Archive for June, 2011

Pain at the Base of the Spine

LowerBack PainThe coccyx (pronounced: cox-ix) is a small, triangular-shaped, bony structure located at the base of the spinal column. Most of us give no thought to it until we inadvertently fall on it. Normally exhibiting little movement, the coccyx is composed of three to five coccygeal vertebrae (four being the most common) that may be fused into one structure, or into segments of two or more vertebrae. Unlike the higher spinal vertebrae, the coccyx has no hole in the middle to allow passage of the spinal cord, nor is it assigned an abbreviation or number as is the case with the other spinal vertebrae (e.g., seven cervical vertebrae numbered C1 to C7, twelve thoracic vertebrae numbered T1 to T12, five lumbar vertebrae numbered L1 to L5, and the five sacral vertebrae numbered S1 to S5).

The length of the coccyx is varies by individual, with a range of roughly one to four inches. It usually curves gently from the end of the spine into the pelvis. The coccyx is larger at the inverted base (where it connects with the lowest vertebrae of the sacrum (L5) forming the sacrococcygeal joint), then tapers downward to a rounded or cleft (bifid) point at the distal tip (apex). Since it gave the appearance of an animal’s tail, in the past it was widely referred to as a tailbone.

Until the 1970s, the coccyx was considered to be a vestigial remnant that served no function other than to remind us of our evolution from apes to man. We now know that the coccyx is an integral part of a complex system of support (the pelvic diaphragm) for our internal organs. Among the nine muscles attached to the coccyx are the gluteus maximus, the levator ani, the sphincter ani externis and the coccygeus. These muscles play a vital role in pelvic floor support and our ability to stand and maintain bowel control.

Of the 31 pairs of nerves that emanate from the spinal cord, the coccygeal nerve is the 31st and lowest nerve pair. The coccygeal plexus (collection of nerve fibers) located in the pelvic cavity arises from the S4 and S5 vertebrae. Its function is to transmit sensory information to the brain from the skin overlying the coccyx.

When pain (coccydynia) occurs at or near the coccyx it can be mild to severe and will often compromise an individual’s quality of life. The pain can be caused by sprains, chips, bruises, cracks, pulled ligaments, dislocations or fractures (a rare but painful occurrence) of the coccyx. These conditions may have been the result of falls (e.g., slipping on ice, ice-skating, etc.), repetitive friction from rowing, cycling or horseback riding, and sports-related blunt trauma (gymnastics, football, etc.). Coccydynia can occur at any age in both males and females. It is said to occur more often in women than men due to the shape of the female pelvis. Racial predisposition has not been reported.

Coccydynia can also be caused by a cyst at or near the tip of the coccyx (e.g., pilonidal cyst), infections, and, in rare cases, malignant tumors (either primary or metastatic). Women sometimes experience painful coccyx bruising when the baby descends through the pelvis during childbirth. The sensation of pain at the coccyx may also be idiopathic (cause unknown), and in some cases, psychosomatic (in the head). The pain, irrespective of cause, is generally more intense when the individual is sitting on a hard surface, stands for long periods of time, engages in sexual intercourse, becomes constipated, or has bowel movement. In some instances, coccyx pain may not be felt at the site of the coccyx itself, but is instead referred to the back, hips, thighs or legs. The wide variety of coccyx pain causes emphasizes the need for a thorough case history and examination by a back and neck specialist to determine the best treatment alternative.

The symptoms of coccydynia include (1) pain that worsens when the coccyx is palpated (touched); (2) non-specific pain around the hips, pelvis or lower back; (3) the inability to stand in place or sit still for periods of time; (4) pain that worsens with constipation and feels better after a bowel movement; (5) pain during sex; and, (6) visible bruising if injury is due to trauma.

The treatment of coccydynia is most often conservative with the application of compresses, bed rest, non-steroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation, and stool softeners to prevent constipation. Depending on the severity of the pain and its impact on daily activities, the back and neck specialist may recommend prescription pain medications, physical therapy, ultrasound or fluoroscopically guided injections of local anesthetics or corticosteroids into the collection of nerve cells (the ganglion impar) located at the sacrococcygeal junction. Immediate pain abatement usually follows the injection into the ganglion impar and can, in some cases, last indefinitely.

In those cases where extensive conservative treatment fails to provide pain relief the surgical removal of the coccyx (coccygectomy) may be undertaken. The removal of the coccyx has the same risks as other surgeries, e.g., wound healing problems, infection, and the possibility that the surgery will not result in pain relief.

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Golf-Related Low Back Injury

The sport of golf is played by more than 27 million Americans – young and old, male and female, novice and professional. Although certainly not a contact sport, golfers experience their share of sport-related injuries to the neck, hand, elbow, and shoulder. The most common injury is to the low back or lumbosacral region of the spine – the discs, muscles and tendons associated with the L5 and S1 vertebrae.

Golf is unique in that it is considered a life-long sport. Frequent extended play, combined with poor golf mechanics (e.g., poor posture, over swinging, improper swing technique, etc.) can contribute to, if not create, low back pain caused by spinal stenosis, age-related degenerative disc disease, disc herniation, pinched nerves or sciatica. Individuals who have these conditions often continue to play golf in order enjoy the social interaction of playing partners, maintain the competitive spirit, or simply undertake something other than the routine of everyday life. When this occurs, a few hours on the golf course often results in days or weeks of very intense pain.

