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THE ENCYCLOPEDIA OF
THE BACK AND SPINE
SYSTEMS AND DISORDERS
Mary Harwell Sayler
with
Arya Nick Shamie, M.D.
Director, UCLA Comprehensive Spine Center
VA Wadsworth Medical Center
Assistant Professor of Orthopaedic Surgery and Neurosurgery
UCLA School of Medicine
The Encyclopedia of the Back and Spine Systems and Disorders
Copyright © 2007 by Mary Harwell Sayler
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, recording, or by any information storage or retrieval
systems, without permission in writing from the publisher. For information contact:
Facts On File, Inc.
An imprint of Infobase Publishing
132 West 31st Street
New York NY 10001
Library of Congress Cataloging-in-Publication Data
Sayler, Mary Harwell.
The encyclopedia of the back and spine systems and disorders /
Mary Harwell Sayler with Arya Nick Shamie.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-8160-6678-0 (hc : alk. paper) 1. Back—Diseases—Encyclopedias.
2. Spine—Diseases—Encyclopedias. I. Shamie, Arya Nick. I I. Title.
II I. Title: Back and spine systems and disorders.
RD768.S6277 2007
617.5′64 —dc22 2006035678
Facts On File books are available at special discounts when purchased in bulk quantities for businesses,
associations, institutions, or sales promotions. Please call our Special Sales Department in New York at
(212) 967-8800 or (800) 322-8755.
You can fi nd Facts On File on the World Wide Web at http://www.factsonfi le.com
Text and cover design by Cathy Rincon
Printed in the United States of America
VB Hermitage 10 9 8 7 6 5 4 3 2 1
This book is printed on acid-free paper.
Dedicated to Backbone
for Bob
The spine defines us:
fish, amphibian,
reptile, bird,
or mammal
crawling,
crouching,
reaching
toward upright.
Uptight or loosely
woven, we struggle
to correct each
complication
of age or accident
we’ve fallen
heir to
in this relentless art
of balancing our act.
Foreword v
Preface viii
Acknowledgments xi
Introduction xii
Entries A–Z 1
Appendix I: National and International Organizations
for the Back and Spine 321
Appendix II: Related Organizations 323
Appendix III: Other Relevant Web Sites 327
Appendix IV: Internet Journals and Magazines 328
Bibliography 329
Index 331
About the Authors 354
CONTENTS
v
B
ack pain and neck pain are very common dis-
orders that affect 90 percent of the adult popu-
lation sometime in their life span. The good news
is that only 10 percent of these disorders require
any treatment, and most will get better spontane-
ously within weeks after the onset of symptoms.
Of the patients who need treatment, only 10 per-
cent will require surgical treatment (1 percent of
all patients). Most will be treated with medica-
tions, physical therapy, and/or injections.
Despite the generally good outcome after the
onset of back and neck pain, the disorder can
be quite debilitating. When severe pain occurs,
patients desperately seek any treatment that may
help, but many of the advertised treatments lack
any sound evidence that they work. The patient
takes herbal medications, gets a massage to relieve
“knots of muscles,” or uses traction that promises
to get rid of pain. The interesting fact is that, in
most cases, if pat ients just wa ited four to six weeks,
the pain would disappear on its own! Unproven
treatments also take money out of a patient’s
pocket because insurance companies do not cover
the costs. Some treatments can even be harmful
to patients or worsen their symptoms. The bottom
line is, use common sense or ask a professional to
help you decide which treatments to invest in.
The most common initial treatments offered to
patients are bed rest for a maximum of one to two
days, anti-inflammatory medications or injections
including steroids, some form of exercise or physi-
cal therapy, and/or pain medication including nar-
cotics like codeine. Bed rest for more than one to
two days is not advised, because it can cause atro-
phy of the muscles and other problems associated
with immobility.
Typically, pain in the spine is caused by inflam-
mation that stimulates pain receptors in the area.
Therefore, medic ations that bloc k infl ammation w ill
also help pain. For instance, the class of medication
called NSAIDs, or nonsteroidal anti-inflammatory
drugs, are generally safe and not habit-forming but
should be taken wit h food to minimize r isks of gas-
trointestinal upset. In some cases, especially with
larger doses and prolonged use, these medications
can cause a peptic ulcer. The first sign of this condi-
tion is pain in the stomach area that may or may
not be relieved by ingesting food. If these symp-
toms develop, you should immediately stop the
medication and consult your physician.
