The 5 Sections of the Spine
The cervical spine makes up the neck and has 7 vertebrae.
The thoracic spine has 12 vertebrae which the ribs attach to.
The lumbar spine has 5 vertebrae which make the lower back.
The sacrum consists of 5 bones which are fused or stuck together and the coccyx is made up of 4 tiny bones and used to be a tail.
Each vertebra is separated by intervertebral discs which are flexible cartilage discs. These allow movement in the spine and have a shock absorbing or cushioning function as well.
The spine is made up of 33 vertebrae and has 5 sections as illustrated.
Each disc is made up of two parts, a tougher fibrous outside and a central substance called nucleus pulposus. When a disc is damaged (or prolapsed) it is the squidgy liquid in the middle which often squeezes out putting pressure on the spinal cord causing pain.
What to expect at your initial consultation
We understand that the first consultation with a new consultant can be quite daunting and in an effort to help with this process we have detailed below what to expect at your initial consultation with me.
Following formal introductions, I will give you an opportunity to explain your problem and symptoms. I will need to know the history of your current condition; I will also need to gain some understanding of your clinical profile and to achieve this I will discuss your past medical history, family history, social history and ask you to provide the details of any medication you are taking as well as any allergies you may have.
Following this discussion I will carry out a complete spinal examination. It will be necessary for me to look at your spine carefully and you will be asked to remove some items of your clothing to allow a complete examination of your spine. This will enable me to assess the shape and balance of your spine. It should be emphasised that a chaperone will be in attendance throughout your consultation and examination and your privacy and dignity will be respected at all times.
Once the examination has taken place I will discuss my initial findings with you and if you have any previous imaging this will be discussed at this time and a plan will be agreed to achieve an initial diagnosis and management plan. This will usually involve a referral for imaging in the form of an MRI and x-rays of your spine in the standing position, which could take place at either The Priory Hospital Midlands Imaging, or at Heath Lodge Clinic, Solihull where there is access to an open MRI scanner.
Once this has taken place a follow up appointment will be arranged to discuss the results of the scans and imaging and at this stage an initial diagnosis and management plan will be discussed and agreed with you.
If at any stage of you feel uncomfortable during your consultation or examination please make your feelings known to me.
If you need a procedure, I will discuss it with you in detail, including the procedure and what it involves. If you have private medical insurance I will give you the procedure code, which will be required by your insurance company to ensure authorisation for funding the operation. I will explain the risks and any possible complications, how long you will need to be in hospital for and what to expect after the procedure.
It may be necessary for you to attend a pre operative assessment clinic at the hospital. This will take place approximately 1 week before your operation and be arranged for you with a specialist pre assessment nurse.
The Reservation Team at the Priory Hospital will send details of your admission to hospital to you in a timely manner, prior to the procedure.
On the day of the operation you will need to starve from midnight prior to being admitted the following morning. You are however allowed sips of water until 6:30am. As I usually operate in the morning, you will be admitted onto the ward at about 07:00am. On admission both Dr Da Silva and I will see you in order to go through the consent and talk you through the procedure and what to expect immediately after the operation.
A post operative follow up will be arranged for you about 3-4 weeks following your procedure.
It may be necessary for a graduated return to work programme after your operation and this will be discussed with you at your post operative appointment.
Spinal injections are performed as a day case procedure usually at either BMI Priory /Wolverhampton Nuffield/Spire Little Aston Hospital under a light general anaesthetic. The procedure will be discussed with you once it has been agreed that an injection is required. Instructions for your admission will be received from the Reservations Team. This will include your admission time and any instructions regarding being “nil by mouth”.
What to expect on the day of the injection
On the day of the injection you will need to have been starved ‘nil by mouth’ from midnight. On admission Mr Ishaque and Dr E J Da Silva will see you in order to go through the consent and talk you through the procedure.
You will then be taken down to the anaesthetic room where you will greeted by the theatre team and all the necessary checks will be performed for your safety. At this stage Dr Da Silva will place a small cannula in the back of your hand to allow him to deliver the anaesthetic agents during the procedure.
You will then be walked into the theatre itself and shown how to climb onto the operating table in order to get comfortable.
