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and well-balanced NUTRITION offer everyday ben-
efits. For example, cold water fish, such as cod or
salmon, aid the body in lubricating joints inflamed
by dryness, while cayenne pepper or ginger sprin-
kled over foods may reduce pain. The bromelain
enzyme found in fresh pineapple may ease inflam-
mation, whereas products containing processed
sugar may increase the symptoms.
If needed, counseling and antidepressant drugs
can improve the mental outlook, relieve the anxi-
ety common to JA patients, and increase an overall
sense of well-being. Counseling may also ensure
timely treatment of pain.
Risk Factors and Preventive Measures
Online information from the National Institute of
Arthritis and Musculoskeletal and Skin Diseases
said, “Juvenile arthritis is one of the most prevalent
chronic diseases in children in the United States.
While arthritis pain has been the focus of much
research in adults, there is an increasing awareness
of the need to focus on pain in children. Children
with juvenile arthritis may have pain that can be
intense and disabling, and comprehensive treat-
ment optimizes their ability to fully participate in
school and social activities.”
Unfortunately, children may not let parents
know about discomfort. As explained in the article
“Childhood Pain” posted by the AF, “children are
sometimes reluctant to complain of pain, and may
deny or under report pain because they: fear it will
result in additional unpleasant procedures or treat-
ments; do not understand the pain can be treated;
wish to protect their parents from the reality of
their disease; desire to please others.”
With ongoing pain, a risk comes in avoid-
ing exercise and social contact. If a child receives
treatment though, pain may subside long enough
to allow enjoyable daily
ACTIVITY. Also, as inflam-
mation eases, joint damage may be less likely to
occur.
Arthritis Foundation. “Arthritis in Children,” AF. Avail-
able online. URL: http://www.arthritis.org/AFStore/
StartRead.asp?idProduct=3369. Downloaded January
14, 2006.
———. “Childhood Pain,” AF. Available online. URL:
http://www.arthritis.org/communities/juvenile_arthritis/
Taking_Control/Childhood_Pain.asp. Downloaded Jan-
uary 14, 2006.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases. “Pain of Juvenile Arthritis May Reduce
School and Social Activity,” NIAMS, National Insti-
tutes of Health. Available online. URL: http://www.
niams.nih.gov/ne/highlights/spotlight/2003/pain-
juvenile.htm. Downloaded January 14, 2006.
juvenile osteoporosis Although primary juvenile
osteoporosis (JO) has no known cause, treatments
for such conditions as
JUVENILE RHEUMATOID ARTHRI-
TIS can produce a secondary form of OSTEOPOROSIS
in
CHILDREN and ADOLESCENTS. Disorders that affect
bone mass, such as
OSTEOGENESIS IMPERFECTA, can
also produce the porous bones that mark JO.
Symptoms and Diagnostic Path
Most common in children between eight and 14,
symptoms include
ACUTE or CHRONIC PAIN in the
BACK, compression of the VERTEBRAE, and, some-
times,
FRACTURE of long bones in the legs or small
bones in the
SPINE. Often, young patients experi-
ence difficulties in walking or just going about their
daily
ACTIVITY. KYPHOSIS or other problems with
POSTURE may develop too.
In addition to a medical history and physical
examination, X-
RAYS may be needed for a diagno-
sis. To assess bone strength, a
BONE MINERAL DENSITY
(BMD)
TEST, such as ABSORPTIOMETRY, establishes a
baseline for annual follow-up testing to assess new
bone growth. To get an accurate reading though, a
BMD test must use pediatric software for compara-
tive analysis with the appropriate age group.
Treatment Options and Outlook
According to The Pediatric Orthopaedic Society
of North America, “the outlook for spontaneous
recovery is good, usually in 2–4 years or at skel-
etal maturity, but protracted disability has been
reported in a small number of adults.”
Besides various forms of
PAIN MANAGEMENT, treat-
ment may include
ANTIRESORPTIVE DRUGS. An article
in the 2005 annual Pediatric Drugs explained, “Bone
mass increases progressively during childhood, but
mainly during adolescence when approximately
40% of total bone mass is accumulated.” How-
136 juvenile osteoporosis
ever, “many disorders, by various mechanisms,
may affect the acquisition of bone mass.” This not
only affects present bone strength in children and
teenagers but determines their future bone mass as
adults and
ELDERLY patients. Therefore, “the use of
bisphosphonates in children and adolescents with
osteoporosis is increasing and their positive effect in
improving bone mineral density is encouraging.”
Recent studies focused on treating childhood
osteoporosis with alendronate (Fosamax). To explain
the rationale for using this particular
BISPHOSPHO-
NATE, ClinicalTrial.gov said, “Bones grow and stay
strong through a continuous process of formation
(building) and resorption (break down). When more
bone is formed than resorbed, the density (level of
calcium) in bone increases and the bones become
stronger. However, if more bone is resorbed than
formed, the density of bone decreases and the bones
become weak.” Since “alendronate (Fosamax) is a
drug that works by stopping bone resorption (break
down),” ClinicalTrial.gov said, “Researchers believe
that children treated with alendronate will improve
bone strength and decrease the amount of fractures
caused by osteoporosis.”