Steroids (a form of hormone) can also be pre-
scribed to cut down inflammation. Steroids are
generally more effective than NSAIDs in treat-
ing inflammation but have more side effects. The
steroids can be given either by mouth (with more
systemic effects) or via direct injection of a small
amount at the site of the inflammation or injury.
Physical therapy offers another treatment pre-
scribed during the acute phase of the disease. This
therapy may include exercise, ultrasound heating
of sore muscles, and/or massage treatments to ease
muscles “knotted” by contraction. There is contro-
versy over whether this treatment modality actu-
ally works, probably because of non-standardized
treatments or variations in the success rate. Physi-
cal therapy theoretically helps patients by stretch-
ing then strengthening muscles around the spine,
which ultimately takes the pressure off the spinal
FOREWORD
joints. Not to be regarded as a quick fix, physical
therapy should be continued in a regimented fash-
ion even after the pain has subsided to prevent a
recurrence of symptoms.
If none of the above treatments helps to allevi-
ate symptoms, then surgical intervention is consid-
ered. A subgroup of patients do need some form of
treatment, but before talking about that, a review
of spine anatomy will help to explain the three
main categories of spine disease: degenerative disc
disease (DDD), stenosis, and instability.
The spinal column consists of bony vertebrae
stacked on top of each other from the neck to the
tail bone. Between each of these vertebrae there is
a cushion known as the intervertebral “disc.” These
discs have a jelly core, much like a jelly doughnut,
and the jelly withstands much of the force that is
transmitted through the vertebrae. The jelly dries up
as we age, and this leads to normal aging or degen-
eration in the spine, a process known as DDD.
As this cushion dries up and the vertebrae settle
on top of one another, pain ensues. This is much
like the degeneration of the hips and knees that
we have been treating for years with hip and knee
replacement. The treatment of the degeneration
in the spine, however, is more complex. First of
all, the spine has many discs that can degenerate
together, and the challenge comes in treating the
correct level that is the source of the pain. Secondly,
we did not have a good way to replace degenera-
tive discs safely until recently. Fusion has been the
mainstay of treatment for degenerative discs. The
logic behind this treatment is that, if the degen-
erated cushion causes pain in adjacent vertebrae,
fusing the two vertebrae together should get rid of
the patient’s pain. The fusion treatment has been
only partially successful though, because after two
vertebrae are fused together, the stresses are trans-
ferred to the levels above and below this fused level,
and this may result in more rapid degeneration of
those adjacent levels. In rare cases, the degenera-
tion or other disease processes can cause instabil-
ity of the spine. When this occurs, one vertebra
slides on top of another, putting the nerves passing
through them at risk. In the case of instability, we
have no choice but to fuse the vertebrae.
Disc replacement is a new alternative to fusion
for DDD. A disc replacement device is implanted in
the disc space that is degenerated. Since the device
has a built-in mechanical joint, it theoretically pre-
serves the motion in the disc space. This prevents
the extra stress that may occur in adjacent discs so
may prevent adjacent level disease. However, disc
replacement devices require a stable spine, so spi-
nal instability precludes their use. Currently, disc
replacement is approved only for the lumbar spine,
but cervical spine disc replacement is under clini-
cal trials and will soon be available.
Since the discs in the spine are in front of the
nerves, disc replacement does not adequately
address stenosis or narrowing around the nerves,
especially if stenosis is caused by structures in the
back of the spine. Stenosis causes pressure on the
nerves and, hence, can result in nerve pain (radic-
ulopathy or sciatica.) DDD often causes stenosis
in its late form. As the discs degenerate, the joints
in the back of the spine called the facet joints see
more stress and enlarge or hypertrophy. Nerves
exit through holes (foramina) in front of the facet
joints at every level of the spinal column. Enlarged
facets can cause stenosis in these holes and, hence,
cause nerve pain. When facet disease is promi-
nent, just addressing the disc in the front with a
disc replacement will not treat the symptoms.
Therefore, stenosis is typically addressed from the
back of the spine to free up nerves in the foram ina.
The exception to this rule is in the cervical spine
(neck) where most of the early stenosis occurs
from a disc herniation or bone spurs in front of
the spine. If a facet is much enlarged and part of
it has to be removed to decompress the nerves, the
patient’s spine also has to be fused. The two facets
act as the posterior (back) stabilizers of the spine,
while the disc is the anterior (front) stabilizer. This
configuration is present in most levels of the spinal
column.
