Physical therapy
Physical therapy encompasses a variety of treatments to promote healing,
relieve pain, build strength and flexibility, and help prevent future injuries.
For example, your physical therapist may create and supervise a program of
exercises and make suggestions to help improve body mechanics (how to sit,
sleep, lift, and move). Other physical therapies include spinal manipulation
(applying force to a spinal joint) and traction.
Traction
Traction is a non-surgical method for decompressing the vertebrae. It’s done
either manually by a specially trained provider, or mechanically with braces
or devices that gently elongate the spine.
Spinal injection
Your doctor may recommend a spinal injection to treat inflammation or
ease pain. An injection can deliver medication directly to the source of your
symptoms. Common injections include:
• Epidural steroid (cortisone) injections. Injections near specific nerves or
directly into the epidural space (the area around the nerves within the
spinal canal) can help diagnose and treat pain.
• Facet joint injections and nerve branch blocks. Injections in or near
the facet joints can treat arthritic joint pain.
• Sacroiliac (SI) joint injections. Injections at the SI joint, where the spine
and pelvis join, can diagnose and treat pain in that area.
• Trigger point injections. Injections into tight, irritated muscle areas
(trigger points) may help the muscle relax and ease pain.
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SPINE GUIDE
Other non-surgical procedures
SOLVING YOUR BACK
PROBLEM — TOGETHER
Other procedures — such as neurotomy and radiofrequency ablation —
use heat, cold, chemicals, or radiofrequency energy to destroy nerves near
a problem joint. This relieves symptoms by preventing pain signals from
traveling to the brain.
At the Spine Program, our goal
is to treat your back problem
in the least invasive and most
effective way we can. This
means that we’ll often suggest
trying other treatments before
recommending surgery. When
surgery is indicated, the goal
of our surgeons is to help you
return to a normal, pain-free
life as soon as possible.
Additional treatments for chronic pain include spinal pumps and stimulators
that are implanted under the skin. A pump can put medication directly into
the spinal fluid at just the right place in your spine. A spinal stimulator delivers
a small electric pulse on the surface of the spinal cord to help mask pain.
Surgery
Most spine problems can be
treated without surgery. In some
cases, however, your spine care
team may suggest surgery as a
good option for relieving your
symptoms. Surgical options
include those listed below.
If your care team recommends
a spinal injection or surgery,
they’ll give you specific
information on the potential
benefits, risks, indications, and
alternatives for the procedure.
You’ll have a chance to discuss
and weigh all the factors
involved in choosing the
procedure. Ask questions and
tell us your concerns. Together,
we can arrive at the best
approach for you.
• Microdiscectomy: Removing part of a damaged spinal disc through a
small surgical incision, using microscopically enhanced techniques.
• Laminotomy, laminectomy (decompression): Removing bone, ligament,
and spurs which cause spinal stenosis. These procedures relieve pressure
on a nerve or the spinal cord.
• Spinal fusion: Joining (fusing) two vertebrae so that there’s no movement between them.
• Anterior Cervical Discectomy and Fusion (ACDF): Removing a disc in
the neck (cervical) region of your spine and fusing the vertebrae above
and below it.
• Vertebroplasty: Injecting a special cement into a collapsed
vertebra to support the damaged bone and help with pain.
• Kyphoplasty: Injecting a special balloon and cement
into a collapsed vertebra, similar to vertebroplasty.
The balloon is inflated inside the vertebra to restore
the original height of the bone, and the cement helps
preserve this shape after the balloon is removed.
FACT SHEET FOR PATIENTS AND FAMILIES
Lumbar Spinal Fusion (posterior)
What is it?
Lumbar spinal fusion is a surgery to join two or more
spinal bones (vertebrae) so that they eventually grow into
one solid bone.
Why do I need it?
The surgery is usually done to correct instability of the
spine. Arthritis, injuries, or simple wear and tear can
cause some of the bones in your spine to slip or shift out
of place. This abnormal bone movement can cause back
pain. It can also pinch nerves, causing pain, numbness,
or weakness in your legs. The leg pain is called sciatica
or radiculopathy.
The goal of spinal fusion is to stop abnormal movement
and thus eliminate pain in your back and legs.
FACT SHEET FOR PATIENTS AND FAMILIES
normal disc
instability
Spinal fusion can treat abnormal movement in the spine.
Benefits
Risks and complications
Alternatives
Spinal fusion may eliminate
pain by stopping abnormal
and painful movement
between diseased vertebrae.
