Archive for May, 2011
Whiplash review by KBNI Houston, Katy, Sugarland, Spring, Woodlands, Baytown, Beaumont, Port Arthur, Tomball
Whiplash / Houston
Each year more than two million Americans experience a whiplash injury (a.k.a. whiplash-associated disorder) to their neck. Numerous studies have shown that the most common cause of whiplash is a 6 to 12 mph rear-end automobile collision where the individual has a sudden, hyper-extension (backward movement) and flexion (forward movement) of the neck. The violent, unexpected motion forces the neuromuscular structure of the cervical region to exceed its normal movement parameters. Collisions at higher speeds have a commensurately higher incidence of severe damage to the cervical spine region.
Whiplash-associated disorder can also be caused by a front-end or side-impact automobile collision, contact sport-related accident, e.g., being struck from behind, diving/swimming pool accident, amusement park ride, or physical abuse (e.g., shaken baby syndrome). The pain the individual feels can be mild to severe and acute (short term) or chronic (long term). It is generally agreed that as many as 40% of patients with acute, whiplash-associated neck pain will develop chronic neck pain.
Soft Tissue Injury
In the majority of cases, the whiplash injury damages the soft tissue of the neck resulting in a sprain or strain of the neck muscles or ligaments. In the past, damage to the soft tissues was nearly impossible to visualize. Even with the aid of various advanced imaging technologies (MRI, CT-scan, standard x-ray with contrast, etc.) visualization remains difficult. There are times when patients will experience soft tissue injury, with pain, yet the imaging studies are completely normal. This means that the key factor in soft tissue diagnosis is the knowledge and experience of the spine specialist.
The symptoms of a soft tissue neck injury include neck pain, arm and hand pain, stiffness, back pain, shoulder pain, ringing in the ears, dizziness, neck-related (cervicogenic) headache, paresthesia (burning, tingling or prickling sensation), or injury to the discs, facet joints of the low back or sacroiliac joints. Some people may also experience cognitive deficits such as memory loss and impaired concentration as well as sleep disorders or psychological conditions, e.g., nervousness, depression or irritability. It is important to keep in mind that while the symptoms of a whiplash-associated disorder usually appear within 24 hours, in some cases the symptoms may not manifest themselves until days or even weeks after the accident.
If a soft-tissue injury is confirmed, there are a number of passive treatment alternatives that may be recommended including bed rest, hot and cold compresses, pain relieving medications such as non-steroidal anti-inflammatory drugs, and muscle relaxants. The decision as to which medication(s) is prescribed will depend on the type and severity of pain being experienced, the individual’s pain tolerance, and their general medical condition. Spine specialists now prefer that the patient pursue their daily activities in as normal a manner as possible. In the past, whiplash patients were advised to wear a cervical collar to limit neck movement. This type of immobilization is no longer considered an effective therapy as prolonged collar wear can cause weakness in the neck muscles.
Most patients with mild to moderate whiplash will have pain relief within a few days to two weeks, with a prognosis of full recovery in 10 to 12 weeks. For those individual’s whose neck pain becomes chronic (more than 12 weeks) or worsens the spine specialist may recommend, in addition to pain medication, some form active intervention including physical medicine, e.g., physical therapy, traction, range of motion exercises, etc. In the rare case of prolonged, debilitating soft-tissue pain the patient may be prescribed anti-inflammatory cortisone injections, opioid analgesics and/or anti-depressants. Surgery is not considered to be a treatment option for a soft-tissue whiplash-associated disorder.
Cervical Spine Injury
The pain symptoms of a cervical spine injury due to whiplash-associated disorder are similar to that of a soft tissue injury. If the spine specialist’s examination and imaging studies reveals damage to the facet joints, intervertebral discs, nerve roots and/or vertebrae of the cervical spine a more aggressive treatment regimen is usually undertaken. This approach may include physical medicine, anti-inflammatory pain medications, injections of cortisone into facet joints, facet joint radiofrequency neurotomy, facet joint laser ablation, therapeutic nerve blocks (steroid plus analgesic), and/or anterior cervical discectomy or laminectomy with fusion.
