Reducing Age-related Spinal Disc Degeneration

back pain, spinal discs, disc degeneration, physical therapy, spinal nerves, Houston, Baytown, Conroe, Galleria, Beaumont, Galleria, Galveston, Humble, Katy, Kingwood, Memorial City, Woodlands, Sugarland

The spinal discs are shock-absorbing pads located between our vertebrae. They are composed of a tough, flexible outer layer that surrounds a soft inner layer. As one might expect, spinal discs help cushion the stresses of everyday movement, helping the spinal column to articulate without pain and keeping the spinal nerves from being compressed by nearby vertebrae. Over time, our spinal discs naturally degenerate, becoming thinner, harder, and less capable of assisting the spine in movement. An older person’s spinal discs are also less likely to prevent compressed spinal nerves, due to the vertebrae being closer together in a patient whose discs have advanced degeneration.

back pain, spinal discs, disc degeneration, physical therapy, spinal nerves, Houston, Baytown, Conroe, Galleria, Beaumont, Galleria, Galveston, Humble, Katy, Kingwood, Memorial City, Woodlands, Sugarland

That is not to say we are all doomed to low mobility as we age, however. Back pain related to spinal disc degeneration is serious, but often treatable at home. Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can help reduce inflammation around compressed spinal nerves and allow back pain patients enough mobility to make adjustments to their lifestyle and course of treatment. Physicians typically start chronic back pain patients off with a regimen of physical therapy designed to develop muscles along the spinal column and throughout the torso. Core strengthening exercises shift the body’s weight distribution and assist the spinal discs in managing loads during everyday movement. For most back pain sufferers, physical therapy with incidental over-the-counter pain medication is enough to improve mobility and mediate pain levels. Depending on the severity of their back pain and the damage in the spinal column, other patients may require stronger prescription pain medication.

A preventive lifestyle that prioritizes regular exercise, healthy dieting, and proper weight management also goes a long way toward reducing age-related spinal disc degeneration. Obesity greatly increases the loads the spine is subjected to during the course of everyday movement and spinal discs and facet joints (the joints that link our vertebrae) bear the cost in the form of accelerated degeneration. Hydration and adequate sleep are essential to give the body time to repair itself from physical therapy sessions. Additionally, rest will allow tensed muscles to relax, promoting blood and oxygen to reach oxygen-starved muscles and aid in recovery.

back pain, spinal discs, disc degeneration, physical therapy, spinal nerves, Houston, Baytown, Conroe, Galleria, Beaumont, Galleria, Galveston, Humble, Katy, Kingwood, Memorial City, Woodlands, Sugarland

For some patients, conservative treatments like physical therapy won’t be enough to restore mobility. There are many different spinal deformities (such as spina bifida, in which a portion of the spinal cord protrudes outside the spinal canal) that will not be cured or even mediated by at-home solutions. These patients generally require back surgery, which can be extremely costly and necessitate a long period of post-operative care and rehabilitation.

Physician experts at the Kraus Back and Neck Institute (KBNI) in Houston, TX, have significant experience in diagnosing and treating spinal disc degeneration.  The Kraus Back and Neck Institute (KBNI) in Houston TX cares for patients in Houston and the surrounding areas, including Sugarland, Woodlands, Katy, Spring, Sealy, Baytown, Pearland, Beaumont, Galleria, Tomball, Conroe, Humble, Kingwood, Port Arthur, Galveston, Memorial City, Texas Medical Center  (TMC) and other Texas TX cities including Dallas, Fort Worth, San Antonio and Austin.

Keywords: back pain, spinal discs, disc degeneration,  physical therapy, spinal nerves, Houston, Baytown, Conroe, Galleria, Beaumont, Galleria, Galveston, Humble, Katy, Kingwood, Memorial City, Woodlands, Sugarland

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      Spine Infection

The organs, tissues and bones of the human body are susceptible to invasion by opportunistic pathogenic microorganisms. When this occurs, the result is very often an infection that may cause injury to the body part and progress to overt disease through cellular or toxic mechanisms. The most common cause of infection is the staphylococcus aureus bacteria, also known as mersa or staph. It can also be caused by streptococci bacteria, pseudomonas aeruginosa bacteria (“blue-green pus” bacteria), escherichia coli (E coli), viral-fungal-parasitic organisms and other pathogens (e.g., cysticercosis, listeria monocytogenes, toxoplasma gondii, brucellosis, etc.). In rare instances, in industrialized countries such as the United States, it may be caused by the mycobacteriumtuberculosis bacteria (sometimes seen in IV drug users). In some cases, the source of the infection can not be identified.

