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Medtronic Sofamor Danek. “Spine Exercise Frequently
Asked Questions,” Back.com. Available online. URL:
http://www.back.com/articles-spine.html. Updated
February 17, 2005.
National Osteoporosis Foundation. “Bone Is Living Tis-
sue That Responds to Exercise by Becoming Stronger,”
Prevention, Exercise for Healthy Bone, NOF. Available
online. URL: http://www.nof.org/prevention/exercise.
htm. Downloaded January 4, 2006.
Quill, Scott. “Muscle News Briefs: Back Relief,” Men’s
Health 20, no. 1 (January/February 2005): 42.
96 exercise
97
facet joint disorder
Also known as facet joint syn-
drome, this disorder involves small joints between
and behind each
VERTEBRA. These joints occur as
vertebral bones connect, with the exception of the
SACRAL VERTEBRAE and the first neck bone in the
CERVICAL SPINE. Working correctly, facet joints sta-
bilize the spinal column while allowing the
SPINE to
twist, turn, and bend backward, forward, or side-
ways in a normal
RANGE OF MOTION.
If the facet joints themselves get bent out of
shape, a multitude of spinal problems may begin.
Under degenerative conditions, for example,
inflamed joints can indicate
OSTEOARTHRITIS or pro-
duce muscle spasm in the
PARASPINAL MUSCLES.
Problems with
POSTURE may also arise, while bone
overgrowth can cause formation of
OSTEOPHYTES. As
those bone spurs form, their growth can produce
SPINAL STENOSIS or other painful BACK conditions
that press the spinal nerves. Conversely, nerves can
be damaged if loosened facet joints allow excessive
movement in the spine.
Symptoms and Diagnostic Path
A
CUTE PAIN emanating from inflamed facet joints
may resemble other conditions, such as a
HERNIATED
DISC, FRACTURE, or SPINAL INFECTION. On the other
hand, an underlying condition, such as
ARTHRITIS,
may seem to be a facet joint disorder. To differen-
tiate, X-
RAY or COMPUTED TOMOGRAPHY SCAN can
reveal abnormalities or changes in a joint. If tests
and a physical examination remain inconclusive, a
SPINAL INJECTION may be needed to locate and treat
the source of pain.
Treatment Options and Outlook
To treat this disorder, Dr. Charles Dean Ray suggested
therapeutic
EXERCISE and posture training. For exam-
ple, “A very useful posture when standing or sitting
is the pelvic tilt—where one pinches together the
buttocks and rotates forward the lower pelvis—and
holding that position for several seconds, done sev-
eral times per day.” Other treatments include
COLD
THERAPY, HEAT THERAPY, SPINAL MANIPULATION, and
NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID)
THERAPY. If PAIN MANAGEMENT does not prove success-
ful with conservative medical treatment or
COMPLE-
MENTARY AND ALTERNATIVE MEDICINE, a BONE GRAFT or
other type of
SURGERY may be needed. As another
option, a
FACET RHIZOTOMY INJECTION may help by
destroying the inflamed nerve, thereby removing
that source of
CHRONIC PAIN.
Risk Factors and Preventive Measures
To clarify risks and preventive measures, an article
posted by Neck and Back Pain Info.com said, “These
small joints are prone to injury, deterioration, and
inflammation. Facet joint syndrome can occur any-
where in the spine including the low back. Pain aris-
ing from the facet joints is usually at the level of the
affected facet joint(s), and is made worse by activities
that put pressure on these joints, i.e. leaning back-
wards and ‘extending’ the lower back or twisting
at the waist.” In addition, “poor body mechanics or
how we use our body can also cause problems with
the facet joints.” Therefore, proper posture, proper
LIFTING, and problem-solving ERGONOMIC FACTORS
may prevent recurrence, so that “most individuals
with facet joint syndrome will recover and return to
normal activities.”
Neck and Back Pain Info.com. “Facet Joint Syndrome,”
Joint Pain Info.com. Available online. URL: http://
jointpaininfo.com/back/backFacetJointSyndrome.
html. Downloaded January 4, 2006.
Ray, Charles Dean, M.D. “Facet Joint Disorders and
Back Pain,” Spine-health.com. Available online. URL:
F
http://www.spine-health.com/topics/cd/facetjoint/
facetjoint01.html. Downloaded January 4, 2006.
facet joint injection See FACET JOINT DISORDER;
SPINAL INJECTION.
facet neurotomy or facet rhizotomy injection
Sometimes used to treat
FACET JOINT DISORDER, this
procedure, in essence, disconnects a hot-wired
nerve. Although a neurotomy seldom provides the
first course of treatment, the procedure may be used
if a
SPINAL INJECTION, COLD THERAPY, PAIN RELIEVERS,
or other forms of
PAIN MANAGEMENT fail to help.
