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246
sacral vertebrae
Below the LUMBAR SPINE, five
VERTEBRAE fuse together to form the sacrum. On
both of the vertical sides of this elongated triangle,
the upper portion wings out to connect with the
butterfly-shaped pelvic bones, while the lower part
extends downward into the
COCCYGEAL SPINE, thus
suspending the tailbone like a cocoon. This pat-
tern comes with slight variations since
CHILDREN
and young
ADOLESCENTS have a flatter joint surface,
whereas men have a narrower, longer sacral tri-
angle than women do. Such subtle variations help
to identify the age and sex of human remains, but
among the living, these differences make a differ-
ence in the
SPINE problems that arise.
Risks and Complications
A shorter, broader sacrum places young to middle-
aged women at greater risk for developing
SACROIL-
IAC JOINT PAIN SYNDROME and varying degrees of LOW
BACK PAIN. However, male and female ATHLETES of
all ages risk problems if they twist abruptly or exert
too much pressure on the sacral vertebrae. Workers
who exceed their
LOAD TOLERANCE or use improper
LIFTING techniques encounter higher risks too. Ironi-
cally, sedentary persons also place too much pres-
sure on the sacrum because of prolonged sitting.
Besides the problems of misuse and disuse, an
injury can
FRACTURE the sacral spine, although this
rarely happens. A more likely occurrence might be
a
VERTEBRAL COMPRESSION FRACTURE in an ELDERLY
patient with
OSTEOPOROSIS or other condition
involving bone loss. I
NFANTS with BIRTH DEFECTS OF
THE SPINE and people who exhibit spinal misalign-
ments, such as
SCOLIOSIS, may have problems that
eventually affect the sacrum too.
Statistics and Studies
Numerous studies have been done on pelvic tilt
or obliquity, but sacral obliquity has not been as
well studied or defined. After studying 63 of their
own patients who exhibited sacral obliquity, a
group of doctors reported for SpineUniverse, “One
patient was found to have a traumatic origin. The
remainder appear to have a congenital abnormality
of varying degrees,” indicating an inherited condi-
tion. For instance, the sacrum may slant to one side
as a patient compensates for an unequal length in
the legs. “In some cases, the sacral obliquity had
little effect on the spine, but in others the obliq-
uity appears to have . . . lumbar scoliosis of varying
degrees.”
Special Aids and Adaptations
Sacral tilt or obliquity may require an
ORTHOTIC
device, such as a shoe insert, to aid balance, com-
pensate for uneven leg lengths, and avoid postural
problems. For sedentary persons,
ERGONOMIC FAC-
TORS, such as a well-chosen chair, may ease sacral
stress. Also, regular
EXERCISE and daily ACTIVITY aid
flexibility in weight-bearing joints while increas-
ing vertebral strength. Often, a simple exercise
can loosen stiff vertebral joints upon awakening or
before going to sleep. For example, as the person
lies flat on the
BACK with knees bent and feet on the
mattress, he or she pushes the
SPINE into the bed
for about five seconds, then relaxes and repeats the
process a few times.
Brown, Courtney, M.D., David H. Donaldson, M.D., and
John L. Brugman, M.D. “Sacral Obliquity, A Poorly
Understood Congenital Anomaly,” SpineUniverse.
Available online. URL: http://www.spineuniverse.
com/displayarticle.php/article2555.html. Last updated
April 26, 2005.
Medtronic Sofamor Danek. “Sacral Spine,” Back.com.
Available online. URL: http://www.back.com/anatomy-
sacral.html. Last updated March 25, 2005.
S
Ullrich, Peter F., M.D. “Sacral Region,” Spine-health.
Available online. URL: http://www.spine-health.com/
topics/anat/a06.html. Last updated August 24, 2004.
sacroiliac joint pain syndrome, sacroiliitis As the
SACRAL VERTEBRAE meet the iliac crest of the pel-
vis, the bones form small sacroiliac joints that bear
the full effects of
WEIGHT and also daily jolts on the
body. Paradoxically, either too little movement or
too much can result in joint dysfunction, produc-
ing episodes of
ACUTE PAIN that feel like SCIATICA or
a
HERNIATED DISC in the LUMBAR SPINE. Temporary
conditions, such as a
SPINAL INFECTION, and chronic
conditions, such as
OSTEOARTHRITIS, can also cause
sacroiliac joint pain. If, however, a sacroiliac joint
becomes inflamed, the condition will more likely
be referred to as sacroiliitis.