Infection of the spine, although rare relative to the incidence of infections in other parts of the body, is very deleterious and can lead to spinal instability and other serious problems. Spine infection is most commonly caused by staphylococcus aureus bacteria. The infection is classified by its location on or in the spine such as (1) infection of the intervertebral disc or disc space (discitis); (2) infection of the vertebral bones of the spinal column (osteomyelitis); or, (3) an infection of the tissue (dura) covering the spinal cord and spinal nerve roots (epidural abscess). In most cases, an individual will experience only one of these clinical entities. Some critically ill patients, however, will present with all three. Failure to accurately diagnose and properly treat spinal infections can lead to catastrophic neurologic damage, paraplegia, and death.

Q: How does infection begin in the spine?

A: Spinal infection can occur spontaneously in the spine. However, infection is usually transmitted to the spine from adjacent tissue or another part of the body through the blood stream (bacteremia or sepsis). Infection most often occurs in the lumbar region of the spine, followed by the thoracic spine and, to a much lesser extent, the cervical spine (found in IV drug users).

Q: Who is at risk for spinal infections?

A: Individuals at risk of spinal infection include the elderly, smokers, the obese, patients who are immunocompromised (e.g., patients who have received organ transplants), patients with significant health problems such as diabetes mellitus, cancer, malnutrition, urological infection, and patients with wound infections. Spine infections can also arise from trauma to the spine and is increasingly found in IV drug users and those with long-term use of steroids.

Any surgery on the human body holds the risk of infection. This includes spine surgery, especially where instrumentation is involved, or when there has been implant/instrumentation migration. In the case of implant/instrumentation migration another surgery is required to correct the situation. Failure to confirm the absence of other infection in the body prior to the surgery is also problematic.

Q: How is spine infection diagnosed?

A: Diagnosing the presence of spine infection can be challenging. One reason is that the symptoms of spine infection – pain, inflammation, weakness, neurological deficits, weight loss, etc. – often mimic other spine condition symptoms or system irregularities such as pancreatitis, meningitis, radiculitis, appendicitis as well as non-specific back pain. When this occurs, an accurate diagnosis may not be made for days, if not weeks or months. Misdiagnosed or late-diagnosed patients may experience unnecessary operations as surgeons attempt to control the suspected pathology.

Once spinal infection is suspected the physician will confirm the diagnosis with blood cultures (e.g., white blood count), erythrocyte sedimentation rates (ESR) and C-reactive protein (CRP)), imaging studies (MRI with contrast medium (e.g., Gadolinium) and X-ray), nuclear medicine scans (PET), and biopsy (usually image guided). These studies may be repeated to evaluate the success of treatment protocols.

Q: After spine infection is confirmed, what are the treatment options?

A: The objective of spine infection treatment is to cure the infection and limit the possibility of further damage.The actual treatment modality depends largely on the severity and duration of the infection and the identification of the micro-organism involved. Once the micro-organism has been identified, specific antibiotics can used be to eradicate the bacteria.

Treatment options include intravenous and oral antibiotics, or injection of antibiotics directly into the infected area. This is often accompanied by bed rest and/or bracing to limit spine movement. If the infection is severe or fails to respond to initial treatment, long-term intravenous antibiotic or antifungal therapy may be required. In this instance, extended hospitalization may be required.

Despite the use of various antibiotics and antifungal agents, the treatment of a spine abscess often requires surgery to reduce pressure on the spinal cord or drain and remove infected material. Surgery is also required when there is evidence of bone destruction, spinal instability, vertebral collapse, spinal deformity, cauda equina syndrome, or other signs of neurologic dysfunction.

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           Spine Tumors: Primary and Secondary, Houston

“Tumor” is a word about which nothing good can be said. It can cause terror in the mind of the listener, especially if the person speaking is their doctor. The word “Tumor” is an ancient Latin word that meant “swelling” on or in the human body. It was thought to be one of the five signs of inflammation (i.e., pain (dolor), heat (calor), redness (rubor), tumor (swelling), and loss of function (functio laesa)). In the contemporary medical lexicon, tumor still means an abnormal swelling of the flesh. It is also considered synonymous with neoplasm, which is a medical term for an abnormal, uncontrolled growth of new cells.

Tumors & Cancer

To the lay person, a tumor is more often than not considered to be synonymous with cancer. However, a tumor can be non-cancerous (benign), pre-cancerous (carcinoma in-situ), or cancerous (malignant). A benign tumor does not consume other tissues and will not become malignant overtime. It will, however, continue to grow in size and can cause pain and system dysfunction. A pre-cancerous tumor falls somewhere in between a benign tumor and a malignant tumor. It has the potential to become cancerous, but its growth has not yet become uncontrolled. In its pre-cancerous state the tumor should be a cause for concern and periodically monitored. Pre-cancerous tumors often appear as moles or uterine fibroids.