Procedure
After anesthesia has taken effect in the patient, a
medical specialist uses the guidance of a fluoroscope
to apply heat from a needlelike probe. As a SpineUni-
verse article explained, “Once the needle is injected,
a mild electrical current is used to stimulate the nerve
and confirm its exact location. You may feel slight
pressure or tingling during this part of the procedure.
Then the electrode is heated to deaden the sensory
nerves. When the procedure is completed, the needle
is removed and the injection site is bandaged.”
A Spine-health article said, “Theoretically, by
deadening the sensory nerve to the facet joint, a
facet rhizotomy effectively prevents the pain sig-
nals from getting to the brain.” Since more than
one facet may be addressed, the time needed for
this outpatient procedure varies from ten minutes
to an hour or so.
Risks and Complications
Any soreness resulting from the injection can usu-
ally be eased with an ice pack applied for about 15
minutes every hour or two. Regarding the facet
pain for which the treatment was intended, about
50 to 60 percent of the patients experience pain
relief within a few days. This means, however, that
a neurotomy provides little or no pain relief about
40 percent of the time. Besides the risk of failure,
an injection can destabilize a facet joint, although
that complication seldom occurs. A more likely risk
arises as growing nerve fibers later replicate the
original problem.
Outlook and Lifestyle Modifi cations
If the procedure offers little or no relief, patients
may need to consider such other options as
BIO-
FEEDBACK to manage pain. With a successful out-
come, the injection can give patients pain-free time
in which to begin therapeutic
EXERCISE, increase
their daily
ACTIVITY, or tackle STRENGTH TRAINING.
Richeimer, Steven, M.D., and Mary Claire Walsh. “Facet
Rhizotomy: Procedure Preparation and Aftercare,”
SpineUniverse. Available online. URL: http://www.
spineuniverse.com/displayarticle.php/article221.
html. Last updated November 21, 2005.
Spine-health.com. “Injections: Facet Rhizotomy Injec-
tion.” Available online. URL: http://www.spine-health.
com/topics/conserv/overview/inj/inj04.html. Down-
loaded January 4, 2006.
failed back surgery syndrome (FBSS) Not really a
syndrome, but the result of failed
SURGERY, this con-
dition may cause disability as a person encounters
CHRONIC PAIN. In the overview, “Failed Back Surgery
Syndrome: What It Is and How to Avoid It,” Dr. Peter
Ullrich Jr. explained, “Spine surgery is only basically
able to accomplish two things: 1) Decompressing a
nerve root that is pinched, or 2) Stabilizing a pain-
ful joint.” In some cases, the area thought to be the
source of pain is not, but “some types of back sur-
gery are far more predictable in terms of alleviating
a patient’s symptoms than others.” For example, “a
spine fusion for spinal instability (e.g. spondylolisthe-
sis) is a relatively predictable operation. However, a
spine fusion for multi-level lumbar degenerative disc
disease is far less likely to be successful in reducing a
patient’s pain.”
The site of the
BACK problem can be a factor too.
According to Dr. Ullrich, “A discectomy (or microdis-
cectomy) for a lumbar disc herniation that is causing
leg pain is a very predictable operation. However, a
discectomy for a lumbar disc herniation that is caus-
ing lower back pain is far less likely to be success-
ful.” Even if the surgery goes well, pain may return
as scar tissue forms. For example, “the one time that
scar tissue . . . may be symptomatic is for a patient
who initially does well . . . only to have recurrent
pain come on slowly between 6 to 12 weeks after
surgery. This is the time period that scar tissue takes
98 facet joint injection
to form.” Conversely, “pain that starts years after
surgery, or pain that continues after surgery and is
never relieved, is not from scar tissue.”
Symptoms and Diagnostic Path
An article posted by Back.com said, “Symptoms may
include diffuse, dull, and achy pain located primar-
ily in the back and/or legs” or “sharp, pricking, and
stabbing pain that radiates from the legs.” In either
case, “A joint may become irritated because surgery
altered the person’s posture and way of moving.”
Symptoms may also include depression and lack of
SLEEP.
To rule out such painful possibilities as a
HER-
NIATED DISC, a diagnostic X-RAY or MAGNETIC RES-
ONANCE IMAGING may be needed. In addition, an
ELECTROMYOGRAM can assess potential damage
involving the spinal nerves.
Treatment Options and Outlook
Options include
ACUPUNCTURE, EXERCISE, NEURO-
STIMULATION, SPINAL MANIPULATION, and, in some
instances, additional surgery. For example, if a
BONE GRAFT has failed to complete spinal fusion,
ARTHRODESIS may help. For some patients, a SPINAL
INJECTION or FACET NEUROTOMY may relieve pain, at
least temporarily.
