Archive for April, 2011

Abnormal Curvature of the Spine

Abnormal Curvature of the SpineIn a normal spine a gradual curvature is present in the cervical, thoracic and lumbar regions. This anatomical architecture is designed to protect the spinal cord from injury by increasing the strength of the spine, assisting in maintaining balance when the body is in the upright position and assisting in the absorption of the mechanical shock of body movement, e.g., walking or running.

More than seven million Americans have an abnormal curvature of the spine. There are three primary types of abnormal spine curvature: kyphosis, lordosis and scoliosis:

Kyphosis: also referred to as humpback or hunchback, is an exaggerated (greater than 50 degrees) outward curvature or rounding of the thoracic and/or cervical spine. There are three categories of kyphosis: (1) congenital kyphosis (CK) occurs when the fetal spinal column fails to develop properly due to the fusing of several vertebrae or an abnormality in vertebral bone formation. CK may progress as the child develops; (2) Scheuermann’s kyphosis (SK) is a more severe form of kyphosis that usually becomes noticeable when the individual is a teenager; and (3) postural kyphosis (PK), which is the most common form of kyphosis, usually occurs during an individual’s adolescent years. It is more common in girls than boys and is usually not associated with pain. PK is generally considered to be caused by poor posture, e.g., slouching, hunching over, etc.

Mild kyphosis, such as postural kyphosis, can be treated with physical therapy and/or non-steroidal anti-inflammatory or pain relief medications. In the case of Scheuermann’s kyphosis surgery may be considered if the patient experiences intense chronic pain, the spinal curve is greater than 75 degrees, or other neurologic, pulmonary or cardiac complaints are present.

Lordosis: also referred to as swayback, is a condition most usually found in the lumbar spine, although it can appear in the cervical region. It is caused by an exaggerated inward curvature of the low back/lumbar spine. If the lordosis is pronounced it can cause pain with movement. Kyphosis, obesity, osteoporosis, spondylolisthesis or dwarfism (achondroplasia) can contribute to the development of this condition. If the condition becomes severe as a result of age-related progression it can result in low back pain, muscle spasm, muscle weakness, etc. When conservative treatment fails to provide relief to the patient, surgery may be performed to apply spinal instrumentation, kyphoplasty (to restore vertebral height), or full or partial artificial disc replacement.

Scoliosis: is an abnormal lateral curvature of the spine in the shape of an S or a C that is greater than 10 degrees distance from a normal spine. It is most usually found in the upper thoracic spine and to a considerably lesser extent in the lumbar spine of young girls. The condition affects more than seven million Americans. The cause of the great majority (80%) of scoliosis cases is unknown (idiopathic). The remaining 20% of scoliosis cases may have been caused by (1) failure of the fetal spine to form correctly; (2) neurological system disorders, e.g., spina bifida, spine tumors, spinal cysts or other neurological deficits; or, (3) neuromuscular disorders such as muscular dystrophy, Marfan’s disease (a condition that affects the body’s connective tissue), etc.

The classification of idiopathic scoliosis is based on the age at which it first develops: congenital scoliosis (develops in the womb); infantile idiopathic scoliosis (child is less than 3 years of age – more prevalent in boys than girls – usually recognized in the first six months); juvenile idiopathic scoliosis (3 to 10 years of age – more prevalent in girls than boys); adolescent idiopathic scoliosis (11 to 18 years of age – more prevalent in girls than boys); and, adult scoliosis (presence of scoliosis past the age of 18 years or skeletal maturity). Adult scoliosis usually originates at an early age and has continued into adulthood. However, there are instances when scoliosis can first develop during the adult years. This condition is known as adult degenerative scoliosis and can be caused by osteopenia (low bone density), osteoporosis of the spine, wear and tear on the spine due to the aging process, advanced disc degeneration, etc.

In a future blog a discussion of the treatment alternatives for the various forms of spinal abnormalities will be presented.

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Back Injuries and Sports

Which sport has the highest incidence of back injuries? If you answered football, hockey or basketball you guessed wrong. Spinal pathology occurs among male and female gymnasts, from children at the earliest competitive level to experienced adolescent and young adult gymnasts at the highest competitive level. Each year more than 80,000 gymnasts at all levels require medical attention. A great number of these injuries are to the back including sprains, strains, and spinal trauma such as herniated discs and fractures. In addition, gymnasts commonly experience injuries to the upper extremities (wrist, hand, elbow, clavicle, etc.) and lower extremities (knees, ankles, hips, tailbone, etc.).

The term gymnastics encompasses seven competitive categories: men’s artistic, women’s artistic, rhythmic, acrobatic, group, trampoline and tumbling. The incidence of injury is highest in the men’s and women’s artistic categories. Both of these groups use various apparatus as part of their competitive routines. The women compete on the balance beam, uneven bars, vault and floor exercise. The men’s competition includes the horizontal (high) bar, parallel bars, still rings, vault, pommel horse, and floor exercise. The etiology of gymnastic spinal injury can include: exaggerated bending, arching and twisting of the spine; the jolt of tumbling routines in the floor exercise; rigorous, repetitive apparatus training; and, falls from the apparatus. In addition, it should be noted that the uneven bars, parallel bars, horizontal bar and rings place an exaggerated traction force on the gymnast.