In a malignant tumor the cells grow uncontrollably and more quickly than benign tumor cells. They seek out other tissue to consume. Unlike a self-contained or non-spreading benign tumor, a malignant tumor will continue to spread to other parts of the body. Malignant tumors are, by definition, always cancerous. Fortunately they are not contagious, but they are also not preventable.

Q: Where are tumors most often located?

A: Tumors, either benign or malignant, can be located anywhere in the body. They can occur in the vital organs (e.g., brain, liver, lungs, kidney, etc.), soft tissues, bone/bone marrow, blood vessels, etc. Tumors in bone, including the spine, are classified as being primary or secondary. The primary spinal tumor first appears in the bones of the spine, whereas a secondary spinal tumor (always malignant) first appears elsewhere in the body and metastasizes (spreads) to the spine. Some spinal tumors occur as a result of genetic defects (e.g., neurofibromatosis 2), for the remainder the pathogenesis or cause is unknown.

Q: How often does spine cancer occur?

A: The answer to this is difficult to quantify. However, the spine is the most common site for bone metastasis. There are estimates that suggest between 30 and 70% of all patients with cancer will have spinal involvement.

Q: Where are the spinal tumors located?

A: Primary and secondary spinal tumors can occur (1) inside the spinal cord (intramedullary), (2) in the membrane (the meninges) that covers the spinal cord (extramedullary-intradural), or (3) between the meninges and the bones of the spine (extradural). Although a small number of tumors occur in the nerves of the spinal cord (e.g., ependymomas and gliomas), the majority of spinal tumors are extradural. Primary spinal tumors are much less common than primary brain tumors. As a spine tumor grows it can place pressure on the spinal cord as well as the bones of the spine, spinal blood vessels, nerve roots and the meninges.

In men, the secondary tumors that most often spread to the spine originate in the prostate and lung. In women, the secondary spine tumors most often originate in the breast and lung. Malignant spine tumors can also originate in the kidney, thyroid, and malignant melanoma. The cancerous cells are then transported to the spine via the lymphatic system or blood.

Q: Is there more than one type of spinal tumor?

A: There are a number of different types of both benign and malignant spinal tumors.

Among the benign tumors that may be present in the spine are:

Aneurysmal bone cyst – an abnormal growth that affects the vertebrae. Treatment includes embolization (cutting off blood flow) and surgical removal

Hemangioma – usually found in the thoracic and lumbar spine. Treatment includes embolization (cutting off blood flow), surgical removal and radiation

Giant cell tumor – an uncommon tumor found in the sacrum and lumbar spine. Treatment includes embolization (cutting off blood flow), surgical removal and possibly radiation

Osteoblastoma – found in the vertebrae and sacrum. Treatment is most often surgical removal

Osteoid Osteoma – found in the spinal column. Treatment is most often surgical removal.

More than 70% of all spine tumors are malignant, of which only 10% originate in the spine.

Among the primary malignant tumors that may be present in the spine are:

Multiple myeloma (cancer of the bone marrow) – most common malignancy of the spine. Treatment includes surgical removal, radiation and chemotherapy. The chemotherapy may be administered before the surgery to shrink the tumor (neoadjuvant chemotherapy) or after the surgery (adjuvant chemotherapy) to destroy any remaining cancerous cells.

Chondrosarcoma – most commonly found in the thoracic spine. Treatment is most often surgical removal

Chordoma – usually found in the lumbar spine and sacrum. Treatment is most often surgical removal if it can be done without affecting nearby nerve structures. Radiation may also be used for treatment.

Non-Hodgkin’s lymphoma – sometimes found in a vertebra and spinal canal. Treatment includes surgical removal, radiation and chemotherapy

Osteosarcoma – rarely found, affects the lumbar and sacral spine. Treatment includes surgical removal, radiation and chemotherapy

Ewing’s sarcoma – rare in persons over 30. Found in the sacrum, lumbar and thoracic vertebrae. Treatment is most often surgical removal combined with radiation and chemotherapy

Plasmacytoma – affects the thoracic vertebrae and can cause compression fracture. Treatment includes surgical removal and radiation

Astrocytomas – affect the nerve cells of the spinal cord. Treatment includes surgery and radiation.

Q: What are the symptoms of a spinal tumor?

A: The symptoms of a spinal tumor depend on the location, type of the tumor and rate of growth. Non-mechanical pain in the thoracic and lumbosacral regions of the back is the most frequent symptom. However, pain in the back is common to many spinal pathologies (cysts, infections, compression fractures, herniated discs, medication complications, etc.) and therefore an accurate diagnosis of a spinal tumor is critical. Other symptoms of a spinal tumor include bone fracture, swelling and inflammation, sciatica, loss of sensation, loss of bowel or bladder function, scoliosis or other spinal deformity. To isolate and pinpoint the spinal tumor the back and neck specialist will usually order a variety of lab tests to be performed (e.g., complete blood count with diff, comprehensive metabolic panel, serum protein electrophoresis, acid phosphatase, urinalysis with Bence Jones Protein, etc.).