Risk Factors and Preventive Measures
Some medications, such as prednisone, used to treat
juvenile rheumatoid arthritis, can decrease bone
density, thus causing secondary juvenile osteopo-
rosis or
OSTEOPENIA. Also, if children and teenagers
have almost any ongoing illness or disorder, they
become less likely to have the
EXERCISE needed
to aid spinal health and
BONE BUILDING. Although
WEIGHT-BEARING EXERCISE would place porous bones
at greater risk during periods of growth, other types
of daily activity can be tailored to the child.
NUTRITION provides another natural preven-
tive, but dietary whims increase the risks. For
example, soft drinks contain
PHOSPHORUS that can
affect
MINERAL BALANCE, especially if sodas replace
bone-building dairy products. To ensure adequate
CALCIUM intake, individual tastes can be assessed.
For example, a child who dislikes milk may have
a lactose intolerance not triggered by yogurt. If the
texture of yogurt seems too unappetizing, the fro-
zen version offers the same amount of calcium and,
for many people, tastes better than ice cream. Most
dairy products also add
VITAMIN D to increase cal-
cium absorption, but playing in the sun for a few
minutes without sunscreen will provide the daily
vitamin D needed and add spine-strengthening
exercise too.
Baroncelli, Giampiero Igli, Silvano Bertelloni, Federica
Sodini, and Giuseppe Saggese. “Osteoporosis in Chil-
dren and Adolescents: Etiology and Management,”
Pediatric Drugs annual issue 7, no. 5 (2005): 295–323.
ClinicalTrials.gov. “Treatment of Childhood Osteopo-
rosis with Alendronate (Fosamax),” U.S. National
Institutes of Health. Available online. URL: http://
www.clinicaltrials.gov/ct/show/NCT00001720.
Downloaded January 12, 2006.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases. “Juvenile Osteoporosis,” NIAMS,
National Institutes of Health. Available online. URL:
http://www.niams.nih.gov/bone/hi/osteoporosis_juv.
htm. Downloaded January 12, 2006.
Pediatric Orthopaedic Society of North America, The.
“Juvenile Osteoporosis,” POSNA. Available online.
URL: http://www.posna.org/index?service=page/core
Curriculum&article=juvenileOsteoporosis.html.
Downloaded January 12, 2006.
juvenile rheumatoid arthritis As the most com-
mon form of
JUVENILE ARTHRITIS, juvenile rheu-
matoid arthritis (JRA) can occur in
CHILDREN or
ADOLESCENTS of any age but rarely in INFANTS under
six months. A family history of
ARTHRITIS or RHEU-
MATOID ARTHRITIS may imply involvement of GENETIC
FACTORS in this chronic inflammatory disease.
Symptoms and Diagnostic Path
According to the Arthritis Foundation, symptoms
vary with each child, and sometimes with each
day, but “the most common features of JRA are:
joint inflammation, joint contracture (stiff, bent
joint), joint damage and/or alteration or change in
growth. Other symptoms include joint stiffness fol-
lowing rest or decreased activity level (also referred
to as morning stiffness or gelling), and weakness
in muscles and other soft tissues around involved
joints. However, because JRA affects each child dif-
ferently, your child may not experience all of these
changes. Children also vary in the degree to which
they are affected by any particular symptom.”
juvenile rheumatoid arthritis 137
In an online article posted by the American Col-
lege of Rheumatology, Dr. Leslie Abramson said,
“Systemic onset JRA affects about 10 percent of chil-
dren with arthritis. It begins with a recurrent fever
that can be 103°F or higher, often accompanied by
a pink rash that comes and goes. Systemic onset
JRA may cause inflammation of the internal organs
as well as the joints. Swelling of the joints may not
be present at onset and may appear months or even
years after the onset of fevers.” While various types
of JRA can affect various areas of the body, “all
cause joint inflammation and begin before the age
of 16, but otherwise are often associated with dis-
tinct symptoms and complications and may require
different approaches to treatment.”
Besides taking a medical history and perform-
ing a physical examination, a rheumatologist or
other specialist will request a blood test to see if
a child tests positive for the rheumatoid factor. If
so, this may indicate the need for more aggressive
treatment.
Treatment Options and Outlook
Incorporating varied approaches to treatment may
provide the best outlook. For example, a medical
team commonly includes a pediatrician, rheuma-
tologist, occupational therapist, physical therapist,
and mental health counselor. If symptoms pres-
ent a concern about eye health, an ophthalmolo-
gist will be needed, whereas an orthopedic surgeon
may become involved if joints show severe struc-
tural damage.