Risk Factors and Preventive Measures
Sometimes failed back surgery occurs because the
patient resumes daily
ACTIVITY too soon, disrupting
the spinal fusion meant to take place over the natu-
ral course of recovery. At other times, inadequate
NUTRITION and lack of EXERCISE cause further weak-
ening in the
BACK or VERTEBRAE. For instance, a per-
son may not get enough dietary
CALCIUM to aid BONE
BUILDING. Or a patient may not be able to perform
stretching exercises that keep scar tissue to a man-
ageable minimum. During the first few weeks after
surgery, stretching and
LIFTING should be avoided as
should other stresses on the surgical site.
Medtronic Sofamor Danek. “Mechanical Disorders: Failed
Back Syndrome (FBS),” Back.com. Available online.
URL: http://www.back.com/causes-mechanical-failed.
html. Last updated March 11, 2005.
Ullrich, Peter F., Jr., M.D. “Failed Back Surgery Syn-
drome: What It Is and How to Avoid It,” Spine-health.
com. Available online. URL: http://www.spine-health.
com/topics/surg/failed_back/failed_back01.html. Last
updated June 1, 2004.
female athlete triad The coining of this phrase
in 1992 publicized a syndrome among female
ATH-
LETES that involves three main symptoms, but more
may exist. Primarily, symptoms include loss of bone
density, loss of menses (amenorrhea), and loss of
weight with the latter sometimes caused by an
EAT-
ING DISORDER, such as anorexia nervosa or bulimia
nervosa. Typically, loss of energy also occurs.
Symptoms and Diagnostic Path
As explained in The Lancet, “Energy restriction is
common in sports, and for many athletes it is nec-
essary to achieve the sport-specific bodyweight and
composition that result in optimum performance.
Because of the importance of fat loss, female ath-
letes in many sports consume 30% less energy per
unit of bodyweight than male athletes. The preva-
lence of disordered eating, involving dietary restric-
tion and purgative behaviours such as vomiting
and misuse of laxatives, ranges from 1% to 62%
dependent on the sport, and is highest in sports
in which low bodyweight conveys a competi-
tive advantage.” However, this short-term advan-
tage pales beside such disadvantages as hormonal
changes that disrupt the menstrual cycle and bone
formation, which “can lead to irreversible bone loss
in adults and can impair the accretion of bone mass
in adolescents.”
To confirm a diagnosis, a medical history, physi-
cal examination, evaluation of symptoms, and
BONE MINERAL DENSITY TEST will usually be needed.
In addition, a blood test to determine any mineral
imbalance may help to diagnose the syndrome and
individualize the course of treatment.
Treatment Options and Outlook
According to an online article first published in
the American Family Physician, “Preservation of
bone mineral density is one of the many reasons
to screen female athletes and diagnose the female
athlete triad early in its course. Postmenopausal
women lose most of their bone mass and density
in the first four to six years after menopause. If this
female athlete triad 99
is also true of amenorrheic athletes, intervention
is needed before bone mass is irreversibly lost.” To
re-establish the menstrual cycle,
HORMONE REPLACE-
MENT THERAPY may be prescribed. “While hormonal
therapy will treat the amenorrhea, the ultimate
goal is the return of regular menses through proper
nutrition, revised training regimens and mainte-
nance of reasonable body weight.” To do this, the
article further suggested, “Optimal treatment of
the female athlete triad includes instruction from
a dietician to educate and monitor the patient for
adequate nutrition and to help the patient attain
and maintain a goal weight. The patient, dietician
and physician should agree on a goal weight, with
consideration for the weight requirements for par-
ticipation in the patient’s chosen sport. A weight
gain of 0.23 to 0.45 kg (0.5 to 1 lb) per week until
the goal weight is achieved is a reasonable expecta-
tion. Helping the patient focus on optimal health
and performance instead of weight is important.
The patient need not stop exercising completely.
Exercise activity should be decreased by 10 to 20
percent, and weight should be monitored closely
for two to three months.”
Risk Factors and Preventive Measures
An article in the Journal of Strength and Condition-
ing Research reported that female gymnasts have a
lower risk of bone loss than do cross-country run-
ners. Therefore, the latter group might “include
more high-impact activities in their training regi-
men to optimize their bone health.”
B
ONE BUILDING efforts, such as increased CALCIUM
intake, can lower the risk of
OSTEOPOROSIS and VER-
TEBRAL COMPRESSION FRACTURE. Also, a BISPHOSPHO-
NATE drug may help, but studies have not adequately
focused on its effects in treating female athlete triad.