Traditionally, stenosis is treated with a lami-
nectomy (and partial facet removal). Lamina form
the posterior arch of the spine, which is removed
in order to decompress the nerves in the center of
the spinal column. Through this posterior opening
the foramina are also accessed and decompressed
using special tools. Laminectomy is a safe proce-
dure and can significantly improve a debilitating
condition. Laminectomy is not, however, without
its potential limitations and complications.
vi The Encyclopedia of the Back and Spine Systems and Disorders
A new alternative to a laminectomy is a proce-
dure performed while the patient is awake. This
procedure does not require bone removal but
accomplishes decompression indirectly by implan-
tation of a device called the X Stop. When the ste-
notic patient bends forward, the foramina in the
back of the spine enlarge and free the nerve from
pressure. X Stop is implanted in the back of the
spine between the spinous processes at the level
where the problem exists, thus functionally open-
ing the foramina.
The field of spine surgery is evolving rapidly.
With the advent of new technology and surgical
techniques, patients are being treated more effec-
tively and safely. This advancement is possible only
through continued efforts of scientists in various
disciplines and their interdisciplinary collabora-
tion. MRI has tremendously advanced the diagno-
sis of spinal disease in the last 20 years. With live
X-ray now available in the operating room, we are
able to perform surgeries through small skin inci-
sions. This translates to more accurate surgeries
and quicker recovery for patients.
With the rapid advancement in technology, it is
imperative that physicians and patients alike are
educated in the best treatment (not necessarily
always the newest) modality for their condition. This
textbook is an attempt to help readers understand
the often complex spinal conditions. Understanding
the nomenclature will possibly aid in understand-
ing the processes and treatments available for the
common condition of spine-related pain.
—Arya Nick Shamie, M.D.
Director, UCLA Comprehensive Spine Center
VA Wadsworth Medical Center
Assistant Professor of Orthopaedic Surgery
and Neurosurgery
UCLA School of Medicine
www.espinecare.com
Foreword vii
PREFACE
A
lmost anywhere you go, you will find a
country overly populated with aching backs.
Undoubtedly, this sad fact helped the Bone and
Joint Decade (2000–10) become an international
event. Yet, despite the global momentum toward
universal back pain, books on the subject often
focus on such specialized treatments as trigger
point therapy or microsurgery. Or the spine of a
book might cover the aging spine.
Although my own back heatedly objects to the
inflammation typically associated with aging, I
wanted a book to consider a wide range of spine-
related topics, including ample options for treating
various levels of pain. I also wanted a broader view
of the back to help me and, I hope, you to avoid pre-
ventable problems, make informed decisions about
our vertebral health, and remain upright inhabit-
ants of our own bodies.
What, for example, should be considered before
you flex muscles that have begun to conform to
an ergonomic chair? Would certain exercises
strengthen your spine without weakening a disc?
Could information about the anatomy and func-
tion of your neck and back help to show you what
has happened and, thereby, clarify what to do?
Do all natural treatments naturally assure
safe usage? Are herbal remedies strong enough
to assuage your night-time pain? Will anything
restore collagen, rebuild bone, or keep your carti-
lage from wearing out? What medical tests might
provide you with a clearer picture? And how much
should you heed ongoing word fights over food?
With conflicting advice to confuse this very per-
sonal issue, do you need more calcium or less?
Remembering the adage, “You are what you eat,”
I like to think there is more to me than mozzarella,
but a one-ounce slice of my favorite part-skim
brand gives 20 percent of the daily requirement
of calcium needed by most adults. The question is
whether I need that much or more. Do you, even
if the calcium comes with 8 percent fat and 5 per-
cent cholesterol squeezing through the creamery?
Would 6 percent calcium in two tablespoons of fat-
free, cholesterol-free sour cream be a better choice
for you, or would 0 percent fat and 2 percent cho-
lesterol warrant a cup of fat-free yogurt with 40
percent of your daily calcium need?
Such mathematical questions might be directed
to a cardiologist or other specialist who assesses
your level of cholesterol and its effects on your
heart and veins. To evaluate your overall food pat-
terns, however, a nutritionist can address your
individual tastes, habits, weight, activities, family
history, symptoms, and unique nutritional needs
before planning the best course of meals and snacks
for you. As a registered dietitian, a nutritionist
can also separate the fat everyone needs from the
amount you personally require to store fat-soluble
vitamins, lubricate joints, and transport hormones
throughout your body. Too much fat, of course, is
literally overkill, but, in moderation, a fatty layer
of protection can shield and cushion your bones in
wintry weather—or in a fall.