As Dr. Abramson recommended, “The overall goal
of treatment of JRA is to control symptoms, prevent
joint damage and maintain function.” This typically
begins with
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
(NSAID)
THERAPY, which, to avoid stomach upset in
children, should be taken with food. If JRA remains
active, a
DISEASE MODIFYING ANTI-RHEUMATIC DRUG
(DMARD) may be added.
Risk Factors and Preventive Measures
Pain or inflammation may make a child want to
withdraw from school or social activities, but the
National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) recommended other-
wise: “Although pain sometimes limits physical
activity, exercise is important to reduce the symp-
toms of JRA and maintain function and range of
motion of the joints. Most children with JRA can
take part fully in physical activities and sports when
their symptoms are under control. During a disease
flare-up, however, the doctor may advise limiting
certain activities depending on the joints involved.
Once the flare-up is over, a child can start regular
activities again.”
Abramson, Leslie S., M.D. “Arthritis in Children,” Ameri-
can College of Rheumatology. Available online. URL:
http://www.rheumatology.org/public/factsheets/
arth_in_children.asp?aud=pat. Downloaded January
14, 2006.
Arthritis Foundation. “Juvenile Rheumatoid Arthritis,”
AF. Available online. URL: http://www.arthritis.org/
conditions/DiseaseCenter/jra.asp. Downloaded Janu-
ary 12, 2006.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases. “Questions and Answers about Juvenile
Rheumatoid Arthritis,” NIAMS, National Institutes of
Health. Available online. URL: http://www.niams.nih.
gov/hi/topics/juvenile_arthritis/juvarthr.htm. Down-
loaded January 12, 2006.
juvenile scoliosis See IDIOPATHIC SCOLIOSIS.
juvenile spondyloarthritis Like other types of
ARTHRITIS, juvenile spondyloarthritis (JSpA) inflames
the joints and often affects the
VERTEBRAE. Although
various forms exist, the most common is juvenile
ANKYLOSING SPONDYLITIS. The term indicates a bent
SPINE, which describes what occurs unless treat-
ment intervenes.
Online information from the Spondylitis Asso-
ciation of America (SAA) said, “Juvenile-onset
spondyloarthritis (JSpA), also known as Juve-
nile Spondyloarthropathy, is the medical term for
a group of childhood rheumatic diseases, which
cause arthritis before the age of 16 and may span
through adult life. The juvenile spondyloarthropa-
thies include undifferentiated spondyloarthropathy,
juvenile ankylosing spondylitis, psoriatic arthritis,
reactive arthritis and spondylitis of inflammatory
bowel diseases.”
138 juvenile scoliosis
Symptoms and Diagnostic Path
According to the SAA, “JSpA typically causes pain
and inflammation in the joints in the lower part of
the body, for example, the pelvis, hips, knees and
ankles. Other areas of the body can also be affected,
such as the spine, eyes, skin and bowels. Fatigue
and lethargy can also occur.”
An article on the Cincinnati Children’s Hospital
Medical Center Web site said, “In SpA, the inflam-
mation often occurs where tendons attach our mus-
cles to bones, or where ligaments attach to bones.”
Comparing the symptoms of JSpA with
JUVENILE
RHEUMATOID ARTHRITIS (JRA), the article continued,
“In general, SpA tends to occur in older boys and
involve a small number of large joints (i.e. hips,
knees and ankles). Back pain or stiffness is more
frequent in pediatric SpAs than JRA.”
Information from the New York-Presbyterian
Hospital reported, “Juvenile spondyloarthropathies
usually affect the spine and the sites where the mus-
cles, tendons, and ligaments are attached to bone.
The disease causes inflammation of the spine and
large joints, resulting in stiffness and pain. When
severe, the disease may result in erosion at the joint
between the spine and the hip bone (the sacroiliac
joint), and the formation of bony bridges between
vertebrae in the spine, fusing those bones.” X-
RAYS
and blood tests may help to confirm the condition.
Treatment Options and Outlook
Treatment often begins with
PAIN MANAGEMENT
that includes
NONSTEROIDAL ANTI-INFLAMMATORY
DRUG (NSAID) THERAPY. Should this fail to relieve
pain,
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS
(DMARDs) may be added.
Some children may need
POSTURE training or
other forms of physical therapy to aid flexibility in
the
SACRAL VERTEBRAE and LUMBAR SPINE. Although
WEIGHT-BEARING EXERCISE can damage inflamed
joints, other types of
EXERCISE, such as swimming or
stretching exercises, will usually be recommended.
Also, programs of daily
ACTIVITY and NUTRITION can
be designed to fit the child and his or her specific
needs and interests. To encourage an active out-
look,
ORTHOTIC devices or cushioned insoles for
SHOES usually make walking more comfortable.
Risk Factors and Preventive Measures
Although juvenile spondyloarthritis may be more
severe than similar conditions arising in adults,
early treatment reduces the risk of
CHRONIC PAIN
and lessens the likelihood of permanent disability.