For most patients, psychological counseling, hydra-
tion, and a sensible course of
NUTRITION will prevent
life-threatening damage and restore the athlete to
health. To encourage her success in reaching that
goal, her coach, family members, and friends must
quickly become her biggest fans.
Bemben, Debra A., Torey D. Buchanan, Michael G. Bem-
ben, and Allen W. Knehans. “Influence of Type of
Mechanical Loading, Menstrual Status, and Training
Season on Bone Density in Young Women Athletes,”
Journal of Strength and Conditioning Research 18, no. 2
(May 2004): 220–226.
Hobart, Julie A., M.D. and Douglas R. Smucker, M.D. “The
Female Athlete Triad,” American Family Physician 61,
no. 11 (June 1, 2000): Available online. URL: http://
www.aafp.org/afp/20000601/3357.html. Downloaded
January 4, 2006.
Loucks, Anne B. and Aurelia Nattiv. “The Female Athlete
Triad,” The Lancet 366, no. 9503 (December 17, 2005):
49–50.
fenoprofen See NONSTEROIDAL ANTI-INFLAMMATORY
DRUG THERAPY.
fibromyalgia Once unkindly proclaimed as being
all in the head, this complex syndrome exhibits ten-
der points almost everywhere but the skull. Char-
acteristically, the dull but widespread pain occurs in
fibrous tissue of muscles, ligaments, and tendons.
Unlike
ARTHRITIS and other rheumatic or degen-
erative conditions, however, fibromyalgia does
not inflame or damage vertebral joints and bone.
Therefore, by ruling out the conditions that cause
those symptoms, a rheumatologist or primary care
physician may come to a diagnostic conclusion.
Symptoms and Diagnostic Path
Since no evidence of this chronic disorder will be
found in blood work, X-
RAYS, or any other tests, the
doctor relies on a medical history and symptoms,
which include fatigue, depression, difficulty focus-
ing, and sensitivity to noise or climatic change.
Stomach upset often occurs too. Interestingly, each
of these symptoms commonly relates to a chronic
lack of
SLEEP, which fibromyalgia patients typically
encounter.
The most telling symptoms occur in pain located
at tender points in precise locations. According to
the National Fibromyalgia Association (NFA), diag-
nostic criteria include “tenderness or pain in at least
11 of the 18 specified tender points when pressure
is applied.” From the front, these points appear on
either side of the throat, at a midpoint below each
collarbone, on the inner fold of each elbow, and
the inside edge of each knee. From the back, ten-
der points reside on either side of the
VERTEBRAE
100 fenoprofen
at the base of the skull, along the top edge of each
shoulder, around the dimpled area on each cheek
of the hip, and on each outer thigh just below the
buttock. The NFA also specified another diagnostic
determinant as “widespread pain in all four quad-
rants of the body for a minimum duration of three
months.”
Treatment Options and Outlook
P
AIN RELIEVERS, MASSAGE THERAPY, SPINAL MANIPULA-
TION, ACUPRESSURE, and other forms of COMPLEMEN-
TARY AND ALTERNATIVE MEDICINE offer some measure
of relief. For example,
HERBAL THERAPY might
include ginkgo biloba capsules to stimulate circula-
tion in the morning and a cup of passionflower tea
to relax muscles at night. Besides taste and visual
appeal, culinary herbs sometimes have medicinal
value too. For instance, a dash of cayenne pepper
or a crushed clove of garlic can boost the immune
system while enhancing the flavor of tomato sauce.
A little turmeric rubbed into fish or ginger sprinkled
onto carrots and chicken may provide a pain-killer
of a gourmet meal.
The National Pain Foundation (NPF) suggested
a variety of treatment options, which, with the
approval of a doctor, includes gradually working up
to a half hour of aerobic
EXERCISE four or five times
a week. According to the NPF, “Flexibility is the
other form of exercise that is necessary to reduce
the symptoms of pain for people with fibromyal-
gia. . . . The old statement, ‘if you don’t use it, you
lose it,’ is true when it comes to muscles, tendons,
and ligaments. They stiffen up and tight muscles are
uncomfortable muscles. You can actually decrease
pain by increasing flexibility. Stretches should be
done daily, but remember to go about all of these
exercises slowly, gently, and yet progressively.”
Besides strengthening the body, exercise improves
mental outlook too.
Risk Factors and Preventive Measures
Preventing a condition usually depends on address-
ing the causal factors, but an article on the Web site
of the American College of Rheumatology said, “No
one knows what causes fibromyalgia. However, we
do know that people with fibromyalgia may have
abnormal levels of Substance P, a chemical that
helps transmit and amplify pain signals to and from
the brain. For the person with fibromyalgia, it is as
though the ‘volume control’ is turned up too high
in the brain’s pain processing areas. Current studies
are underway to examine how the brain and spinal
cord (the central nervous system) process pain and
the role Substance P plays.”