The two predominant types of spinal injury are strains of the spinal muscles and spondylolysis. Also occurring to a lesser extent is spondylolisthesis. Both spondylolysis and spondylolisthesis are usually manifested at the 5th lumbar vertebra (L5), and to a lesser extent at the 4th lumbar vertebra (L4). Spondylolysis is a medical term for a lateral fracture of is a thin segment of vertebral bone (the pars interarticularis). Spondylolisthesis is the term used to describe the forward slippage of all or part of one vertebra onto an adjacent vertebra. The slippage is thought to be the result of the gymnast’s performance of repetitive hyperextension movement, such as an apparatus dismount. Spondylolysis and spondylolisthesis can occur at the same time, however, spondylolysis is not necessarily a precursor of spondylolisthesis. Another back injury gymnasts experience is Scheuermann’s disease (adolescent kyphosis) which involves two vertebra segments being forced into aberrant wedge-like shape. This causes a distended outward curve of the upper back.

The long term result of the various insults to the bones and muscles of a gymnast’s spine is pain running down the leg, limited mobility and chronic low back pain. “Herniated discs and disc degeneration also occur but to surprisingly lesser extent.” This is thought to be due to the gymnast’s intense conditioning, muscle strength and flexibility. Fortunately muscle sprain and ligament strain can be treated with rest and physical therapy. When pain persists, it is recommended that the gymnast be evaluated by a neurosurgeon or an orthopaedic surgeon. It is also fortunate that catastrophic injury to the athlete is a relatively rare occurrence.”

The prevention of injury is of paramount importance. Parents and coaches should insist that all safety precautions are taken, especially in non-competitive situations (practice) where the bulk of injuries occur. This includes ensuring that spotters are in attendance, the apparatus is in good working order, the athlete uses the appropriate safety gear (hand grips, braces, pads, etc.), and there is a de-emphasis on “working through the pain.”

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Hydration and Back Health

One alternative for relief from pain in the back that is very often overlooked is simply keeping the body properly hydrated, i.e., a necessary and sufficient intake of water. Every organ, tissue, and cell must have an adequate amount of water so that they can function properly. This is particularly true for the vertebral discs and muscles that support the spinal column.

Q: What role does water have in basic human physiology?
A: Water is the primary component of the heart and other muscles (75%), brain (85%), blood (80%), kidney and liver (83%), and lungs (90%). In sum, water accounts for approximately 75% of our body weight. Without water, our body could not survive.

Q: What does water have to do with back pain?
A: There is a strong, positive correlation between back pain and the lack of adequate water intake (dehydration). This is particularly true for the intervertebral discs. The disc serves as a hydraulic shock absorber and experiences downward pressure when we stand or sit. In order for the disc to function properly it must have an adequate water supply. The water in the disc is retained by specialized molecules that are capable of holding more than 500 times their weight in water. This unique capacity accounts for the disc’s hydrostatic pressure when properly hydrated. A disc that becomes dehydrated loses hydrostatic pressure and cannot support the load placed upon it. When this happens the disc becomes inflamed (swells), causing soreness and pain. It can also become herniated and/or susceptible to disc disease. Simply consuming the proper amount of water on a daily basis can prevent back pain due to disc hydration.

Q: What proof is there that discs lose water?
A: Perhaps the most obvious evidence that this happens is referred to as the “Diurnal Change.” This means that our height is greater in the morning than at night by as much as a ¼ to ½ inch. The change is attributed to the fact that gravitational force and various load factors on the spine during the day cause the water content of vertebral discs to diminish. During the sleep cycle the water content of the disc is replenished, assuming adequate water is available. Although some attribute the change in spine length to changes in disc hydration and changes in spine curvature, a recent study found the change is solely attributable to changes in non-degenerated disc height. They also found that 40% of the diurnal change occurs in the lumbar spine. (see John R. Ledsome MD, et.al., “Diurnal Changes in Lumbar Intervertebral Distance, Measured using Ultrasound” at www.johnledsome.com)

Q: What is the proper amount of water intake needed to maintain back health?
A: For years we have been told that we “should” drink 64 ounces of water (8/8 oz. glasses/day). That may well be the correct amount, however, there is no scientific evidence to support that level of intake. The amount of water we need will be a function of the state of your health, level of physical activity, ambient temperature, etc. At a minimum we should take in enough water to replace the amount of water lost due to urination, bowel movements, breathing, perspiration, etc. Of course this amount is highly subjective due to an individual’s physical activity, body weight, age, diet and climate. It should also be noted that we take in about 25% of our water from the foods we eat, e.g., fruits, vegetables, meat, etc.

Q: Does coffee, tea and/or soft drinks and alcohol count towards the needed water intake?
A: They do, but drinking eight cups of coffee a day is not the equivalent of drinking eight cups of water. The reason for this is coffee, tea and drinks other than water are diuretics: they increase the production of urine. Fruit drinks are often overloaded with sugar and power drinks are loaded with caffeine and carbohydrates. It should be noted that consuming multiple cans or bottles of soda pop per day is now thought to be related to various pathologies. One of the most obvious is the development of oral disease, particularly in children and adolescents. Awareness of this phenomenon has caused many school districts to ban soda pop dispensers in their schools.

Q: How will I know if I am dehydrated?
A: Unfortunately, there is a high probability that you already are. This is because various experts estimate that as many as 75% of all Americans are chronically dehydrated. Specific indicators include (but are not limited to) excessive thirst, day time fatigue, dry mouth, infrequent urination, changes in the color of urine, joint pain and non-specific pain in the low back.

Q: Should I drink water even when I’m not thirsty?
A: Yes. This is particularly true as we age. Studies have shown that the perception of thirst diminishes with age. Signs of dehydration in the elderly include back pain, constipation, kidney stones, arthritis and indigestion. A good rule of thumb, irrespective of age, is that we should not wait until we are thirsty to drink water.

Q: Is there such a thing as drinking too much water
A: Yes. This is particularly the case if you have kidney problems or your doctor has you taking prescription diuretics. To be on the safe side, consult your doctor for a recommended amount of water and other fluids you should drink.

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