Symptoms and Diagnostic Path
Often, radiating pain extends from the lower
BACK
then branches into one or both legs. If stiffness
occurs in the lower
SPINE, the RANGE OF MOTION
may become limited, but a doctor can check this by
giving the patient simple exercises to do during a
physical examination. To further aid the diagnosis,
an X-
RAY, COMPUTED TOMOGRAPHY SCAN, or other
imaging test may be requested. If a patient limps in
with a fever though, the doctor may suspect sacroi-
liitis, which can usually be confirmed with a labora-
tory blood culture.
Treatment Options and Outlook
Conservative treatments for sacroiliac joint pain
commonly include
COLD THERAPY, NONSTEROIDAL
ANTI-INFLAMMATORY DRUG THERAPY, physical therapy,
and
ULTRASOUND THERAPY. If these prove ineffective,
other options include
STEROID THERAPY, TRANSCUTA-
NEOUS ELECTRONIC NERVE STIMULATOR (TENS) UNIT
therapy, and joint injections with the guidance of
FLUOROSCOPY. If needed, a NERVE BLOCK or other
type of
SPINAL INJECTION may be used, not only to
treat pain but to determine its point of origin.
A spinal adjustment by an osteopath or chiro-
practor can also address sacroiliac pain. Describing
this type of treatment, a Spine-health article said,
“Chiropractic manipulation of the sacroiliac joint is
usually accomplished with the patient lying down
on his or her side. More specifically, the knee oppo-
site the side the patient is lying on is flexed and
raised toward the patient’s chest. The bottom shoul-
der is positioned forward producing a stretch in the
low back and pelvic region.” With this very precise
positioning, “a low force, high amplitude manip-
ulation is applied by the chiropractor and usually
results in an audible release (created by oxygen,
nitrogen, and carbon dioxide escaping from the
joint). This chiropractic maneuver creates the typi-
cal ‘crack’ often associated with joint manipulation
and sounds similar to ‘cracking the knuckles’,” a
procedure that traditionally brings some measure
of relief.
Risk Factors and Preventive Measures
Patients with
ANKYLOSING SPONDYLITIS, people
with
POSTURE problems, and ELDERLY patients with
ARTHRITIS may be more apt to develop sacroiliac
joint pain syndrome. Risks also increase for
ATH-
LETES and young workers who exceed their LOAD
TOLERANCE or use improper LIFTING techniques.
Conversely, care in lifting can help to prevent epi-
sodes of joint pain. As a general preventive, well-
designed
EXERCISES aid posture, increase PARASPINAL
MUSCLE strength, and assist joint mobility.
Malanga, Gerald, M.D. “S-1 Joint Injections to Manage
Back Pain,” SpineUniverse. Available online.URL:
http://www.spineuniverse.com/displayarticle.php/
article1858.html. Last updated August 12, 2005.
Medtronic Sofamor Danek. “Inflammatory & Infectious
Disorders: Sacroiliitis,” Back.com. Available online. URL:
http://www.back.com/causes-inflammatory-sacrolitis.
html. Last updated March 11, 2005.
Wood, Debra. “Sacroiliac Joint Pain,” Holy Cross Hospi-
tal. Available online. URL: http://healthychoice.epnet.
com/GetContent.asp?siteid=holycross&docid=/dci/
sacroiliac. Downloaded April 18, 2006.
Yeomans, Steven G. “What is Sacroiliac Joint Dysfunc-
tion?,” Spine-health. Available online. URL: http://
www.spine-health.com/topics/cd/sjd/sjd01.html.
Downloaded April 18, 2006.
SAPHO Syndrome Initially, this acronym stands
for Synovitis, Acne, Pustulosis, Hyperostosis, and
Osteitis, which basically translates to bone, skin,
SAPHO Syndrome 247
and joint problems occurring sometime between
CHILDHOOD and ELDERLY years. More specifically,
synovitis inflames synovial joints producing symp-
toms akin to
ARTHRITIS. Acne and pustulosis involve
skin eruptions, while hyperostosis indicates an
overgrowth of bone. Similar to
SPONDYLITIS, osteitis
produces bone inflammation that primarily pro-
vokes pain and swelling in the
BACK and CERVICAL
SPINE.