G
ENETIC FACTORS and ENVIRONMENTAL INFLUENCES
also warrant study. Meanwhile, young to middle-
aged women have seven times the risk men have
of developing fibromyalgia.
Clauw, Daniel J., M.D. and Denise Taylor-Moon. “Fibro-
myalgia,” American College of Rheumatology, ACR.
Available online. URL: http://www.rheumatology.
org/public/factsheets/fibromya_new.asp. Downloaded
January 5, 2006.
Holistic online.com. “Treatment of Fibromyalgia.” Avail-
able online. URL: http://holistic-online.com/Remedies/
cfs/fib_herbal.htm. Downloaded January 4, 2006.
National Fibromyalgia Association. “About Fibromyal-
gia,” NFA. Available online. URL: http://fmaware.org/
fminfo/brochure.htm. Downloaded January 4, 2006.
National Pain Foundation, The. “Fibromyalgia Treatment
Options,” My Pain. Available online. URL: http://
www.nationalpainfoundation.org/MyTreatment/
TreatmentOptionsContinuum_Fibromyalgia.asp. Last
updated August 19, 2005.
fibrous dysplasia This skeletal disorder causes
abnormal growth in one bone or many, with the
ribs a more likely location than the
VERTEBRAE. Brit-
tleness and deformity can occur at a single site, at
random sites, or on one side of the body, including
the face.
Symptoms and Diagnostic Path
A fact sheet from the National Institutes of Health
(NIH) listed bone pain, bone deformity, and
FRAC-
TURE as common symptoms of this uncommon
disorder. Characteristically, “bone pain may occur
due to the expanding fibrous tissue in the bone.
The onset of pain may signal an impending frac-
ture in a bone that has been weakened by this
gradual expansion. A fracture may cause a sudden
increase in severe pain. It is also possible, although
less common, for abnormal bone to produce pain
by pressing on an adjacent nerve. In patients with
fibrous dysplasia 101
considerable deformity of the weight-bearing long
bones (thighs and shins), arthritis can develop in
the hips and knees.” Besides
ARTHRITIS, some indi-
viduals develop hormonal problems, such as early
puberty or high blood calcium from
PARATHYROID
HORMONE (PTH). Although rare, patients may also
encounter the skeletal deformities of
RICKETS. In
any case, X-
RAYS confirm the diagnosis.
Treatment Options and Outlook
Regarding treatments, the NIH recommended vari-
ous specialists, such as “orthopedic surgeons, since
most symptomatic patients have bone pain and/or
skeletal deformity; Craniofacial or plastic surgeons
who are needed for correction of facial deformities;
Neurosurgeons who are needed for treatment of
brain or spinal complications; and Endocrinologists
who are best for treating patients who develop hor-
monal problems.”
For most patients, appropriate
EXERCISE assists
skeletal health and joint mobility. An improved
outlook also comes through ongoing
RESEARCH of
GENETIC FACTORS. As the NIH reported, “Recent stud-
ies indicate that fibrous dysplasia may be caused by
a chemical abnormality in a protein in the bone that
leads to an overgrowth of bone cells that produce
fibrous tissue. The chemical abnormality occurs
because of a mutation or change in the structure of
the gene that produces the protein. Fibrous dyspla-
sia is thought to be a congenital disorder, meaning
that individuals who have it probably had it when
they were born. There is no evidence, however,
that the disorder can be inherited.”
Risk Factors and Preventive Measures
For a potential preventive of bone malformation
and pain, the American Academy of Orthopaedic
Surgeons (AAOS) said, “Bisphosphonates are med-
ications that decrease the activity of cells that dis-
solve bone. . . . These medications have not been
used extensively in the treatment of fibrous dyspla-
sia, but early studies have demonstrated effective
relief of the pain associated with fibrous dysplasia.”
With or without
BISPHOSPHONATES, some patients
may need
SURGERY to prevent spinal deformity. If
so, the AAOS said, “stabilization of the bone with
metal implants such as rods or plates and screws
can be useful to fix a fracture or deformity, or pre-
vent bone breakage.” Also, “braces may occasion-
ally be used to prevent fracture, but they have not
been effective in preventing deformity.”
In assessing the risks of this chronic disorder, the
NIH reported, “Young patients who have fibrous
dysplasia in many bones may have more problems.”
However, “patients with one or only a few lesions
may have mild or no symptoms. Related hormonal
abnormalities are usually successfully treated once
a problem is recognized.”
American Academy of Orthopaedic Surgeons. “Fibrous Dys-
plasia,” AAOS. Available online. URL: http://orthoinfo.
aaos.org/fact/thr_report.cfm?Thread_ID=485&topcate
gory=Tumors. Downloaded January 4, 2006.