I will then mark your back with a marker pen using the x-ray machine to guide him regarding the entry point for the spinal injections. I will then clean your back using standard surgical iodine and the procedure is carried out using a sterile technique.
You may feel a slight sharp sensation like a pinch which last a few seconds before Dr Da Silva administers the intravenous general anaesthetic which is the local anaesthetic being placed at the needle entry point but often you will already be asleep at this point. You will not feel the actual spinal injection which is much more comfortable and safer for yourself and Mr Ishaque, as he can be sure you will not move at a crucial point during the injection.
Please be aware that if you are needle-phobic (very scared of needles) then Dr Da Silva can make sure that you will not even feel this initial injection just under the skin.
Mr Ishaque routinely performs an epidurogram using either Omnipaque or Niopam in order to confirm correct placement of the spinal needle after using x-ray guidance in two planes, taking x-rays from both side to side and from front to back.
Once you have had your injection you will be helped back onto your bed and transferred to the recovery suite. As you have had an epidural injection it is standard practice to monitor your blood pressure for about half an hour before being sent back to the ward.
Once back on the ward you will be able to eat and drink in order to get your blood sugar levels up and you will be asked to rest for 90 minutes to allow the sensation to return to your legs and the effects of the general anaesthetic to wear off.
Usually you will be discharged by about 3pm and you will need to be picked up, as you will not be fit to drive on the day of the injection.
What to expect following a spinal injection
Immediately after the injection it is not unusual to have a slight increase in back pain but often the leg pain is immediately relieved. I would advise you take a few days off after the injection to rest and during this time it is important to keep taking your anti-inflammatory (Diclofenac, Ibuprofen or Naproxen) medication as well as any painkillers. It is fine to drive the following day but I would limit journeys to less than 40 minutes. I have had a number of patients who have flown short haul within 1 week of the injection which although is not recommended, is possible provided you keep well hydrated, keep mobile during the flight and keep wearing your compression stockings to reduce the chances of a deep venous thrombosis (DVT) and more importantly a Pulmonary Embolism (PE). In the weeks immediately following the injection I would advise you to walk regularly as your symptoms allow and to avoid any strenuous exercise and in particular excessive bending, lifting or twisting. Swimming is an ideal exercise as you are supported and if you can’t swim then walking widths in the pool at progressively increasing depth provides increasing resistance helping to build strength and stamina.
In the majority of cases any discomfort associated with the injection should have passed within 2 weeks and the effects of the steroid should be becoming more apparent. I usually advise patients to wait 4 weeks before starting physiotherapy, which will also help with the longer-term recovery.
Simple back pain advice
Bed rest is not recommended. Reduce your activity for the first couple of days. Then, slowly start your usual activities after that. Avoid heavy lifting or twisting or your back for the first six weeks after the pain begins. You should start exercising again after 2-3 weeks.
Be good to your back: follow these tips to reduce your risk of back problems.
The first thing to remember is posture. Remind yourself to stand up straight, and if you need support when you're sitting or driving, use a lumbar roll (a specialist cushion) to support your lower back. Avoid bending down for routine tasks such as emptying a washing machine. Instead, lower yourself by bending your knees, allowing your spine to keep relatively straight.
Also, 'no pain, no gain' was not a phrase designed for backs. An occasional twinge is one thing but if you find yourself in real, persistent pain don't try to push on through it. If possible keep mobile and seek specialist advice. Back pain associated with arm or leg pain will often benefit from a surgical opinion and any disturbance of bladder or bowel function requires an urgent appointment. If you're lifting things, make sure you know the right technique to keep your spine straight.
Getting your muscles right
Your spine is a bit like the mast on a ship: it's long and tall and depends on the rigging around it to keep it stable. Similarly, our internal 'rigging' (the muscles in our back, abdomen, buttocks and thighs) has the job of holding the spine stable and straight. If they're out of condition, or out of kilter, the forces on your spine are no longer neutralised - and it starts to hurt.
These muscles can be developed through exercises with a physiotherapist, chiropractor or osteopath. Pilates is an excellent alternative. Regular endurance-type exercise us also important, and even a 20-30 minute power walk can have a positive effect.