End Note: Although whiplash injuries occur with ever-greater frequency, the diagnosis of a whiplash-associated disorder is a challenging undertaking. The success of whiplash treatment will be a function of the thoroughness and accuracy of the spine specialist’s diagnosis.
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If you ask a person with sciatica to describe the pain that they feel the answer can range from a mild numbing, burning or tingling sensation to an excruciating pain that severely affects their quality of life. This complex pain syndrome, felt usually on one side of the body, is caused by the compression and inflammation of one of the two sciatic nerves. The nerves are formed by a collection of nerve roots exiting from the vertebral foramen at L4, L5, S1, S2, and S3 on each side of the lumbosacral spine. They are the longest and widest nerves in the body, and serve as an extension of the spinal cord. Each nerve has two branches, the articular branch that controls hip movement and the muscular branch that controls leg and foot movement. The nerves travel through the pelvic girdle and buttocks and continue down the back of the leg to the foot.
Q: What is the cause of sciatica?
A: There are a large number of neurological and musculoskeletal issues that can cause sciatica. A herniated (bulging) vertebral disc in the lower lumbosacral region causing compression of a sciatic nerve root is most often the cause of sciatica. The condition can also be caused by:
- Narrowing (stenosis) of the lumbar spine
- Spondylolisthesis – the slippage of one vertebra over an adjacent vertebra resulting in severe leg pain that is aggravated by walking, sitting or standing
- Spondylitis – infection or inflammation of the spinal joints, osteomyelitis (infection in the bones of the spine), or sacroiliitis (inflammation in the sacroiliac joints)
- Degenerative disc disease
- Pirformis syndrome – inflammation of the sciatic nerve due to irritation from the pirformis muscle
- Spinal irregularities – lordosis, osteoporosis in the low back, spinal tumors
- Anatomical irregularities – non-symmetric lower limb growth
- Excessive weight/obesity
- Physical trauma – injury to the pelvis, buttocks or thigh due to falls, accidents, etc.
- Improper lifting technique
- Lack of exercise/poor muscle tone
- Poor posture
Q: How is sciatic nerve damage diagnosed?
A: It is estimated that 5 to 15 percent of patients with low back pain have sciatica. The first indication that an individual is experiencing sciatic nerve pain as opposed to other forms of low back pain is the referral of the pain (sciatic radiculitis) into the buttock, thigh, knee, calf and foot. Sciatic pain may worsen when standing, walking, twisting, sitting, coughing, or sneezing.
Given the large number of possible causes for sciatica, an accurate and timely diagnosis of the condition by a back and neck specialist is critical to effective treatment. The specialist’s diagnosis includes a thorough medical history, physical examination and evaluation supported by one of more of the following diagnostic techniques:
- Standard x-ray – with or without discography or a myelogram
- Computer-aided radiography – CT scan or magnetic resonance imaging (MRI)
- Thermography, sonography or a bone scan
- Electromyography (EMG), nerve conduction studies, and/or evoked potential (EP) studies
Q: What are the treatment alternatives for sciatic nerve pain?
A: The success of any sciatica treatment depends on determining the exact cause of the problem. As is the case with other spinal neuropathy, sciatic nerve pain can be treated conservatively (non-surgically) or aggressively (surgery). Most spine specialists prefer that the patient undergo conservative treatment for a specific period of time. If, at the end of the period, the patient has not experienced a significant improvement, surgery is considered. Experience has shown that sciatic pain can respond very well to non-surgical treatment, provided it is diagnosed early.