No cure exists, but JSpA may go into remission,
providing the child with an opportunity to build
strength. Should flare-ups return, prompt treat-
ment can prevent the condition from getting out
of hand and also encourage the child to continue
participating in activities important to childhood.
Cincinnati Children’s Hospital Medical Center. “Juvenile
Spondyloarthritis.” Available online. URL: http://www.
cincinnatichildrens.org/health/info/rheumatology/
diagnose/spondyloarthritis.htm. Downloaded January
12, 2006.
NewYork-Presbyterian. “Juvenile Spondyloarthritis,” The
University Hospitals of Columbia and Cornell. Avail-
able online. URL: http://wo-pub2.med.cornell.edu/
cgi-bin/WebObjects/PublicPediatrics.woa/2/wa/
viewContent?contentID=1721&wosid=A7T1Ockk9t
1wbr1mXsjQP0. Downloaded January 12, 2006.
Spondylitis Association of America. “Juvenile Spondylo-
arthritis (JSpA),” SAA. Available online. URL: http://
www.spondylitis.org/about/juvenile.aspx. Downloaded
January 12, 2006.
juvenile spondyloarthritis 139
140
ketoprofen
See NONSTEROIDAL ANTI-INFLAMMA-
TORY DRUG THERAPY.
kyphoplasty This MINIMALLY INVASIVE SURGERY
uses X-
RAY guidance to stabilize the SPINE after a
VERTEBRAL COMPRESSION FRACTURE. Although not
appropriate for young patients or people with
SPINAL
STENOSIS, kyphoplasty provides a new and encour-
aging surgical option for many
ELDERLY patients,
OSTEOPOROSIS patients, and CANCER patients. Since
the procedure can be used to treat one or more
compression fractures, it can restore height and
prevent severe
POSTURE problems, such as KYPHOSIS,
from progressing.
Procedure
Dr. Arya Nick Shamie of the UCLA Spine Center
explained, “Kyphoplasty is performed with a probe
placed into the fractured vertebral body through
two small skin incisions. A deflated balloon is then
inserted and expanded to bring the compressed
bone back to its desired height. Bone cement is
injected to hold the fracture in place. The cement
acts as an internal cast to hold the bone in place
until it heals. About 80 to 90 percent of patients
have immediate pain relief after the procedure.”
Usually, each quarter-inch slit can then be closed
with a single stitch.
Risks and Complications
An article in Neurosurgical Focus compared kypho-
plasty with
VERTEBROPLASTY, stating, “Complica-
tions are rare, but they can be serious, and their
exact incidence is unknown.” For example, bone
cement can leak outside the vertebrae or damage
the spinal cord. Although “complications have
been reported for both procedures, . . . . a review of
Food and Drug Administration safety data revealed
58 reported complications from 1999 through 2003
of approximately 200,000 procedures performed.”
Outlook and Lifestyle Modifi cations
The American Academy of Orthopaedic Surgeons
advised, “For the best results, kyphoplasty should be
performed as soon as possible after spinal bone col-
lapse or fracture. The results are less predictable in
older fractures but in certain circumstances may still
be beneficial.” Although pain may persist in some
patients, “Most patients have excellent pain relief
and straighter backs. This may result in added height.
More than 95 percent of patients rate their treatment
as successful and report that they are able to return to
all their pre-fracture activities.” Other than continu-
ing the pre-operative treatment for an underlying
medical condition, “most patients do not need physi-
cal therapy or any other form of rehabilitation.”
American Academy of Orthopaedic Surgeons. “Spinal
Surgery for Fractured Vertebrae,” AAOS. Available
online. URL: http://orthoinfo.aaos.org/fact/thr_report.
cfm?Thread_ID=464&topcategory=Spine. Downloaded
January 12, 2006.
Burton, Allen W., M.D. Laurence D. Rhines, M.D. and
Ehud Mendel, M.D. “Vertebroplasty and Kyphoplasty:
a Comprehensive Review,” Neurosurgical Focus 18, no.
3 (March 2005).
UCLA Healthcare. “New Spine Surgeries Allow Quicker,
Less Painful Recovery,” UCLA Health Sciences. Avail-
able online. URL: http://www.healthcare.ucla.edu/
vital-signs/article-display?article_id=315. Downloaded
January 21, 2006.
kyphosis In this type of POSTURE problem, the
upper
BACK acquires a rounded look, but kypho-
K
sis can also develop in the lower back or LUMBAR
SPINE. Often, spinal problems become apparent dur-
ing teen years, but congenital kyphosis occurs in
INFANTS whose bones did not form correctly prior to
birth. One type of the disorder known as Scheuer-
mann’s kyphosis begins in an older child or young
adult and typically presents a smooth curve in the
THORACIC SPINE. Also, ELDERLY patients can develop
secondary kyphosis if bones have been weakened
by
OSTEOPOROSIS or if bone CANCER produces VERTE-
BRAL COMPRESSION FRACTURES.