Symptoms and Diagnostic Path
Bone pain and skin eruptions mark this chronic
condition, but specific tests do not. For a diagnosis, a
rheumatologist may need to rule out such disorders
as
ANKYLOSING SPONDYLITIS or JUVENILE ARTHRITIS. As
an Orphanet article explained, SAPHO syndrome
involves several diseases, so symptoms for each
must be considered. “Definite diagnosis can be hard
to establish.” However, “SAPHO must be suspected
when a patient is affected by a . . . skin disease
associated with rheumatic pains. If examination
shows that the pains are caused by . . . inflamma-
tion of bones or joints, the hypothesis tends to be
confirmed” unless a fever suggests something else,
such as a
SPINAL INFECTION.
Treatment Options and Outlook
The team effort of a dermatologist, rheumatologist,
and physical or occupational therapist will work
toward an effective course of treatment. Symptoms
may ease with regular use of
NONSTEROIDAL ANTI-
INFLAMMATORY DRUG THERAPY, perhaps with STEROID
THERAPY prescribed for a limited time. Some patients
may be given an antibiotic, but that will usually be
an individual option rather than a standard treat-
ment. To protect bone mass, some patients, includ-
ing children and
ADOLESCENTS, may be prescribed
CALCITONIN. In any case, each treatment option
attempts to alleviate the symptoms of this chronic
condition for which no cure exists. On occasion,
however, self-healing or remissions may occur.
An article in a 2002 issue of Rheumatology said,
“The natural history of SAPHO follows a prolonged
relapsing and remitting course. As patient num-
bers have been small, evidence for treatments has
been based on anecdotal evidence and small case-
control studies. Treatments thought to be of ben-
efit include tetracycline, azithromycin, colchicine
and calcitonin. Corticosteroids and non-steroidal
anti-inflammatory drugs (NSAIDs) can produce
symptomatic improvement but are limited by their
potential side-effects in long-term use.” Therefore,
“we postulated that intravenous disodium pami-
dronate, a bisphosphonate that reduces bone turn-
over, would be beneficial in the management of
this syndrome as bone biopsies often demonstrate
evidence of increased bone turnover, often similar
in appearance to Paget’s disease, and calcitonin,
which reduces the rate of bone turnover, has previ-
ously shown benefit.” The patient in this case study
required an intravenous treatment since she had
a preexisting condition of the esophagus that pro-
hibited her taking an oral
BISPHOSPHONATE, but “the
associated attacks of musculoskeletal pain were
dramatically reduced in terms of severity and dura-
tion such that, after the three treatments, she was
completely pain-free and able to return to work.”
As the medical researchers concluded, “This case
study demonstrates significant and rapid symptom-
atic benefit from intravenous pamidronate therapy
in a woman with SAPHO. It may be that a similar
response could be achieved using oral bisphospho-
nates.”
Risk Factors and Preventive Measures
A combination of skin lesions and musculoskeletal
disorders affecting the joints and
SPINE may not be
preventable, but prompt treatment can keep symp-
toms manageable. A prompt diagnosis may not
always be possible though. As an article in Skeletal
Radiology said, “The diagnosis of SAPHO syndrome
is not difficult when the typical” skin lesions or
eruptions “are located in characteristic target sites.”
However, “the diagnosis is more difficult if atypical
sites are involved and there is no skin disease.”
Earwaker, J. W. and A. Cotton. “SAPHO: Syndrome or
Concept? Imaging Findings,” Skeletal Radiology 32, no.
6 (June 2003): 311–337.
Marshall, H., J. Bromilow, A. L. Thomas and N. K. Arden.
“Pamidronate: a Novel Treatment for the SAPHO Syn-
drome?” Rheumatology 41, no. 2 (2002): 231–233.
Schilling, Fritz. “SAPHO Syndrome,” Orphanet encyclo-
pedia, January 2003. Available online. URL: http://
orphanet.infobiogen.fr/data/patho/GB/uk-sapho.
html. Downloaded April 20, 2006.
248 SAPHO Syndrome
sarcoma See CANCER.
Scheuermann’s kyphosis Sometimes referred to as
Scheuermann’s disease, this developmental type of
KYPHOSIS is not a disease but a POSTURE disorder that
occurs in growing
CHILDREN and ADOLESCENTS, espe-
cially boys. According to Holger Scheuermann, the
Danish radiologist who discovered the disorder, one
side of the
SPINE grows faster than the other, pro-
ducing wedge-shaped
VERTEBRAE. Why this happens
has not been ascertained, but some scientists credit
GENETIC FACTORS while others point to previous inju-
ries or vertebral damage. Regardless, the disorder
often produces a
HERNIATED DISC, SCHMORL’S NODE,
or symptoms similar to
DEGENERATIVE DISC DISEASE.
