The Spine Institute
We have five of the finest spine and pain management specialists in the Hudson Valley. Drs. William Barrick, Richard Perkins, Nicholas Renaldo, Richard Dentico, and Vishal Rekhala have highly-specialized training in the latest diagnostic and therapeutic techniques for the treatment of spinal disorders, including back and neck pain, herniated discs, vertebral compression fractures, scoliosis, and spinal instability.
Our advantage over other orthopedic practices in the Hudson Valley Region is that we work together as a team to select the best treatment for each patient, considering individual needs and setting goals to achieve the best possible outcome. For difficult cases, we consider multiple paths when deciding how to achieve optimum solutions for our patients’ needs.
Millions of Americans suffer from back pain. It can make daily activities difficult and sometimes unbearable. The specialists that make up our Spine Team are fellowship-trained, board-certified orthopedic surgeons, physical medicine specialists, and non-surgical spine specialists. We offer a full spectrum of non-surgical and surgical treatment of spinal disorders, encompassing trauma, degenerative, and deformity conditions. Should surgery be necessary, our Spine Team offers minimally invasive procedures such as microdiscectomy, kyphoplasty, and spine fusion.
In the Hudson Valley, we are fortunate to have five of the finest spine specialists right here at Orthopedic Associates of Dutchess County. Dr. William T. Barrick, Dr. Richard B. Perkins, Dr. Nicholas Renaldo, Dr. Richard Dentico and Dr. Vishal Rekhala have highly specialized training in the latest diagnostic and therapeutic techniques for the treatment of spine disorders including herniated discs, back and neck pain, vertebral compression fractures, scoliosis, and spinal instability.
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DDD is the most common cause of Lower back pain and neck pain from ages 10 -50. DDD is a primarily genetic condition caused by defective collagen cross linking which results in faster wear and tear on the spinal discs. The discs act like shock absorbers to support the spine yet allow motion. Many patients with DDD have a close relative(s) with the condition. The other 30 % of DDD is felt to be due to environmental factors such as normal aging, injuries, poor body mechanics such as improper bending and twisting, obesity ( only a minor risk factor ) and nicotine use /smoking. Nicotine and smoking are the number one reversible cause of DDD progression. Nicotine and cigarettes damage the capillary blood vessels which supply the vertebral endplates.
The Discs in the spine get their nutrition and oxygen from diffusion through the endplates because the discs do not have their own direct blood supply. Over time, if the blood supply to the vertebral endplates is damaged, then the discs are starved of oxygen and nutrients and cannot repair and maintain the strength of the disc. Stopping smoking and nicotine use is the best way to protect the healing power of the discs and slow progression of DDD.
As a disc degenerates, the soft inner gel of the disc can leak back into the spinal canal. This is known as a disc herniation. Once inside the spinal canal, the herniated disc material puts pressure on the nerve, causing pain to radiate down the nerve. This may lead to sciatica or leg pain the case of a herniated lumbar disc, or arm pain in the case of a herniated cervical disc.
Osteoarthritis is the most common cause of back and neck pain after age 50. Osteoarthritis is caused by the progression of DDD and involves the formation of bone spurs at the edges of the disc space from loss of disc fluid. The disc space and motion segment become unstable and shift suddenly, causing the back or neck to “go out.” From this repetitive abnormal shifting of the vertebrae, the body responds by forming bone spurs to try to restabilize the spine and protect the nerves. When the disc wears out, stress is also transferred to the paired “facet” joints in the back of the spine, causing them to wear out their articular cartilage (same type of cartilage as in the knee and hip joint). The facet joints then also form bone spurs as the body tries to re-stabilize the spine. The friction caused by the loss of the smooth gliding surface in the facet joints also causes back and neck pain.
If the Bone spurs and ligaments enlarge from the chronic instability or “shifting” caused by DDD, the nerves can eventually become pinched by the bone spurs both from the discs in front and the facets in back. The bone spurs and ligaments which buckle in and thicken due to loss in disc height and instability both narrow the spinal canal and can use pain, numbness, tingling or weakness radiating down into the arms or legs. When this happens, the condition is called Spinal Stenosis. Spinal Stenosis is a complication of Osteoarthritis of the Spine.
SIJ pain is often seen in patients with previous lumbar spine fusion because of stress transfer to the SI joints. It is also seen in patients with trauma to the SI joints from car accidents or falls onto the buttock region which can cause a shear stress across the joint and damaging the cartilage inside the joint.
There are many types of scoliosis. Sometimes young people develop it in preteen or teenage years. Much more commonly it occurs over time due to aging and arthritis.
Scoliosis can cause pain and dysfunction but not always. There are many treatments for scoliosis.