Regarding kyphosis among
CHILDREN, the Spine
Center of the Colorado Springs Orthopaedic Group
said, “The cause of Scheuermann’s kyphosis has
not been discovered, but there are many possible
theories about its development. Scheuermann, the
Danish radiologist for whom the disease is named,
was the first to notice the problem. He proposed
that the problem was a result of a process of ‘avas-
cular necrosis’ of the cartilage ring of the vertebral
body. This means the cartilage of the spinal bone’s
ring died because it lacked the necessary blood
supply. Scheuermann believed that this inter-
rupted bone growth during development, lead-
ing to wedge-shaped vertebrae.” Indeed, “most
researchers think that some sort of damage to the
growth area of the vertebrae starts the process.
The abnormal growth that follows is what causes
the excessive kyphosis.”
Symptoms and Diagnostic Path
While kyphosis can usually be seen with the eye, a
physical examination and X-
RAYS reveal the extent
of curvature. Over 50 degrees is considered abnor-
mal, but
SURGERY will seldom be needed unless the
curve exceeds 75 degrees.
Treatment Options and Outlook
To treat postural kyphosis, the American Academy
of Orthopaedic Surgeons (AAOS) said, “Exercises
to strengthen the abdomen and stretch the ham-
strings may help take away associated discomfort.
But exercises probably won’t result in significant
correction of the postural kyphosis.” If needed,
NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID)
THERAPY can be used to treat pain, but the AAOS
said, “This condition does not lead to problems in
adult life.”
For Scheuermann’s kyphosis, the AAOS advised,
“An initial program of conservative treatment is
also recommended for patients with Scheuer-
mann’s kyphosis. This includes exercises and anti-
inflammatory medications. If the child is still
growing, the doctor may prescribe a brace. The
child wears the brace until skeletal maturity is
reached.”
Back.com further explained, “Other forms of
treatment, including bracing and surgery, are con-
sidered when there is a rapid increase in the size of
the curve; worsening of the vertebral body wedging,
back pain that will not improve with conservative
measures, and difficulties with pulmonary function
that are related to the kyphotic deformity. The deci-
sion about when and how to brace the spine of a
patient with Scheuermann’s disease, or to perform
surgery, is made on an individual basis.”
For elderly patients who develop kyphosis
because of vertebral compression fracture, treat-
ment may include
MINIMALLY INVASIVE SURGERY,
such as
KYPHOPLASTY or VERTEBROPLASTY. Young
infants may need other types of corrective sur-
gery to straighten the
SPINE and avoid respiratory
problems.
Risk Factors and Preventive Measures
In growing children and
ADOLESCENTS, an ORTHOTIC
brace will commonly be prescribed to prevent fur-
ther development of the curvature and avoid spinal
deformity. Also, well-designed
EXERCISE can lessen
pain, improve posture, and strengthen the spine.
Although slouching can exaggerate curvature,
kyphosis may cease to progress after the child or
teenager reaches full growth.
American Academy of Orthopaedic Surgeons. “Kyphosis
(Curvature of the Spine),” AAOS. Available online. URL:
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_
ID=247&topcategory=Spine. Downloaded January 12,
2006.
Medtronic Sofamor Danek. “Developmental Disorders:
Scheuermann’s Kyphosis,” Back.com. Available online.
URL: http://www.back.com/causes-developmental-
scheuermann.html. Last updated March 11, 2005.
SpineUniversity. “Introduction,” Spine Center, Colorado
Springs Orthopaedic Group. Available online. URL:
http://www.spineuniversity.com/public/spinesub.
asp?id=52. Downloaded January 12, 2006.
kyphosis 141
142
laminaplasty
See CERVICAL LAMINAPLASTY.
laminectomy, laminotomy Often referred to as
spinal decompression, this type of
SURGERY removes
all or part of the bony lamina covering the spinal
canal at a particular point of pressure. Commonly,
the procedure involves the lower back, but spi-
nal decompression can reduce pressure on spinal
nerves in the
CERVICAL SPINE or the THORACIC SPINE
as well as the
LUMBAR SPINE. A laminectomy can be
done alone, but the surgery may be an aspect of
LUMBAR SPINAL FUSION or other type of ARTHRODESIS
used to fuse
VERTEBRAE and stabilize or strengthen
the
SPINE.
Procedure
According to the North American Spine Society
(NASS), “after an incision is made in the midline
of the neck or back, the muscle is moved away to
expose the lamina, which are the bony shingles. . . .
The lamina can be removed in whole or in part to
expose a single nerve . . . or more . . . as needed.”
Partial removal of lamina in a laminotomy may
suffice, but “In the case of spinal stenosis, a more
extensive laminectomy is performed, and may
require removal of an entire lamina, on both sides
of the midline, and including the spinous process,”
the column of bony ridges that can be felt on the
BACK, “where the lamina from both sides meet. This
permits the surgeon to uncover the canal contain-
ing the nerves and to extend the decompression
laminectomy to the area of the facet joints, where
bony spurs can be removed. In some cases, it is nec-
essary to remove the entire lamina and a portion of
the facet joint (through the same exposure). If the
surgeon is concerned that instability will occur, a
fusion may be performed in addition.”