Symptoms and Diagnostic Path
With
CHRONIC PAIN as the main warning sign,
Scheuermann’s manifests itself in a noticeable cur-
vature of the
THORACIC SPINE, usually around the
T7 to T9 vertebrae. X-
RAYS can confirm the con-
dition, but family members may be able to detect
the problem early at home. As a Spine-health arti-
cle said, “Postural roundback can be easily distin-
guished from Scheuermann’s kyphosis by the fact
that the deformity goes away when the patient lies
down. Typically, patients with true Scheuermann’s
kyphosis need to sleep on two or three pillows at
night to stay comfortable because their deformity
remains when they lie down.”
Treatment Options and Outlook
If kyphosis reaches or exceeds 40 degrees of cur-
vature, a young patient may be fitted with an
ORTHOTIC back brace or individually molded cast.
Reporting on a case study in the Journal of Prosthetics
& Orthotics, a medical team described their method
for achieving a proper fit. While reclining, “the
patient’s hips and knees were kept flexed during
the casting in order to attempt to reduce the . . .
tilt of the pelvis and specifically, the angle of L5-
Sl. We believe that by stabilizing the pelvis in this
position and by utilizing the . . . region to apply our
primary point of force . . . to ‘unbend’ the kypho-
sis, we were able to achieve our results. Also, this
technique allowed the patient to achieve good . . .
alignment (head over pelvis) using comfortable
levels of force.” The patient wore the device for 17
hours a day, and, “after only one month, the in-
brace reduction was nearly half that of the original
kyphosis. The patient also reported relief of back
pain after only one month in the brace.”
Risk Factors and Preventive Measures
While bracing will not be effective in adults and
older adolescents, patients who still have at least a
year or more of growing to do may lose some pain
and regain vertebral height with the aid of a well-
fitted brace. Timeliness can be especially important
since early treatment can sometimes prevent per-
manent
BACK deformity. Patients who have not
received this assistance in earlier years of bone
growth may be able to strengthen their
PARASPINAL
MUSCLES through therapeutic EXERCISE. However,
anyone with a curvature of 70 degrees or more
may need
SURGERY involving DISC removal and a
BONE GRAFT to straighten and strengthen the spine.
A Spine School article explained, “Surgery for
the correction of Scheuermann’s kyphosis typically
consists of a fusion of the abnormal vertebrae. The
operation has two parts—one operation is done on
the front of the spine and another on the back of
the spine. A posterior-only fusion is rare because
of the rigidity of the curves.” Some patients may
want surgery for cosmetic reasons, but since “the
surgery is serious and involves the spine, it gener-
ally is not recommended just to improve appear-
ance.” The potential surgical complications include
injury to the
SPINAL CORD, increased pain, and a
SPINAL INFECTION. In cases involving an extreme
degree of curvature though, the problems caused
by the condition may generate more risks than
surgery has. For instance, “the disorder can cause
decreased lung and cardiac functions. The curve
of the spine causes the chest to have less room
inside the chest cavity. If the deformity is severe,
the chest cannot expand fully when you breathe.
Eventually, the heart can be affected by the poor
lung function.” In such instances, corrective sur-
gery may provide a timely and, possibly, life-sav-
ing option.
Gomez, Miguel, M.D., Patrick Flanagan, and Thomas
Gavin. “An Alternative Bracing Approach to Scheuer-
mann’s Disease: A Case Study,” American Academy
Scheuermann’s kyphosis 249
of Orthotists and Prosthetists, Journal of Prosthetics &
Orthotics 14, no. 3 (2002): 109–112.
MacAfee, Paul, M.D. “Scheuermann’s Disease of the
Thoracic and Lumbar Spine.” Spine-health. Available
online. URL: http://www.spine-health.com/topics/cd/
scheuermanns/scheu01.html. Downloaded April 20,
2006.
Spine School. “Scheuermann’s Kyphosis,” SpineUniver-
sity. Available online. URL: http://www.spineuniversity.
com/public/spinesub.asp?id=48. Downloaded April 20,
2006.
Schmorl’s node Injuries to the THORACIC SPINE
or
LUMBAR SPINE combine with the GENETIC FAC-
TORS thought to be responsible for this condition.