Spondylolisthesis – is a Latin term which means a “slipped spine.” The most common type of Spondylolisthesis can be associated with DDD in adults in the 30-60 year age range when the spine becomes unstable because of disc height loss . This is called a Degenerative Spondylolisthesis . Another common cause of Spondylolisthesis is a stress fracture in the part of the bone between the facet joints ( the pars interarticularis ) which tends to occur in teenagers . This type of Spondylolisthesis is called a Lytic Spondylolisthesis . Lytic Spondylolisthesis or Spondylolysis associated with a genetic condition in which a thin pars region is fractured due to repetitive stress. It is commonly seen in gymnastics who tend to be hyper flexible , football and soccer players which often involve sudden or violent twisting and bending of the spine.
Non-Surgical Treatment Options
Surgical Treatment Options
Younger patients in their 30-40s without bone spurs and soft disc hernations at one single disc space are the best candidates for ADR /TDR.
(aka Spinal Arthrodesis ) refers to joining two vertebrae together permanently using a variety of different approaches and techniques. The most common reason the spine is fused is from Spinal Instability due to conditions such as spondylolisthesis , fractures, tumors, infections and from planned instability caused by having the remove the facets joints in patients with severe spinal stenosis to decompress the nerves. The Spine Institute at Orthopedic Associates work with our patients to select the best technique for each patients unique situation.
The spine can be fused from different directions or approaches i.e Anterior, Lateral, Posterior. The most common performed Fusion is a Posterior Lumbar Fusion where the low back is fused from an incision in the back. The sides of the vertebrae and facets joints are exposed and decorticated (the outer surface of the bone is removed allowing bone to grow outwards)
A bone graft is obtained from the patients own bone removed to decompress the pinched nerves (local bone graft ), from the patients pelvis ( iliac crest auto bone graft) , cadaver bone (allograft) , patients own bone marrow (aspirate) , synthetic bone graft, or sometimes a hormone which causes bone formation (Bone Morphogenic protein) . The choice of bone graft is part of the decision making process between the patient and the surgeon and all have risks and benefits. The bone graft is placed on the exposed spine surfaces and the graft grows the spine together over a period of several months to years. When the bone grows together, the excess motion which causes pain is eliminated and the pain is often reduced. Sometimes in order to improve healing rates of the fusion, the disc is removed from the front of the spine (Anterior/ALIF), the Side of the spine (Lateral or XLIF) or from the posterolateral region (TLIF or PLIF) and bone graft usually in a supportive device made from plastic, titanium or cadaver bone called a Cage is placed to maintain or restore the disc height and allow the bone to grow through one vertebrae into another. Often, titanium Screws and rods or plates are used to stabilize the spine to reduce pain and to decrease motion and allow a greater chance of the fusion healing, this is called spinal instrumentation. The instrumentation we use is MRI compatible.
More recently, Lumbar Fusion surgery is being done more often using X-ray image guidance or computer guided navigation in carefully selected patients through smaller incisions with less blood loss, less muscle trauma and quicker recoveries. This is called Minimally Invasive Spine Surgery (MISS)or Minimal Access Surgery. (MAS)
The Spine Institute at Orthopedic Associates Board Certified, Fellowship Trained Orthopedic Spine Surgeons were the first in our area to perform MISS/MAS spine surgery and have been doing this for over 15 years in the Hudson Valley region.
An artificial disc like Mobi-C is an option instead of a fusion that will also be placed inside the disc space to restore height and remove pressure on the pinched nerves. However, the Mobi-C device is designed to allow the neck to maintain normal motion and potentially prevent the adjacent levels from degenerating, possibly preventing future surgeries.
The M6-C artificial cervical disc is a next-generation artificial disc developed to replace a vertebral disc damaged by cervical disc degeneration. The M6-C disc is designed to help restore motion to the spine and is an option for patients needing artificial disc replacement as an alternative to cervical fusion. By allowing your spine to move naturally, the M6-C artificial disc is designed to potentially minimize the stress to adjacent discs and other vertebral structures.
During kyphoplasty surgery, a small incision is made in the back through which the doctor places a narrow tube. Using fluoroscopy to guide it to the correct position, the tube creates a path through the back into the fractured area through the pedicle of the involved vertebrae.
Using X-ray images, the doctor inserts a special balloon through the tube and into the vertebrae, then gently and carefully inflates it. As the balloon inflates, it elevates the fracture, returning the pieces to a more normal position. It also compacts the soft inner bone to create a cavity inside the vertebrae.
The balloon is removed and the doctor uses specially designed instruments under low pressure to fill the cavity with a cement-like material called polymethylmethacrylate (PMMA). After being injected, the pasty material hardens quickly, stabilizing the bone.
A lumbar laminectomy, also known as a decompression, is typically performed to alleviate pain caused by the neural impingement from lumbar spinal stenosis. The laminectomy is designed to remove a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the root more space and a better healing environment.
In a microdiscectomy (or decompression) surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and to provide more room for the nerve to heal. A microdiscectomy is typically performed for a herniated lumbar disc and is more effective for treating leg spine than lower back pain.
UNDERSTANDING THE PAIN IN YOUR BACK