In addition, one or more imaging studies may be undertaken, e.g., plain x-ray, MRI with contrast medium, CT Scan with Myelogram, Technetium bone scan or other nuclear medicine bone scans, or positron emission tomography (PET) scan.

Q: Assuming a tumor is found, what next?

A: To determine the exact type of tumor the back and neck specialist will have the patient undergo a needle biopsy (with image guidance) to obtain a sample of the tumor tissue so that the exact type, stage (severity) and grade (how quickly the cancer is likely to spread – low grade tumors being the least aggressive) of the cancer can be determined. Once this is done, a decision is made as to the treatment that will be pursued. This may mean a non-surgical treatment approach such as observation, the use of corticosteroids, palliative drug therapy, radiation, chemotherapy (administered in pill form, injection, intravenously, or via an implanted vascular access device (VAD)), bone marrow aspiration, radio-frequency ablation, or, in some cases, stem cell transplants.

Surgery is recommended when (1) other treatments have failed, (2) it is deemed necessary to stabilize the spine, or (3) the spinal nerves are being compressed. In this case all or a part of the tumor will be removed. During this procedure the surgeon will attempt to stabilize and reconstruct the spine by performing a spinal fusion with bone grafts, use of bone cement and instrumentation. Tumors that were found to have aggressive microscopic (histopathological) characteristics are subject to post-operative radiation therapy.

Q: Is spinal tumor surgery a high risk operation?

A: There are risks associated with any spinal surgery. These include infection, post-operative neurological problems, residual pain, failure to excise the entire tumor due to structural considerations, etc.

Q: If the decision is for the spine tumor to be removed by surgery, how long can I expect to be in the hospital?

A: Hospital stay can be up to 10 days or longer depending on complications, followed by bed rest and possibly rehabilitation.

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The human spine extends from the skull to the pelvis and is the primary structural component of the body. It consists of 33 bones (vertebrae) stacked in a vertical column held in place by a complex assortment of back muscles, ligaments and tendons. The spinal column serves to (1) protect the spinal cord and the 31 pairs of nerve roots that branch off the spine; (2) provide stability and support for the head, chest and shoulders allowing the body to stand and walk upright; and, (3) and enables flexibility and mobility of the upper body. Adjacent vertebrae are separated by a fibrocartilaginous disc that serves as a shock absorber by cushioning the stress forces placed on the spine when the individual walks, runs or jumps. The intervertebral discs account for one-quarter to one-third of the spine’s length. The hollow center of the vertebrae create a canal or tunnel that houses a collection of nerve fibers known as the spinal cord, which originates at the base of the brain and ends at the first lumbar vertebra. The spinal cord and the brain are the primary components of the central nervous system.

The vertebrae of a healthy spine can withstand considerable pressure, but when the compressive force being applied exceeds the load limit of the bone, one or more vertebrae can collapse causing a decrease in the intervertebral space and the height of the vertebra. This is usually accompanied by a vertebral compression fracture that is most commonly located in the thoracic spine (primarily at T7-T8 and T12 and L1 – the thoracolumbar junction). Vertebral compression fractures can also be caused by trauma to the spine as a result of (1) automobile accidents, falls, sports injuries or improper lifting of heavy objects; (2) localized infection of the bone (osteomyelitis); (3) cancer in the vertebra that has metastasized from the liver, colon, prostate, breasts or lungs; or, (4) long-term use of steroid medication.

The most common cause of compressive spinal fractures is osteoporosis. In the U.S. alone, it is estimated that this bone-weakening, metabolic disease is the cause of between 750,000 and 800,000 vertebral compression fractures annually. If the osteoporotic or other type of compressive fracture impacts the spinal cord or nerve roots the individual usually experiences acute pain. However, in the case of osteoporosis, more than two-thirds of the fractures are atraumatic (i.e., clinically silent) even though they may occur at several levels of the spine. This means that the individual experiences little or no discomfort from a neurological deficit (the risk still exists that additional compressive fractures may occur). If mild pain does occur it usually goes away within a few weeks. In older patients the pain is often attributed to the natural aging process and is tolerated by the individual without seeking a medical evaluation. Symptoms of a compressive fracture other than pain include loss of body height, pain when standing or walking, evidence of kyphosis (dowager’s hump or humpback at the top of the back which is common in older women), loss of balance, psychological disturbances or neurological symptoms such as numbness and tingling.

If not treated properly vertebral compression fractures can lead to (1) a progressive misalignment, segmental instability and deformity of the spine; (2) loss of body height and mobility; (3) feelings of isolation and depression; and (4) gastrointestinal and pulmonary problems. When an osteoporotic compression fracture occurs in a vertebra, there is a 40% chance that an adjacent vertebra will experience a similar fracture within one year.