National Institutes of Health Osteoporosis and Related Bone
Diseases, The. “Information for Patients about Fibrous
Dysplasia,” NIH, National Resource Center. Avail-
able online. URL: http://www.osteo.org/newfile.asp?
doc=p111i&doctitle=Fibrous+Dysplasia&doctype=
HTML+Fact+Sheet. Downloaded January 5, 2006.
flat back or flatback Normally, the BACK has a
forward curve (
KYPHOSIS) and a backward curve
(
LORDOSIS.) These natural curves enable the SPINE
to maintain
POSTURE, flexibility, and balance in
standing, walking, or carrying a load. With a flat
back, however, the
VERTEBRAE form a straight line,
causing a forward-motion look even if the person
is standing still. Since that rigid posture throws the
body off balance, a cane or walker may be needed
to retain mobility.
Sometimes, flat back results from a
BIRTH DEFECT
OF THE SPINE, but the problem can occur later. For
instance, the doctor who performs a spinal fusion
must take the natural curve of the back into
account, or flat configuration will occur.
Symptoms and Diagnostic Path
The appearance of rigidity and presence of
CHRONIC
PAIN make this disorder readily apparent. Neverthe-
less, a diagnosis will likely include X-
RAYS, a physi-
cal examination, and a medical history.
Treatment Options and Outlook
Prompt treatment of
SCOLIOSIS or other contrib-
uting factors, such as a
VERTEBRAL COMPRESSION
102 flat back or flatback
FRACTURE and DEGENERATIVE DISC DISEASE, can pre-
vent flat back from occurring. Mild cases may be
helped with
SPINAL MANIPULATION and more severe
ones with a
BONE GRAFT, osteotomy, or other type
of
SURGERY. However, ORTHOTIC devices may not
provide an optimal form of treatment. In an article
for eSpine.com, Dr. Robert S. Pashman explained,
“Since symptoms are produced through abnormal
mechanics of the spine, pelvis and upper legs, a
brace intended to support a decompensated spine
would have to cross each of these structures. Such
braces are not usually effective. Similarly, trunk
braces, which also capture the leg are not well
tolerated by most individuals. In general, bracing
is not an option for symptomatic flat back. When
conservative methods fail and the patient is symp-
tomatic to the point of being dysfunctional due to
the pain, surgery is indicated.”
Risk Factors and Preventive Measures
According to iScoliosis.com, “Patients can develop
a painful flat back deformity as the result of degen-
erative arthritis of the spine, or as a consequence
of a previous spinal fusion operation. . . . Today,
surgeons are often able to correct scoliosis while
still preserving as much of the normal alignment
of the spine as possible. This is largely the result
of advances in the techniques and types of instru-
ments that are used to correct scoliosis.”
Medtronic Sofamor Danek. “Flat Back Syn drome,”
iScoliosis.com. Available online. URL: http://www.
iscoliosis.com/symptoms-flat.html. Downloaded Jan-
uary 5, 2006.
Pashman, Robert S., M.D. “Back to Basics: Flatback,”
eSpine.com. Available online. URL: http://www.espine.
com/flatback.html. Downloaded January 5, 2006.
flexion-extension injury A flexion-extension
injury can occur in any joint as a person exceeds
his or her grasp. For instance, a tennis player might
overextend a racquet to score a tennis elbow, or a
surfer might catch a wave of hip pain. In the
BACK,
VERTEBRAE, and CERVICAL SPINE, however, a flexion-
extension injury most often results from what is
commonly known as a whiplash.
Symptoms and Diagnostic Path
Similar to a
STRAIN or SPRAIN, a flexion-extension
injury usually occurs after a precipitous event, such
as a sports accident or car crash. Although the latter
may involve other areas of the
SPINE, an information
page from the National Institute of Neurological Dis-
orders and Stroke (NINDS) addressed the neck, say-
ing, “Symptoms such as neck pain may be present
directly after the injury or may be delayed for sev-
eral days. In addition to neck pain, other symptoms
may include neck stiffness, injuries to the muscles
and ligaments (myofascial injuries), headache, diz-
ziness, abnormal sensations such as burning or
prickling (paresthesias), or shoulder or back pain.
In addition, some people experience . . . conditions
such as memory loss, concentration impairment,
nervousness/irritability, sleep disturbances, fatigue,
or depression.” If a flexion-extension injury involves
the cervical spine,
CERVICOGENIC HEADACHES may be
present too.