Q: What is the primary cause of a golfer’s pain in the low back?
A: The simple answer is trying to swing the golf club too fast, particularly when hitting the ball off the tee. The innate desire to put the ball as far down the fairway as possible requires the individual to flex, bend and rotate the spine while simultaneously engaging multiple groups of muscles in the back, arms, hands, abdomen, buttocks and legs in what is best described as a violent outburst. This seemingly unnatural motion places significant shear, compression and torsion forces on the architecture of the lumbosacral spine. Since the average golfer will take between 50 and a 90 full swings over an 18-hole round (plus those on the practice range), there is bound to be some degree of muscle and joint fatigue and/or strain. Complicating the problem of over-swinging is the fact that this action is unilateral (one sided), requiring a right versus left side strength imbalance and asymmetrical musculoskeletal flexibility.

Q: What treatments are usually recommended for golf-related low back pain?
A: If pain is not abated by rest, massage and over-the-counter pain relief medications, it is in the golfer’s best interest to consult a back and neck specialist for examination and diagnosis of the source of the pain. This is usually followed by prescribed pain and anti-inflammation medications and perhaps some low-back exercise instructions and/or physical therapy. In rare cases, surgery to correct the cause of the pain may be recommended.

Q: What can be done to prevent golf-related low back pain?
A: Every professional golfer, golf course pro or physiotherapist can offer suggestions to avoid injury while playing golf. Some of the most frequently recommended include:

  • Learn the proper technique for swinging a golf club – i.e., take a lesson from a golf pro
  • Don’t over swing – incorrectly swinging the golf club as fast as you can results in excessive force and torsion being applied to the low back, resulting in injury or exacerbating an existing cervical or lumbar problem
  • Strengthen the muscles in your lower back and abdomen through exercise to develop torsional flexibility – emphasize the shoulder, torso, hip, and hamstring
  • Warm-up thoroughly before beginning your round (include stretching and simulating your golf swing)
  • If you go to the practice range to warm up, start with the pitching wedge and work your way up to the driver. This incremental approach helps avoid muscle sprain
  • If you chose to walk the course, use proper bag lifting technique, carry the bag properly (bag straps over both shoulders to evenly divide the weight), push the bag cart instead of pulling it, and, if you decide to ride, be the driver so you can anticipate rough terrain.

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Discogenic Low Back Pain

The low back or lumbar spine has five vertebrae with intervertebral discs located between the adjacent vertebrae that serve as shock absorbers. Each disc has two parts, a soft, gel-like interior (the nucleus pulposus) containing mostly water and a fibrous outer, ring-like structure (the annulus fibrosus) that surrounds and protects the nucleus. Nerve fibers are not present in the nucleus or inner two-thirds of the annulus. However, the outer third of the annulus does have nerve fibers. When you have intervertebral disc problems in the low back it is most often caused by a vertebral abnormality that can be identified by the spine specialist’s diagnostic process, e.g., disc herniation, spondylosis, spinal stenosis, lumbar sprain, etc. The pain the patient experiences from these conditions is caused by an irritation of a spinal nerve root (s) or the spinal cord itself.

The imaging studies sometimes show no evidence of vertebral abnormality, yet the patient is experiencing moderate to debilitating low back pain. This condition is often attributed to the slow deterioration of a disc resulting from age-related changes in the chemical and physical composition of the disc itself. The changes cause inflammation and/or tears or cracks in the disc’s annulus (internal disc disruption) that irritates the nerve fibers in the outer third of the disc’s annular ring. In addition, the gradual leakage of fluid from the disc causes the height of the disc to collapse and the nucleus to become dried and firm. Other contributors to discogenic pain include genetic factors, nutrition and mechanical or traumatic disruption.

Pain or other symptoms of neural pathology may not be present in the early stages of chronic disc degeneration. As the condition advances, discomfort in the low back becomes evident. The discogenic pain, which occurs most frequently in patients between 30 and 65 years of age, differs from other low back pain symptoms in that it is usually a dull ache, sometimes accompanied by unilateral radicular pain in the buttock or thigh, but not in the lower leg and foot (as is the case with sciatic pain).

Patients with low back discogenic syndrome are categorized as having (1) chronic persistent (constant) pain or (2) chronic recurrent (episodic) pain. The later presents as intermittent pain episodes that may last for several weeks or months followed by a brief, pain-free period before reoccurring. Pain in both categories will intensify when the pressure inside the disc (intradiscal pressure) increases, e.g., when the individual engages in strenuous physical activity, sits, bends forward, twists, stands in a stationary position, coughs, or sneezes.

The diagnosis of discogenic pain follows the spine specialist’s examination of the patient, followed by careful analysis of MRI and/or CT scans. In some cases the specialist may use a discogram to confirm the location of the pain and assist in the decision as to whether surgical fusion of the lumbar disc should be undertaken. The minimally invasive discogram procedure is somewhat controversial in that it induces pain in the patient in order to more precisely locate the actual source of the disc pain.

As with most other spine-related abnormalities, there are a number of treatment options for discogenic pain that the spine specialist may consider including conservative treatments such as non-steroidal anti-inflammatory medications, pain medications (including oral steroids), epidural steroid injections, opiods, physical therapy, and spinal bracing. In the event conservative treatments fail to alleviate the pain, or the pain worsens, the specialist may consider using thermal annuloplasty or Intradiscal Electrothermal Annuloplasty to seal cracks in the disc and deaden the nerves. Finally, the specialist may decide to perform endoscopic or traditional open surgery. This usually means that the patient will undergo a lumbar discectomy with fusion. History has shown that when this procedure is performed the cause of the pain is eliminated in 80% or more of cases.

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