In order to diagnose a vertebral compression fracture the spine and neck specialist develops a complete case history, performs a physical examination, and employs imaging technology (x-ray, CAT scan, or MRI) to confirm the presence and severity of the fracture. If a fracture is confirmed, the specialist will usually recommend a conservative course of treatment including rest, over-the-counter and prescription pain medication, and bracing to limit spinal movement. In those cases where the individual is experiencing severe pain, the back and neck specialist may undertake a minimally invasive vertebroplasty or kyphoplasty procedure.

If a vertebroplasty is selected the patient receives a local anesthetic and intravenous sedation. The specialist then uses a fluoroscope to place a trocar (large bore needle) into the collapsed vertebra. Once proper needle placement has been achieved, bone cement (polymethylmethacrylate) is injected under pressure into the vertebra to stabilize the fracture and support the spine. The cement hardens quickly, preventing the fracture from collapsing further while it heals. The procedure, which is usually performed on an outpatient basis, takes less than two hours.

If the kyphoplasty procedure (aka Balloon Assisted Vertebroplasty) is selected, the specialist inserts two fluoroscopically guided needles, each containing a deflated balloon, into the vertebra. The balloons are then inflated to increase the height of the vertebra. After the balloons are deflated and removed, bone cement is inserted into the space created by the balloons. Patients usually experience immediate pain relief with either procedure. Complications following vertebroplasty or kyphoplasty are extremely rare. However, there is a very slight risk that the cement will leak, causing pressure on the spinal nerves. In addition, numbness, tingling and infection at the injection site have infrequently been reported.

In some instances, the patient’s intractable pain and imaging studies showing a severe fracture may indicate that open surgery is necessary. In this case, the back and neck specialist may elect to fuse the vertebrae and/or insert spinal instrumentation (plates, rods, hooks, pedicle screws, or cages) to stabilize the spine.

Patients with any one of the following should not undergo a vertebroplasty or kyphoplasty:

• There has been a greater than 80 percent collapse of the vertebra
• Osteomyelitis or discitis is present in the vertebra
• The compression fracture has been present for more than one year
• There is spinal curvature (scoliosis or kyphosis) that is due to causes other than osteoporosis
• There is spinal stenosis or herniated discs with nerve or spinal cord compression and loss of neurological function not associated with the compression fracture
• The patient has coagulopathy (a disease or condition affecting the blood’s ability to coagulate)
• There has been significant compromise of the spinal canal caused by an impeding bone fragment or tumor

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The 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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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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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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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
• Hydrotherapy
• 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.

Autograft

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.

Allograft

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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Abnormal Curvature of the Spine

In 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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   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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   Excess Weight and Back Pain

There is ample evidence to state that excess weight can cause acute and chronic back pain. This is particularly true for those who are considered obese. It is alarming to note that in 2009, more than one third of the adult population in the United States was considered obese. Compare this to 14 percent of this same population in 1980. It has long been known that there is a strong correlation between obesity and the onset of coronary heart disease, diabetes, high blood pressure, and colon cancer.

In addition, various studies have found a strong correlation between low back pain and being overweight or obese. Although painful spinal conditions such as spinal and knee joint arthritis, systemic inflammation of spinal muscles and ligaments, degenerative disc disease, etc. are prevalent among this group of people, they are not fatal. Perhaps this is the reason why research into the relationship between excessive weight and back health has been relatively limited.

Q: Is being overweight and being obese the same thing?
A: No. According to the National Institutes of Health overweight persons and obese persons fall into two separate categories as determined by the Body Mass Index (BMI).

Q: What is the Body Mass Index or BMI?
A: The BMI is simple number calculated by the relationship of two numbers – your height in feet and inches and your weight. The BMI categories are as follows:

• Underweight = <18.5
• Normal weight = 18.5–24.9
• Overweight = 25–29.9
• Obese = BMI of 30 or greater

(To find your BMI go to http://www.nhlbisupport.com/bmi/)

Q: How do I reduce my BMI?
A: The best way is to undertake a regimen that includes a proper diet, exercise and, if necessary, dietary supplements. In extreme cases, a person may also undergo behavioral therapy, surgery, or pharmacotherapy.