Treatment Options and Outlook
A
MUSCLE RELAXANT, NONSTEROIDAL ANTI-INFLAM-
MATORY DRUG THERAPY, SPINAL MANIPULATION, and
ORTHOTIC device, such as a cervical collar or brace,
usually begin the conservative treatment. Initially,
COLD THERAPY may be needed to reduce inflam-
mation, but after swelling subsides,
HEAT THERAPY
can relieve the muscle
TENSION. According to the
NINDS, “Most patients recover within 3 months
after the injury, however, some may continue to
have residual neck pain and headaches.” Some-
times this lasts up to two years.
If
CHRONIC PAIN extends beyond a normal recov-
ery time, X-
RAYS or MAGNETIC RESONANCE IMAGING
may reveal
FACET JOINT DISORDER, a HERNIATED DISC,
or
SACROILIAC JOINT PAIN SYNDROME, each of which
involves various treatments. In any case, the best
outlook comes by identifying and treating dam-
age to a joint, bone, muscle, or soft tissue. To ease
inflammation in spinal nerves or locate a damaged
nerve, a
SPINAL INJECTION may help. If, however, an
injured
DISC or vertebra causes spinal nerve pres-
sure,
SURGERY may be needed.
The North American Spine Society (NASS)
offered this insight into chronic pain after a flexion-
extension injury: “Muscle strain of the neck and
upper back can cause acute pain. However, there is
flexion-extension injury 103
no evidence that neck muscles are a primary cause
of chronic neck pain, although muscles can hurt if
they are working too hard to protect injured discs,
joints, or the nerves of the neck or there is some-
thing else wrong that sustains the muscle pain, such
as poor posture and work habits.”
In addition to improving
POSTURE, the NASS sug-
gested, “Strength training is necessary to develop
sufficient muscle strength to be able to hold the
head and neck in positions of good posture at rest
and during activity. Strengthening the muscles will
also improve their range of motion.”
Risk Factors and Preventive Measures
Automobile safety measures, such as proper seat
belt usage, airbag installation, and impact-resistant
designs, offer the best preventives for whiplash,
while sturdy equipment can ease spinal worries for
ATHLETES. Therapies typically begun after a flexion-
extension injury can act as preventives too. For
instance,
STRENGTH TRAINING builds PARASPINAL MUS-
CLES and neck muscles, enabling them to endure
greater levels of stress while increasing flexibility
and
RANGE OF MOTION.
National Institute of Neurological Disorders and Stroke.
“NINDS Whiplash Information Page,” NINDS, National
Institutes of Health. Available online. URL: http://
www.ninds.nih.gov/disorders/whiplash/whiplash.
htm. Last updated November 23, 2005.
North American Spine Society. “Whiplash and Whiplash
Associated Disorders,” NASS. Available online. URL:
http://www.spine.org/articles/whiplash.cfm. Down-
loaded January 5, 2006.
fluoride See ENVIRONMENTAL INFLUENCES ON SPINE
HEALTH.
fluoroscopy Instead of an X-rated movie, fluoros-
copy offers an X-
RAY movie. As explained on the
University of Maryland Medical Center (UMMC)
Web site, “A continuous x-ray beam is passed
through the body part being examined, and is
transmitted to a TV-like monitor so that the body
part and its motion can be seen in detail. . . . Fluo-
roscopy is used in many types of examinations and
procedures, such as barium x-rays, cardiac catheter-
ization, and placement of intravenous (IV) catheters
(hollow tubes inserted into veins or arteries).”
In treating or testing
SPINE problems, fluoroscopy
may be used for a biopsy,
MYELOGRAM, or SPINAL
INJECTION, such as a LUMBAR PUNCTURE or facet joint
injection. While fluoroscopy provides a picture of
the
VERTEBRAE and other BACK bones, the Baptist
Memorial Health Care Web site said, “It reveals
less detail than a standard still X-ray. It exposes the
person to somewhat more radiation than a stan-
dard X-ray. Therefore, doctors use it only when
they need to see internal movement.”
Procedure
Depending on the reason for the test, fluoroscopic
procedures can be performed in either an outpa-
tient clinic or a hospital setting. As an article from
OhioHealth.com explained, “Although the specif-
ics vary depending on the type of fluoroscopic test
you undergo, in general you will be asked to lie or
stand between the X-ray machine and a fluorescent
screen after putting on a hospital gown. An intrave-
nous line may be started in your arm or a catheter
may be inserted. An X-ray scanner produces fluo-
roscopic images of the body part being examined.
The procedure itself is generally painless.”
Risks and Complications
Pregnant women should generally avoid fluoroscopy
because of the radiation exposure. Most patients,
however, encounter only the minimal risks usually
associated with low-dose radiation. Some patients
react to barium, but with a lot of water, this quickly
washes from the digestive system.
Outlook and Lifestyle Modifi cations
Often, fluoroscopy provides only a small role in
the overall picture. Satisfactorily solving a mystery
determines whether this medical scene ends on an
upbeat scene.