Besides removing some portion of the lamina,
the surgeon eliminates bone spurs (
OSTEOPHYTES),
scar tissue, or ruptured areas of a
DISC. Typically,
the procedure takes about two hours and includes
insertion of a small drainage tube to keep blood
from collecting in the surgical site. The next day, the
drain will be removed and the dressing changed, but
an intravenous (IV) pump may remain for two or
three days to administer antibiotics or pain medica-
tion. An IV may also be inserted to ensure adequate
intake of food and liquids.
As an alternative to laminectomy, a new
MINI-
MALLY INVASIVE SURGERY uses the recently approved X
STOP implant to allow room for exiting nerves. Like
a laminectomy, this procedure relieves pressure on
the spinal nerves, but the X STOP decreases recov-
ery time. As the Center for Devices and Radiological
Health said, “The X STOP® is a titanium implant
that fits between the spinous processes of the lower
(lumbar) spine. It is made from titanium alloy and
consists of two components: a spacer assembly and
a wing assembly.” Implanted at one or two lumbar
levels, “The X STOP® is designed to limit extension
of the spine in the affected area, which may relieve
the symptoms of lumbar spinal stenosis.”
Risks and Complications
In patients who undergo spinal decompression
surgery, depression and fatigue typically set in
by the second or third day. A number of sources
mention the importance of an optimistic attitude
during recovery, presumably to prevent discour-
agement when pain continues. However, the stress
of surgery, the proximity of the spinal cord in a
laminectomy, and the residual effects of anesthe-
sia complicate attempts at cheeriness. Most patients
need rest, time to heal, and gradual restoration of
activities before a full recovery occurs.
L
Patients also risk CHRONIC PAIN of FAILED BACK
SURGERY SYNDROME and the dangerous complica-
tion of
CAUDA EQUINA SYNDROME (CES), particularly
if spinal decompression involves extensive removal
of lamina in a laminectomy. In an article for Neuro-
surgical Focus, Dr. John P. Kostuik said, “The gener-
ally accepted frequency of CES is between 2 and
6% of all laminectomies performed for lumbar disc
herniation. . . . One of the most common errors
that arises following discharge from the hospital
includes the failure of the physician or other medi-
cal personnel to ask appropriate questions over the
telephone or in an office setting. This situation is
particularly unfortunate if the patient has experi-
enced changes in any symptoms including increased
back pain and/or radicular pain and perhaps diffi-
culty in urination. Bladder function inquiries are
crucial.” The potential of CES arising after surgery
increases if a patient experiences
ACUTE PAIN in the
back, limited leg raising, or sensory motor loss. In
the same issue of Neurosurgical Focus, Dr. Randy L.
Jensen also addressed the potential complication of
CES, adding, “Factors that might precipitate post-
operative CES include inadequate decompression,
nerve root swelling, hematoma,” or blood clot, and
“retained disc fragments.”
Outlook and Lifestyle Modifi cations
Spine Inc. described what commonly occurs after
a laminectomy: “Initially, you are permitted to
get out of bed following surgery with assistance
from a nurse. Thereafter, you should be up walk-
ing as much as tolerated. The goal is to do more
walking each day. Start with short trips and set a
graduated pace so that each day more activity is
accomplished.” For those who have difficulty get-
ting up, “the easiest way for you to get out of bed is
to raise the head of the bed as far as it will go, bal-
ance yourself in a sitting position, then stand with
weight distributed on the skeletal frame, to avoid
straining of back muscles. Avoid prolonged sitting.
Initially, you should only sit for meals.”
At home,
ERGONOMIC FACTORS should be
addressed with upright furniture to encourage
proper
POSTURE and correctly support the spine. Not
only does this design provide the best positioning
for the lower back but for the upper back and neck
too.
Regarding other modifications, Spine Inc. said,
“Follow-up to remove staples will be scheduled for
ten to fourteen days following surgery. Another
follow-up to see progress will be scheduled four
to six weeks following surgery. Other follow-ups,
which may continue for as long as a year after sur-
gery, will be scheduled depending on progress.”
To aid that progress, the patient should com-
pletely refrain from bending over for several
weeks. Except for light-weight objects under two
pounds,
LIFTING should be totally avoided in the
first weeks, but daily
ACTIVITY, physical therapy,
and doctor-recommended
EXERCISE should gradu-
ally increase. An abundance of fresh water and
fresh fruit or other natural forms of
NUTRITION also
assist recovery.