Q: Is there a relationship between diet, the BMI and back health?
A: Absolutely. Eating a proper diet not only reduces the BMI, it also serves to reduce and prevent back pain. By proper diet we mean one that includes:

• lean meat, fish and chicken
• plenty of fruit (apple, pear, peach, pineapple, grapes, oranges and papaya) and vegetables
• low fat dairy foods
• whole grains, including whole-wheat bread and pasta, cereals and brown rice
• nuts (e.g., almonds, walnuts and peanuts) and seeds
• plenty of water – be careful of flavored waters as they may contain unwanted calories

You should also limit or avoid:

• eating red meat as it can cause or exacerbate chronic back pain and joint inflammation
• processed meat
• high-fat dairy products
• coffee and tea
• fried foods
• white flour
• foods high in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars

More to come on the subject of diet and back health…

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   Intimacy and Back Pain

Each day millions of Americans suffer from back pain caused by muscle strain, sciatica, herniated disc, traumatic fracture, bone spurs, spinal arthritis, degenerative disc disease, or other forms of spinal pathology. Depending on the severity of the pain, most people will make physical and behavioral adjustments to their lifestyle in an effort to achieve some level of comfort or relief. One of the first aspects of daily living to be affected by back pain is that of intimacy.

For most people sex is the most important part of intimacy. A recent survey found that 56 percent of those with severe back pain would voluntarily discontinue sexual relations if it resulted in an end to their back pain. The same study revealed that 46 percent of the respondents had chosen to discontinue all sexual activity, while others in the survey had sex less often or had less satisfying sex when it did occur. When back pain negatively affects a previously healthy sex life, problems are likely to arise in the relationship.

If back pain has affected the intimacy that you and your partner previously enjoyed you may want to consider the following:

• Consulting a spine specialist to obtain an accurate diagnosis of the cause of your problem and a recommendation as to treatment alternatives. This information is critical to understanding what has happened to your back and what the future may hold. Keep in mind also that untreated pain can lead to proven relationship destroyers such as frustration, anger and depression
• Having a frank discussion with the spine specialist regarding back pain and sex. Your back pain is unique to you. Don’t make the mistake of thinking your partner understands how your pain affects you. For this reason, it is preferable that your partner be present to share their questions and concerns
• Asking the spine specialist for guidelines regarding positions and movements that will support your back and minimize pain during sex. As you experiment with different positions and movements keep in mind that you need to be gentle, and if it hurts, don’t do it.

Back pain doesn’t have to mean the end of sexual intimacy or the end of sexual satisfaction. It does mean, however, that you have to take affirmative steps to understand and manage it.

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  Neck Pain Relief

  Epidural Nerve Block

If you are experiencing neck pain due to whiplash, spinal stenosis, disc herniation or arthritis in the facet joints of the cervical spine, your back and neck specialist will seek to determine the source of the pain. By knowing the exact source of the pain the most effective and long-lasting treatment alternative can be selected. One of the most useful tools in the specialist’s diagnostic armamentarium when dealing with neck pain is the nerve block. The purpose of the diagnostic nerve block is to identify the area causing the pain as precisely as possible. The procedure entails injecting an anesthetic (usually lidocaine to numb the pain) and a contrast agent (to identify the spinal structure) into the affected area. Lidocaine is a fast-acting anesthetic that usually wears off in about two hours. Other slower-acting anesthetics are sometimes used for longer lasting pain relief.

A nerve block can also be very useful in the management of chronic neck pain. The primary difference between a diagnostic and therapeutic nerve block is that the latter contains an anesthetic and a steroid such as cortisone (to reduce swelling). The pain reducing effects of cortisone can last for months. In some cases the specialist may mix morphine or fentanyl (a synthetic narcotic analgesic) with cortisone to obtain increased pain relief. If the nerve block is successful, surgery is not necessary.

Epidural Spine Block

Depending on the objective data, the back and neck specialist may choose to inject an anesthetic and a steroid into the epidural space that exists between the covering of the spinal cord and the inside of the bony spinal canal. An epidural spinal injection is a non-surgical treatment option that may provide long-term relief from neck pain radiating to the arm. The injected medication coats the targeted nerve roots and the outside lining of the facet joints near the area of injection. In some instances the epidural spinal injection can provide permanent relief.

The epidural spine block procedure is performed on an out-patient basis with the assistance of fluoroscopy (x-ray) to monitor the placement of the needle into the epidural space. A small amount of contrast dye is injected to confirm that the needle is placed properly and that the medication is in the area where it’s needed. The procedure usually takes between 15 and 30 minutes.

There is no guarantee that a therapeutic nerve block will work in every instance and there is no way to predict what a particular individual’s outcome will be. Experience has shown that they work about 50% of the time. When they work, a second block is not needed nor is there a need for other treatment (e.g., surgery). In some cases the block is successful but its effectiveness wears out. It is recommended that no more than three blocks be performed per year.

As is the case with all invasive treatment procedures the possibility of side effects exists. Your specialist will describe what these are and provide you with specific after-care instructions for you to follow. In rare instances the specialist may determine it is unsafe to perform a spinal block if certain medical conditions exist.