Conservative treatments for sciatica are intended to relieve pain symptoms, i.e., make the patient more comfortable with his or her pain. Abatement of the pain, should it occur, will most likely occur gradually over a period of several weeks or longer. The non-surgical treatment altenatives (tried singly or in combination) include:
- Bed rest
- Application of hot and cold compresses
- Physical therapy, yoga, physician-directed exercises, low-impact exercise (aerobics, walking, swimming, stationary bicycle)
- Muscle relaxants, NSAIDs (non-steroidal anti-inflammatory medications such as aspirin, ibuprofen, etc.), anti-depressants
- Spinal decompression therapy
- Cortisone injections, epidural steroid injections
- Massage, acupressure, etc.
- Glucosamine, herbal treatment, bio-feedback (to change your reaction to the pain)
Surgery is generally regarded as an option of last resort for the treatment of sciatica. The goal of the surgery is to remove the cause of sciatic pain. Depending on the severity of the pain, extent of sciatic-related disability, and various other patient characteristics, the surgeon may elect to perform (1) traditional open discectomy or foraminotomy surgery or (2) a minimally invasive (endoscopic) discectomy or foraminotomy surgery.
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Cervical Spinal Fusion
It is estimated that more than 175,000 cervical vertebral fusion surgeries are performed each year in the United States. Fusion (stabilization) of spinal vertebrae is an anterior or posterior surgical procedure that has become the “gold standard” for cervical pain management. The surgery usually follows the failure of conservative, non-surgical treatment alternatives, e.g., rest, pharmacologic treatments (anti-inflammatory medication, opioid or non-opioid analgesics, antidepressants), cervical collar, etc.) to achieve pain relief. The surgical goal of a cervical fusion is to abate the patient’s pain caused by the compression of the spinal cord or spinal nerves as a result of vertebral disc herniation, degenerative disc disease that causes spinal instability, or spinal trauma (e.g., whiplash).
The fusion forms a fixed bridge between two or more cervical vertebrae facilitated by the introduction of a bone graft with or without instrumentation (plates, rods, screws, etc.). In recent years the bone graft material could be obtained from the patient (autograft) or taken from a cadaveric donor (allograft). A second type of allograft manufactured from synthetic material has been widely adopted by spine surgeons.
Although the majority (75 to 98%) of cervical spine fusions result in a positive outcome, the surgical procedure is not without controversy. A sizeable number of patient’s reported that following the surgery they experienced prolonged pain at the surgical site and/or at the autograft removal site. This has prompted the recommendation that patient’s considering cervical fusion surgery discuss in detail the risks and benefits of both types of graft acquisition procedures with the surgeon prior to the surgery. Smoking, obesity, osteoporosis, prior back surgery and other patient-related factors have been linked to unsuccessful fusion surgery.
An autograft had historically been a piece of graft bone most commonly taken from the patient’s hip or pelvis. Once removed and shaped, the graft bone is placed between the vertebrae to fuse with vertebral bone and/or packed around the interbody instrumentation that is inserted to insure fusion stabilization. The advantages of an autograft were (1) faster healing due to the graft’s osteoinductive and osteoconductive properties, (2) the autologous bone graft was usually well incorporated into the graft site, and (3) the surgical outcome had been more predictable than when allografts or synthetic bone substitutes are employed.
In 2002 a bioengineered, osteoinductive human protein (rhBMP-2) graft implant was approved by the FDA for spinal fusion surgery. BMP is a growth substance that encourages bone cells to proliferate. BMP was initially used for fusion in all regions of the spine, however, as the use of BMP expanded undesirable side effects in anterior cervical spine surgery were noted. These included hematoma formation in the neck causing painful anterior swelling and respiratory distress as well as compression neurological structures. In some cases these results required longer hospital stays and additional surgery. Many surgeons no longer use BMP for cervical fusion procedures, relying instead on allograft material.
An allograft is graft material obtained from a source outside the patient’s body. The most commonly employed allograft continues to be a section of cadaveric bone obtained from a bone bank. The cadaveric bone material has a negligible risk of disease transmission provided approved preparation procedures have been followed. In recent times bio-compatible cell-based, polymer-based or ceramic-based synthetic bone graft substitutes and demineralized bone matrices (DBMs) have been added to the surgeon’s choice of allograft alternatives.