If a sensation of pressure continues after an
incision has healed,
COLD THERAPY may relieve the
swelling that commonly causes that pressure. Some
patients find relief in alternating
HEAT THERAPY with
cold. For example, after a hot shower, an ice pack can
be applied for five minutes. Otherwise, either hot or
cold treatments may help, depending on which feels
best to the patient. For general pain, prescription
medication or
NONSTEROIDAL ANTI-INFLAMMATORY
DRUG (NSAID) THERAPY can be used as needed during
the recovery, which may take a few months.
CDRH Consumer Information. “New Device Approval X
STOP® Interspinous Process Decompression System
(XSTOP) - P040001,” Center for Devices and Radio-
logical Health, U.S. Food and Drug Administration,
Department of Health and Human Services. URL:
http://www.fda.gov/cdrh/mda/docs/p040001.html.
Last updated January 4, 2006.
Jensen, Randy L. “Cauda Equina Syndrome as a Postop-
erative Complication of Lumbar Spine Surgery,” Neu-
rosurgical Focus 16, no. 6 (June 2004): 34–38.
Kostuik, John P., M.D. “Medicolegal Consequences of
Cauda Equina Syndrome: an Overview,” Neurosurgical
Focus 16, no. 6 (June 2004): 39–41.
North American Spine Society. “Laminectomy or Lami-
notomy,” NASS. Available online. URL: http://www.
spine.org/fsp/prob_action-surgical-laminectomy.cfm.
Last updated March 3, 2005.
Spine Inc. “Laminectomy.” Available online. URL: http://
www.spine-inc.com/glossary/l/laminectomy.html.
Downloaded January 16, 2006.
laminectomy, laminotomy 143
lifting After almost any type of SURGERY, patients
should avoid lifting more than a pound or two
during the recovery period. At any time, how-
ever,
CHILDREN, ADOLESCENTS, younger adults, and
ELDERLY adults need to be aware of the LOAD TOLER-
ANCE of the BACK and SPINE, especially as relates to
their particular age or condition. By taking care not
to overload spinal
DISCS and VERTEBRAE, such back
conditions as a
HERNIATED DISC or SPINAL INJURY can
often be prevented.
To provide tips on safe means of lifting, the Occu-
pational Safety & Health Administration (OSHA) of
the U.S. Department of Labor said, “Lift loads close
to the body.” Also, “limit the number of allowed lifts
per worker per day. Avoid heavy lifting especially
with spine rotated.” To avoid the back injuries that
often occur among hospital personnel and home
caretakers, OSHA further advised, “Never transfer
patients/residents when off balance. Never lift alone,
particularly fallen patients/residents.” Instead, “use
team lifts or use mechanical assistance.”
Risks and Complications
Homes and small medical facilities may not have
mechanical patient lift systems or other equipment
needed to assist caretakers in lifting patients. For
other types of lifting, complications commonly
arise if the person happens to twist slightly at the
moment of lift-off. Additional risks occur if a per-
son has weak
PARASPINAL MUSCLES or bone loss due
to
OSTEOPENIA, OSTEOPOROSIS, and other conditions.
People with
DEGENERATIVE DISC DISEASE should also
avoid lifting heavy objects because of the pressure
this exerts on the spinal discs.
Statistics and Studies
An abstract of “Prevention of Disabling Back Inju-
ries in Nurses by the Use of Mechanical Patient Lift
Systems” stated, “According to the National Insti-
tute for Occupational Safety and Health (NIOSH),
occupational back injury is the second leading
occupational injury in the United States. Among
health care personnel, nurses have the highest rate
of back pain, with an annual prevalence of 40–50%
and a lifetime prevalence of 35–80%.” Studies con-
sistently show, however, that assistive equipment
can enable caretakers to handle patients safely,
thereby reducing risk of musculoskeletal disorders
and injuries, not only in themselves but also in
their patients.
Similarly, an article in Spine addressed the effects
of wearing a back belt. Although studies offer con-
flicting evidence about belt usage, this study of 28
workers determined that belts helped to reduce
torso motions and remind workers to lift slowly.
Furthermore, back belts caused workers to rely on
squat-lift techniques that distributed weight evenly
around the body, thus lessening the spinal load.
Special Aids and Adaptations
An article posted by Back.com defined the two most
common mistakes in lifting as using back muscles
instead of muscles in the legs and buttock and lift-
ing an object too far from the body. As the article
said, “Just to illustrate, if you lift a 10-pound weight
at arms length, it will put 150 pounds of pressure
on your back. Lifting an object that weighs 86
pounds puts over 700 pounds of force on the discs
in the lower back. An object that weighs over 86
pounds should not be lifted more than a distance of
12 to 13 inches and should not be lifted more than
once every five minutes if possible. The heavier
the object, the shorter distance it should be lifted.”
Besides the extra lift of a stepping stool or ladder,
motions should be adapted “to limit twisting when
lifting.” Likewise, the person must take care not to
twist the neck or head in order to prevent injuries
in the
CERVICAL SPINE and THORACIC SPINE.