To help you keep your balance, a healthful diet
includes energizing carbohydrates and muscle-
building protein. As a general rule, well-balanced
meals tip the scales toward fresh fruit, vegetables,
and whole grains with dairy and meat products
viii
dished lightly on the side. Since the optimum
amounts of proteins, carbohydrates, and fats fluc-
tuate from person to person, a nutritionist can
determine the percentages appropriate for you. If
any changes occur in your health or habits though,
your nutritional needs will change too.
As yet another variable, the level of stress you
experience today will seldom be the same a week
or a month from now. If tension builds, so will
muscle tightness, thereby restricting blood flow
and causing muscle cramps. Back pain may then
arise with a new slew of questions. For example,
would a good massage help your muscles to relax
and, if so, what type would be best for you? Do you
need kneading? Or would pressing pressure points
release those bundles of nerves? A licensed mas-
sage therapist can explain the styles and purpose
of each stroke, but if you’re worried about having a
stroke, ask your doctor about the elevation in blood
pressure a massage conceivably could cause.
Questions about the minimal risks of a stroke
might also go to your osteopath or chiropractor,
e s p e c i a l l y i f y o u r c e r v i c a l s p i n e n e e d s t o b e r e a l i g n e d .
Both specialists have been trained to manipulate
neck and back vertebrae to treat musculoskeletal
complaints. However, differences between these
medical professionals occur not only in their train-
ing but also in the theory behind each approach to
treatment. A chiropractor, for example, may focus
on the nerves involved in adjusting your tendons
and joints. After taking your medical history and,
possibly, X-rays, a chiropractor might treat your
neck or backache with spinal manipulation, mas-
sage, ultrasound, acupressure, trigger point therapy,
or a combination of those options. An instrument
such as an Activator might also be used, but more
likely, you will be given hands-on treatment. If poor
postural habits, stress, or injury have caused your
spine to lose its natural curves, your vertebrae may
need a well-planned series of adjustments to get
back in shape.
A doctor of osteopathy (D.O., or osteopath)
performs similar treatments but with the under-
standing that proper alignment of the spine allows
a body to function better. Because your spinal
column houses the nervous system that controls
your bodily functions, the condition and position
of your vertebrae can affect your entire body. This
viewpoint may lead an osteopath to educate you
about self-care and disease prevention.
A D.O. might also choose a medical specialty
similar to the ones pursued by a medical doctor
(M.D.). Although a D.O. and an M.D. both adhere
to the Hippocratic oath, “First, do no harm,” they
may have slightly different interpretations of what
this rule means. For example, a D.O. may see your
symptoms as an indication of some disorder in
your defense system, which, when set right, could
evoke a natural response of healing. Despite a
belief in the healing mechanisms inherent in the
body, a D.O. can still prescribe medication as, of
course, an M.D. can. Prior to writing prescriptions
or practicing medicine though, both types of phy-
sicians must pass their state licensing exams. Both
can then opt to continue their studies to obtain
certification in such specialized areas as pediatrics,
or the spinal care of infants, children, and teens.
As another specialist of the musculoskeletal
system, a rheumatologist treats autoimmune dis-
orders and conditions of the spine, such as juvenile
arthritis, ankylosing spondylitis, or rheumatoid
arthritis. Similarly, an orthopedic specialist treats
disorders of muscles, bones, joints, and connec-
tive tissue, such as tendons and ligaments. How-
ever, a rheumatologist generally concentrates on
soft tissue as an underlying indicator of back pain,
whereas an orthopedist often focuses on the hard
matter in matters of bone fracture, injuries, and
abnormalities in bone growth.
To treat spinal cord injuries and spinal nerve
involvement, a D.O. or M.D. may decide to special-
ize in neurology, or, to repair structural problems,
a physician may elect surgery. With numerous
procedures available, surgeons usually avoid any
invasive course of action unless an identifiable
condition shows a particular procedure to be the
best choice. If so, minimally invasive surgery can
often be used to speed recovery, thereby enabling
you to resume your normal activities or begin
therapy more quickly.
The type of therapy depends, of course, on what
you need. For instance, physical therapy usu-
ally addresses larger groups of muscles to get you
mobile again. Occupational therapy aids smaller
Preface ix
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