The primary advantage of the allograft is that the surgeon does not have to perform a second surgery to obtain graft material from the patient. This means that the patient spends less time in the operating room (including less time under general anesthesia), experiences less blood loss, and avoids pain and other possible problems such as infection at the graft incision site.
The disadvantages of using an allograft may include (1) slightly longer recovery times and (2) the possibility that the sterilization process (e.g., demineralization, freeze-drying, gamma radiation, etc.) necessary to prevent the transmission of disease from the donor to the patient has decreased the graft’s osteogenic integrity. This could result in the graft having a diminished potential to incorporate with the patient’s bone. If this event occurs, there is a possibility of a failed fusion and the need for another surgery to correct the problem.
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Scoliosis Onset and Treatment
In a normal spine the vertebrae are stacked in a straight, forward-facing direction. When the vertebrae have a lateral (side to side), C or S-shaped curve greater than 10 degrees the individual is said to have developed scoliosis. This debilitating, progressive condition affects between seven and twelve million Americans who are usually otherwise healthy. Scoliosis is most often located in the upper back (thoracic spine) but can also develop in the lower back (lumbar spine). It is also sometimes found in the area between the upper back and lower back known as the thoracolumbar spine. Scoliosis appears most often in the thoracic spine of individuals (girls more than boys) who are ten to fifteen years of age, and to a much lesser extent in children and adults.
The condition primarily impacts the body’s musculoskeletal system (spine, ribs, and pelvis). As scoliosis progresses during the adolescent growth spurt and into adulthood it can affect the individual’s pulmonary and cardiac function, as well as his or her neurological, digestive, and hormonal systems. Scoliosis can manifest itself in rib deformity, shortness of breath, back and hip pain, chronic fatigue, acute headaches, mood swings, and menstrual disturbances. It had been believed that once the individual reached skeletal maturity (stopped growing) increases in the curvature would end. Recent research, however, has indicated that the increase in curvature most often continues into adulthood.
Q: How does an individual develop scoliosis?
A: Approximately twenty percent of scoliosis cases can be attributed to one or more of the following: spinal injury, congenital spine defect (fetal spine fails to form properly), genetic abnormality/hereditary scoliosis, spina bifida, cerebral palsy, muscular dystrophy, vertebral deformity/spine muscle atrophy, spine tumor, infection, unequal limb growth, back muscle spasms, etc.
For the remaining eighty percent of cases the cause is unknown. In this situation the individual is said to have idiopathic scoliosis. There are four categories of idiopathic scoliosis:
- Infantile idiopathic scoliosis – the condition develops when the child is less than three years old
- Juvenile idiopathic scoliosis – the condition develops when the child is between 3 and 9 years of age
- Adolescent idiopathic scoliosis – the condition develops when the individual is between 10 and 18 years of age
- Adult idiopathic scoliosis – this condition develops when the individual is past the age of a 18 years. There are two forms of adult idiopathic scoliosis. The first is a continuation of adolescent idiopathic scoliosis that may or may not have been recognized and/or treated. The second is degenerative (de novo) scoliosis that develops in the lumbar spine in the middle to late adult years. The causes include traumatic injury, osteoarthritis or rheumatoid arthritis, or a degeneration of the intervertebral discs and facet joints of the spine. De novo scoliosis usually appears in association with a narrowing of spaces in the spine (spinal stenosis) which can put pressure on the spinal cord and/or spinal nerves resulting in back and leg pain.
Q: What are the symptoms of scoliosis?