Baptist Memorial Health Care. “Fluoroscopy.” Available
online. URL: http://www.baptistonline.org/health/
library/test3236.asp. Downloaded January 5, 2006.
OhioHealth.com. “Fluoroscopy,” American Radiology
Services, Inc., Radiological Society of North Amer-
ica. Available online. URL: http://www.ohiohealth.
104 fluoride
com/facilities/outpatient_facilities/imaging/details/
fluoroscopy.htm. Downloaded January 5, 2006.
University of Maryland Medical Center. “Radiology: Fluo-
roscopy,” UMMC. Available online. URL: http://www.
umm.edu/radiology/fluroscopy.html. Downloaded Jan-
uary 5, 2006.
flurbiprofen See NONSTEROIDAL ANTI-INFLAMMA-
TORY DRUG THERAPY.
folate or folic acid (B9) As a member of the
VITAMIN B-COMPLEX family, this nutrient has been
singled out for its fine contribution to the
SPINE of a
healthy baby. Most notably, folate or folic acid can
prevent neural tube defects, such as
SPINA BIFIDA.
To be effective though, this vitamin must be in the
system before a woman becomes pregnant. As the
Centers for Disease Control and Prevention (CDC)
explained, “Birth defects of a baby’s brain or spine
happen in the first few weeks of pregnancy, often
before a woman knows that she is pregnant.”
Dosage and Potential Side Effects
According to the Office of Dietary Supplements,
National Institutes of Health (NIH), “Folate is a
water-soluble B vitamin that occurs naturally in
food,” whereas “folic acid is the synthetic form of
folate that is found in supplements and added to
fortified foods.”
Most multi-vitamin supplements for
INFANTS,
CHILDREN, and adults include the daily minimum
requirement of folic acid as do fortified breakfast
cereals and bread products. As a good source of
NUTRITION in general, fresh foods also contain the
natural form of folate. Named from the Latin word,
folium, for leaf, folate leafs out in spinach, turnip
greens, and asparagus but can also be found in cit-
rus fruits and dried peas or beans.
Since vitamin B9 is water soluble, an excessive
dose washes out of the system. In adults, however,
the NIH said, “Intake of supplemental folic acid
should not exceed 1,000 micrograms (mcg) per day
to prevent folic acid from triggering symptoms of
vitamin B12 deficiency.” For children and
ADOLES-
CENTS, the maximum daily dosage lowers to 300
micrograms for one- to three-year-olds; 400 mcg
for children four to eight; 600 mcg for ages nine to
13; 800 mcg for 14- to 18-year old teens; and 1,000
mcg for anyone older.
Concerns about B12 deficiency can be resolved
by taking more of that vitamin. Regarding a B9 defi-
ciency, the NIH said, “In infants and children, folate
deficiency can slow overall growth rate.” For most
age groups, “other signs of folate deficiency are often
subtle. Digestive disorders such as diarrhea, loss of
appetite, and weight loss can occur, as can weak-
ness, sore tongue, headaches, heart palpitations,
irritability, forgetfulness, and behavioral disorders.”
Statistics and Studies
According to the CDC, “Scientists don’t know how
folic acid works to prevent birth defects. But they do
know that folic acid is needed to make healthy new
cells, like the ones that make up a baby’s brain and
spine. Taking folic acid every day, starting before
and during pregnancy, can reduce the risk for these
serious birth defects by 50% to 70%.”
Despite the ongoing efforts of the CDC, March
of Dimes, and other groups who try to educate the
public about B9, only about 30 percent of the peo-
ple in the United States have an adequate amount
in their diets. An update in Nutraceuticals World said,
“A team of researchers . . . reported that folic acid
fortification accounted for a 36% decline in neural
tube defects (NTDs) in the Hispanic population and
a 34% drop among the white, non-Hispanic pop-
ulation between 1995 and 2002.” However, “the
prevalence of NTDs in the black, non-Hispanic pop-
ulation did not decrease significantly.” As aware-
ness rises in all races, the race may be on to protect
the spinal health of every unborn child.
Centers for Disease Control and Prevention. “Folic Acid
Topic: Home,” CDC, Department of Health and Human
Services. Available online. URL: http://www.cdc.gov/
ncbddd/folicacid/index.htm. Downloaded January 5,
2006.
Kurtzweil, Paula. “How Folate Can Help Prevent Birth
Defects,” U.S. Food and Drug Administration, FDA
Consumer July 1996, revised February 1999. Available
online. URL: http://vm.cfsan.fda.gov/~dms/fdafolic.
html. Downloaded January 6, 2006.
Office of Dietary Supplements. “Dietary Supplement Fact
Sheet: Folate,” National Institutes of Health. Available
folate or folic acid 105
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