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  Texting and Neck/Arm Pain

Neck and arm pain related to texting is a growing phenomenon. Initially referred to as “BlackBerry thumb,” the repetitive stress that comes from excessive use of a wireless device’s tiny keyboard to send text messages has been found to strain muscles, tendons, and ligaments in the hand, arm and neck. In addition, prolonged flexed-neck posture, or “hunching over,” as the keyboard is manipulated can cause cervical nerve disruption accompanied by acute or chronic neck pain. This non-traumatic pain often radiates down the arm causing a combined pain that is greater that arm or neck pain alone. Similar outcomes have long been associated with using a computer keyboard.

It is predicted that if excessive texting behavior continues unabated, the number of nerve-related disorders such as osteoarthritis and degenerative disc disease will increase and lead to a debilitating pain syndrome that negatively impacts school and/or work performance. A more immediate concern is that inflammation of the basal joint at the base of the thumb due to excessive texting will result in thumb arthritis. This condition manifests itself in hand pain, swelling, decreased strength and limited range of motion.

Simple steps to take to prevent the development of a texting-related pain include:

• Stopping texting at the first sign of discomfort or pain – if you can’t stop, cut back on the number of messages sent each day
• Try to avoid hunching over – position the keyboard in such a manner as to limit pressure on your neck and upper back muscles as they work to keep your head from falling forward
• Don’t sit in the same position for long periods of time
• Use both thumbs – and give your thumbs a rest when typing long messages.

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   Your Mattress and Your Back: Houston

Four facts are indisputable. First, more than 40 million adults experience recurring or chronic back pain, most of which is non-specific. This means that there is no specific therapy to remove the source of the pain. Second, we spend one-third of our lives lying on a mattress. Third, there is a definite relationship between the mattress you sleep on and your back pain. Restful sleep is essential for maintaining a healthy back and spine. Fourth, choosing the right mattress can (1) improve your condition if you have an existing back pain issue, and (2) prevent you from developing back pain.

Mattresses come in a variety of types – memory foam, innerspring, latex, air, adjustable, etc. If any of these mattresses is too soft, the body will “sink in” causing low back pain and irritated spinal joints. If the mattress is too hard it can cause pressure points and reduce blood circulation. Today it is generally acknowledged that any type of medium firm mattress is preferable provided (1) it conforms to the spine’s natural curves thereby keeping the spine in alignment when you lay down; (2) distributes pressure evenly; and (3) minimizes transfer of movement from one sleeping partner to the other. This last point is important since most of us will change position more than 50 times during our sleep cycle.

Other factors that influence mattress selection include:

• Preferred sleep position – lying flat, lying on the side, or lying on the stomach (not recommended as it forces the spine into an unnatural angle and may aggravate back and neck problems)

• A proper cervical pillow will lessen the chances of neck and back pain

• Your height and body weight

• Mattress size, material, warranty, test period, cost, etc.

Mattresses have a definite role in the management of back pain. The best mattress for you is one that is tailored to your particular needs. If you have questions about back pain, or are uncertain as to how to proceed with mattress selection, you should consult a back and neck specialist.

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Cervical Pillow

Neck Pain and Cervical Pillows

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Chronic cervical or neck pain is a widespread problem that can be the result of a neck injury (e.g., whiplash), pinched nerve, arthritis (osteoarthritis or rheumatoid), spinal stenosis, degenerative disc disease (e.g., bone spurs), and muscle related conditions such as neck strain, fibromyalgia and severe neck ache and stiffness (e.g., polymyalgia rheumatica (PMR)).

A cervical pillow can provide some relief from cervical pain by providing support to the head and neck while you sleep. Unlike regular pillows, cervical pillows are ergonomically designed to change the shape of the cervical spine whether you are lying on the back or the side. Selecting the best cervical pillow for you can be a trial and error situation since there are a number of factors to consider.

For Example:

• Pillow Design – there are numerous pillow designs to consider – the contour pillow, roll pillow, dogbone pillow, wave or S shape, wedge, etc.
• Pillow Material – foam, fiber, memory foam, water-filled, air-filled, buckwheat, etc.
• Firmness/Softness of the pillow material
• The Size of the person and the amount of neck support that can be tolerated
• Size – pillow should support the back of the neck as well as the back of the head
• Cost
• Trial Period – is necessary to find the pillow that is most comfortable to you
• Warranty

Other Factors to Consider Include:

• A cervical pillow that restricts changes in sleeping postures or places more pressure on the back of the neck than on the back of the head might actually cause neck trouble. Don’t use the cervical pillow if it causes discomfort of any kind.
• Although cervical pillows can provide temporary overnight relief from neck pain, it is always prudent to consult a head and neck specialist to determine the cause of your neck pain and to discuss alternative solutions.

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Osteoporosis in Men
Evaluation in Houston

Osteoporosis is a progressive, degenerative bone disease most commonly associated with aging. This abnormal thinning of bones can progress without pain or other symptoms until a break occurs. Osteoporosis is incurable, but it is preventable and treatable.