• Blood loss. With any surgery there is always the potential
Spinal fusion surgery is usually
done after non-surgical
treatment options have failed.
These can include:
for life-threatening blood loss, but with current techniques
this is rare.
• Damage to the nerve sac, with leak of spinal fluid
(2 to 5 in 100 cases). If the nerve sac is unintentionally opened
during surgery, it will be repaired. This should not have any
effect on your long-term outcome, but you may have to spend
a day or two flat in bed to allow the repair to strengthen.
Rarely, further treatment may be necessary.
• Infection (1 or 2 in 100 cases). Even with antibiotics and
• Total disc replacement (arthroplasty): Removing an
entire damaged spinal disc and replacing it with an
artificial disc to help preserve motion between
two vertebrae.
Spinal Injections
degenerated disc
careful sterile technique, there is still a small risk of developing
a wound infection.
• Damage to spinal nerves (fewer than 1 in 1000 cases). This
could cause ongoing pain, numbness, or weakness in your legs.
• Failure of fusion. If the fusion fails, you may need to have
more surgery.
• Failure to relieve symptoms. Your surgeon will do
everything possible to give you the best results. Even so,
surgery may not relieve all your symptoms.
•
•
•
•
•
What is it?
Why do I need it?
A spinal injection is a procedure in which your doctor
injects medication into a specific area of your spine. It is
used to either diagnose the source of your back pain, or to
reduce swelling and relieve your pain. The injection you
will have depends on your symptoms, the location of your
pain, and the goals of your treatment.
Your doctor may recommend a spinal injection if you
have back pain that has not responded to other
treatments, such as physical therapy. Spinal injections
are an alternative to back surgery. They can be used to
both diagnose and treat back pain.
The most common types of spinal injection are listed
below and are illustrated and described in more detail on
the following pages.
• Epidural steroid (cortisone) injections near specific
nerves or directly into the epidural space (the area that
surrounds the nerves within the spinal canal)
Medications
Physical therapy
Traction
Spinal injections
Watching and waiting
• Facet joint injections and nerve blocks in or near
the facet joints that connect the vertebrae
• Sacroiliac (SI) joint injections into the SI joint,
located between the sacrum and pelvic bones
If your symptoms are caused by
an unstable spine, lumbar spinal
fusion is probably your only
effective treatment option.
Other types of spinal injections — such as diagnostic
discograms, neurotomies, and trigger point
injections — are described on separate fact sheets.
If you feel your symptoms are not
severe enough to have surgery,
tell your doctor. He or she will
respect your decision.
1
• To diagnose your pain: The doctor injects numbing
medication (anesthetic) into one or more specific areas
of your spine, blocking all feeling in those areas. If the
injections relieve your pain, they can confirm the
source of your pain and help the doctor know how to
treat it. If you still feel pain after the injection, it may
mean the pain is coming from somewhere else. You
may need several injections or types of injections to
find the source of your pain.
• To relieve your pain: Once the source of your pain
is confirmed, the doctor can use spinal injections to
relieve your pain, reduce swelling, or improve mobility.
An anti-inflammatory medication such as cortisone is
injected directly into the place the pain is coming from.
Depending on the type of medication injected, you
may feel pain relief right away, or it may take a few
days or more to take effect. Pain relief may be
temporary (lasting several weeks or months) or
long lasting.
Potential Benefits
Risks and Potential Complications
Alternatives
• May relieve or diagnose pain
Different types of spinal injections carry different risks.
Your doctor will explain the specific risks of your procedure.
These potential risks are common to many spinal injections:
• Neurological changes, such as motor weakness
• Increasing numbness
• Briefly increased pain or severe increased pain
• Incontinence
• Spinal headache
• Bleeding, infection (rare)
• Stroke
• Spinal cord injury
Spinal injections are used after patients
have experienced pain for several
months and have already tried other
approaches, such as:
• Ice
• Oral pain medication
• Physical therapy
• Watching and waiting
• Less invasive than surgery,
and so have fewer risks
• Allow fast recovery
• Do not require hospital stay
If the spinal injection does not help,
your doctor may recommend surgery.
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SPINE GUIDE
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My spine care team:
My appointments:
Date:Time:
Provider:
Date:Time:
Provider:
Date:Time:
Provider:
Date:Time:
Provider:
To f i n d t h e s e a n d o t h e r re s o u rc e s, g o t o :
i n t e r m o u n t a i n h e a l t h c a re. o rg
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