Edlich, Richard E. “Prevention of Disabling Back Injuries
in Nurses by the Use of Mechanical Patient Lift Sys-
tems,” Journal of Long-Term Effects of Medical Implants
14, no. 6 (2004): 521–533.
Giorcelli, Rebecca J., Richard E. Hughes, James T. Was-
sell, Hongwei Hsiao. “The Effect of Wearing a Back
Belt on Spine Kinematics during Asymmetric Lifting
of Large and Small Boxes,” Spine 26, no. 16 (August
15, 2001): 1,794–1,798.
Medtronic Sofamor Danek. “Lifting Techniques,” Back.
com. Available online. URL: http://www.back.com/
articles-lifting.html. Updated April 15, 2005.
Occupational Safety & Health Administration. “Health-
Care Wide Hazards Module—Ergonomics,” OSHA,
U.S. Department of Labor. Available online. URL:
http://www.osha.gov/SLTC/etools/hospital/hazards/
ergo/ergo.html. Downloaded January 9, 2006.
144 lifting
liniment See TOPICAL ANALGESIC.
load tolerance How much weight can one SPINE
carry? Does a back belt keep a
BACK from buckling?
Should parents of
CHILDREN and ADOLESCENTS peer into
schoolbags to help each child bear
BACKPACK SAFETY?
Will poor
LIFTING techniques bring a load of load intol-
erance no matter how little something weighs?
With cautions about
POSTURE also arising, load
tolerance takes into account the age, biomechan-
ics, and condition of the spine, joints, and vertebral
DISCS of each individual. Therefore, load tolerance
varies from one person to the next. For example,
the spinal concerns of
ELDERLY persons or OSTEOPO-
ROSIS patients differ greatly from those of a young
adult using
STRENGTH TRAINING and other forms of
EXERCISE to pump up PARASPINAL MUSCLES.
In a report on load tolerance, Robin Burgess-
Limerick stated, “Injuries occur when loads on ana-
tomical structures are, either instantly or over time,
greater than the structures can withstand. Anatomi-
cal complexity, individual variability in tissue toler-
ances, and the interactions between biomechanical,
environmental, and psychosocial risk factors make
the determination of valid threshold limit values for
exposure to biomechanical risk factors exception-
ally difficult.” Yet “more attention has been paid to
determining threshold limits for preventing back
injury than any other region.” However, “these
approaches predominately focus on the compres-
sive forces applied to the lumbar spine, comparing
estimates of spinal compression based on biome-
chanical models of varying complexity. . . . The
general problems with this approach are: a) tissue
tolerances vary with age and sex, and load history;
b) compression is only one contributing factor; c)
accurate estimates of tissue load require complex
measurement techniques; and d) exposure to whole
body vibration interacts with other risk factors.”
Risks and Complications
A large risk factor comes not necessarily with limi-
tations but with lack of awareness of those limits.
For example, children and teenagers may not real-
ize the undue pressure exerted on growing bones
as they lug around a backpack weighing more than
10 percent of their own body weight. Stepping on
scales could sidestep that problem, but parents may
need to intervene by weighing a backpack or help-
ing a child sort out necessary items from those best
left in a bedroom or school locker.
People of all ages risk load intolerance each time
they lift items over their heads, twist their bodies
while lifting, or bend their backs and necks instead
of their knees. Equally important, all weights are
not created equal. For example, lifting ten pounds
away from the body places not ten but 150 pounds
of pressure on the back. Besides the risk of improper
lifting, load intolerance increases with each repeti-
tion of weight until fatigue presents a final straw in
overloading the spine.
Statistics and Studies
An article in Occupational Ergonomics reported on a
study comparing the effects of continuous and dis-
continuous loads. Using
ELECTROMYOGRAM (EMG) to
measure and analyze data “showed that constant load
caused higher muscular fatigue than intermittent
loads despite the lower value of the external force
and lower muscle activation.” Furthermore, “the
results of the study support the thesis that all biome-
chanical factors which influence upper limb load and
fatigue (upper limb posture, external force and time
sequences) should be considered when work stands
and work processes are designed. They also indicate
that constant load should be especially avoided.”
Regarding the influence of posture on spinal
overload, a Spine article reported on a study of
“Muscle Activation Strategies and Symmetry of
Spinal Loading in the Lumbar Spine with Scolio-
sis.” For this study, “spinal loading was estimated
in a lumbar spine model with increasing degrees
of scoliosis. External loading was each of three
pure moments or forces acting at T12” in the
THO-
RACIC SPINE, “with magnitudes of either 50% or
75% of maximum effort.” Focusing on
SCOLIOSIS
patients, the researchers concluded, “We speculate
that individuals with scoliosis can adopt different
muscle activation strategies and that these strate-
gies may determine whether or not the spinal load-
ing causes scoliosis progression during growth.” In
other words, different movements produce differ-
ent effects. Therefore, patients can be shown how
to move in ways most helpful to their spine health,
especially if they still have growing bones.
load tolerance 145
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