A: In some instances a scoliosis curve is very noticeable. In other cases there are a number of visual indicators to suggest the presence of scoliosis including:
- The spine curvature is evident upon radiographic examination
- Shoulder or hip height is asymmetric
- There is a difference in shoulder blade height or position
- There is a difference in the way the arms hang beside the body when the individual is standing straight
Pain in the back or legs is not usually associated with idiopathic scoliosis until the spinal curve reaches an exaggerated stage (greater than 40 degrees). If you suspect a child may be developing scoliosis it is always wise to consult a spine specialist for a determination and/or confirmation of the condition. The specialist’s examination will usually include an x-ray of the spine in the standing position, and if deemed necessary CAT-scan or MRI evaluation. If scoliosis is evident, the specialist will measure the degree of the curvature (Cobb angle) and then prescribe a course of treatment.
Q: Does the scoliosis curve always go in one direction?
A: The scoliosis curve pattern varies according to spine region:
- Thoracic spine – the predominant curve (90%) is to the right side
- Thoracolumbar spine – the predominant curve (70%) is to the left side
- Lumbar spine – the predominant curve (80%) is to the left right side
- A protruding rib or uneven rib cage
- Curves that occur on both the right and left sides are known as double major curves
Q: What are the treatment options for the of scoliosis?
A: There are three basic treatment options for scoliosis that are based on the degree of spinal curvature: observation and measurement, bracing and surgery. Until the scoliosis curve reaches 25 degrees conventional wisdom suggests that the curvature be periodically monitored (including x-rays) and measured. Most school districts now have mandatory student scoliosis screening in the fourth through eighth grades to facilitate early detection. Once a curve has been detected it is recommended that the individual undergo a thorough examination and begin a rehabilitation program that takes into consideration the child’s age (spinal maturity), severity and location of the curvature, gender and if other health conditions are present. The rehab program usually includes physical therapy and/or exercises designed to maintain a healthy back. It will not, however, reduce the curve angle or retard curve progression.
Bracing is deemed appropriate when the curve exceeds 25 degrees. If the curve exceeds 40 or more degrees corrective surgery may be recommended. Early detection of scoliosis is essential for treatment option success.
Q: What type of bracing is most appropriate?
A: The subject of bracing is not without controversy. There are reports that provide evidence of bracing success in preventing progression and, in some cases, substantial correction. However, there are other reports that indicate bracing does not serve a therapeutic purpose. While the correction issue can be debated, it is generally agreed that bracing can retard curve progression. Depending on the individual’s age and degree of curvature custom-designed braces made from plastic or other synthetic material are intended to be worn 23 hours/day, while others are to be worn only at night. The spine specialist may select a bracing option from the following alternatives:
- A thoracolumbrosacral orthosis (TLSO) brace (Boston brace, Milwaukee brace (used for high thoracic curves), etc.)
- Charleston scoliosis brace – worn only at night, studies have shown comparable outcomes to TLSO braces
- Risser jacket – brace should be worn 23 hours/day
- Providence brace – designed to be worn at night
- Copes scoliosis brace – a dynamic brace that is frequently adjusted to achieve treatment objectives
- Rosenberger brace – low-profile TLSO brace intended to improve patient instructional compliance
- SpineCor Dynamic Corrective Brace – effectiveness being evaluated
Q: When should the surgery option be considered?
A: Scoliosis surgery is indicated when a growing child or adolescent has a highly progressive curve greater than 40 degrees, the patient is experiencing severe pain, or the scoliosis curve is greater than 50 degrees accompanied by severe trunk asymmetry. The surgeon most often uses spinal fusion techniques and a variety of instrumentation alternatives including rods, screws, hooks, wires, etc. to reduce and stabilize the scoliosis curve. The particular surgical approach the surgeon selects is function of the following:
- Spinal maturity—is the patient’s spine still growing?
- Degree of pain experienced and impact on the patient’s health and lifestyle
- Degree and extent of the curvature
- The spine region (s) in which the curve occurs
- Success or failure of previous treatment alternatives
- Estimate of probable progression following surgery
Summary: Scoliosis is a frequently occurring spinal abnormality that negatively affects the quality of life of young Americans, but can also affect individuals of all ages. Although treatment alternatives continue to be refined, early detection and treatment of the condition continues to be of critical importance.
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