Although current media attention focuses on osteoporosis in women, the National Osteoporosis Foundation (NOF) reports that more than 2 million men have osteoporosis and another 12 million men have osteopaenia (low bone density), a precursor to osteoporosis. Based on their statistical analysis, the NOF predicts that 25% of men over 50 will break a bone due to osteoporosis and (2) that men over 50 are more likely to break a bone due to osteoporosis than they are to get prostate cancer. Despite the gravity of these statistics, male osteoporosis and osteopaenia too often remain undiagnosed and inadequately treated conditions.

Risk factors for osteoporosis in men include: age, family history of osteoporosis, low body weight, smoking, excessive alcohol consumption, inadequate calcium or vitamin D intake, low estrogen levels, a sedentary lifestyle, previous fracture not related to trauma, and disease or medication affecting bone metabolism (e.g., corticosteroids, certain anticonvulsants, or excess doses of thyroid hormones). In addition, other medical problems such as chronic kidney, lung or gastrointestinal disease, prostate cancer and some autoimmune disorders such as rheumatoid arthritis can contribute to the development of osteopaenia and osteoporosis.

The importance of screening for osteopaenia and osteoporosis must not be underestimated. Early detection is the most important step toward the prevention and treatment of these conditions. A non-invasive, painless bone density test will determine whether you have osteoporosis or are at risk of developing the condition. Because standard x-rays cannot detect osteoporosis in its early stages, the following procedures are commonly employed:

1. Dual energy x-ray absorptiometry (DEXA) – x-ray beams of differing energy are used to detect bone and soft tissue density separately. This fast and highly accurate technique can be used to measure bone density in the spine, hip, forearm and the total body.
2. Single energy x-ray absorptiometry – a single x-ray beam is used to measure bone density at peripheral sites like the forearm and heel. In this technique, the area to be tested is wrapped in a tissue-like substance or immersed in water to improve the quality of the results.
3. Ultrasound – measurements taken during an ultrasound may provide data on the structural integrity of bone. New ultrasound devices such as quantitative ultrasound (QUS) can estimate bone density of the heel within minutes, providing an automatic print-out of results.
   Each of these tests will allow your doctor to (1) detect osteoporosis at its earliest stages, so that treatment can begin, (2) monitor your rate of bone loss, and (3) monitor your response to treatment.

All men 50 and over should take the following essential steps to keep bones strong: (1) engage in regular weight-bearing exercise (brisk walking, weight-lifting, stair-climbing, etc.) and (2) follow a healthy diet, with an emphasis on calcium, low-fat or nonfat dairy products as well as fruits, vegetables, and whole grains.

If you or a loved one have one or more risk factors for osteoporosis, it’s important that you consult with your doctor without delay.

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Questions About the Spine

Q: What are the regions of the spine?
A: Starting at the top, the spine has four regions with a total of 33 vertebrae:

1. The first region is comprised of the seven cervical or neck vertebrae (labeled C1–C7).
2. The second region is comprised of the 12 thoracic or upper back vertebrae (labeled T1–T12).
3. The third region, known as the lower back, is comprised of the five lumbar vertebrae (labeled L1–L5).
4. The fourth region is known as the sacrum and coccyx. This group of nine bones (5 in the sacral and 4 4 in the coccygeal region) is fused together at the base of the spine.

Q: Is the spinal column straight?
A: No. The spinal column has three gradual curves. These curves serve to increase spine strength, maintain balance in upright positions, absorb shock when walking, and protect the spinal cord from injury. Abnormal spine curvature (scoliosis) usually occurs in the thoracic region due to a congenital condition, sciatica, poor posture, one leg being shorter than the other, or paralysis of muscles on one side of the body.

Q: What is the spinal canal?
A: The spinal canal is a tube formed by the stacked vertebrae.

Q: Are all vertebrae the same size?
A: No. Although vertebrae differ in size and shape in the different regions of the spinal column, they all share the same structure. The exception is the first and second cervical vertebrae which differ structurally in order to support the skull.

Q: How long is the spinal cord?
A: An adult male has a spinal cord roughly 18 inches in length. An adult woman has a spinal cord roughly 17 inches in length. The spinal cord extends from the brain to the lower back. An injury to the spinal cord can cause a
loss of communication between the brain and the parts of the body below the injury.

Q: What keeps the vertebrae from rubbing together?
A: Each of the 24 moveable vertebrae in your spine are separated and cushioned by an intervertebral disc. The discs, which account for ¼ the length of the spinal cord, serve as shock absorbers and allow movement of the spinal column.

Q: Does the spinal cord have nerves?
A: Thirty-one pairs of spinal nerves branch off the spinal cord. The nerves are numbered according to the vertebrae above which it exits the spinal column.

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