According to an article for Dynamic Chiropractor,
“Schmorl’s nodes are defined as herniations” or
protrusions “of the intervertebral disc through the
vertebral end-plate,” which is a cartilage-like plate
or covering that attaches the
DISCS to the VERTE-
BRAE. Normally, each vertebral end-plate provides
nutrients to the whole disc unless herniation dis-
rupts that process, thereby producing nodes as first
described in 1927 by the German pathologist Chris-
tian G. Schmörl. Active male
ADOLESCENTS and ATH-
LETES most commonly encounter the injuries that
trigger this condition. Usually, the nodes cause no
problem in adulthood, but their disruptive appear-
ance can cause an affected disc to degenerate at an
early age.
Symptoms and Diagnostic Path
Most Schmorl’s nodes present no symptoms as
such, but
BACK pain, stiffness, and tenderness over
the affected
VERTEBRAE can occur, limiting RANGE OF
MOTION. Patients may also show evidence of KYPHO-
SIS or have muscle spasms in the PARASPINAL MUS-
CLES. Besides the results of a physical examination,
X-
RAYS may confirm a diagnosis. If not, a COMPUTED
TOMOGRAPHY SCAN or MAGNETIC RESONANCE IMAGING
can rule out a
SPINAL TUMOR or a HERNIATED DISC.
An article in the American Journal of Neuroradi-
ology said, “Schmörl’s nodes are typically seen on
plain film and CT scans as . . . lesions of varying size
contained within the vertebral body at the endplate
and . . . in extreme cases may involve most of the
vertebral body. . . . Diagnosis of Schmörl’s nodes is
usually established after late changes have occurred
and become visible on plain radiographs or CT
scans.” However, “in the acute stage, Schmörl’s
nodes are difficult to diagnose and even to detect,
because . . . the herniation has not had time to
develop.” Although generally occurring in the tho-
racic or lumbar spine, formations of the nodes have
also been reported in the
CERVICAL SPINE.
Treatment Options and Outlook
Rest and
SPINAL MANIPULATION offer conservative
treatment options with daily
ACTIVITY gradually
resumed. Eventually, most athletes can return to
play. Although very uncommon, some patients
require
SURGERY.
A journal article entitled “Painful Schmorl’s
Node Treated by Lumbar Interbody Fusion”
reported, “Painful Schmorl’s node can be diagnosed
by discography, which demonstrates an intraver-
tebral disc herniation with . . . back pain. Surgical
treatment should be considered in a patient with
persistent disabling back pain. When surgical treat-
ment is indicated, eradication of the intervertebral
disc including Schmorl’s node and . . . fusion are
preferable.”
Risk Factors and Preventive Measures
A group of doctors from Australia discussed Schmorl’s
nodes in Spine. According to the article, “Seventy . . .
spines from cadavers of individuals killed in motor
vehicle accidents were examined . . . particularly for
the occurrence of acute Schmorl’s nodes” in order to
“document whether Schmorl’s nodes occur acutely
as a result of trauma.” As the researchers concluded,
“Schmorl’s nodes do occur acutely as the result of
a single traumatic episode, and are almost always
associated with other acute spinal injury. The fre-
quency and occurrence of acute Schmorl’s nodes in
motorcyclists suggest that axial loading,” or intense
pressure on the spine, “is an important mechanism.
Their predominance in the T8-L1 region” of the tho-
racic and lumbar spine “suggests that this region is
particularly susceptible to stress.”
Fahey, V., K. Opeskin, M. Silberstein, R. Anderson, and
C. Briggs. “The Pathogenesis of Schmorl’s Nodes in
Relation to Acute Trauma. An Autopsy Study,” Spine
23, no. 21 (November 1, 1998): 2,272–2,275.
250 Schmorl’s node
Grivé, Elisenda, Alex Roviraa, Jaume Capelladesa, Antoni
Rivasa, and Salvador Pedrazaa. “Radiologic Find-
ings in Two Cases of Acute Schmörl’s Nodes,” ©1999
American Society of Neuroradiology, American Journal
of Neuroradiology 20, no. 10 (1999): 1,717–1,721.
Hasegawa, K., A. Ogose, T. Morita, and Y. Hirata. “Painful
Schmorl’s Node Treated by Lumbar Interbody Fusion,”
Spinal cord: the official journal of the International Medical
Society of Paraplegia 42, no. 2 (February 2004): 124–
131.
Pate, Deborah. “Schmorl’s Nodes,” Dynamic Chiropractic 9,
no. 19 (September 13, 1991). Available online. URL:
http://www.chiroweb.com/archives/09/19/16.html.
Last modified August 17, 2005.
sciatica A number of disorders, such as a HERNI-
ATED DISC and PIRIFORMIS SYNDROME, can cause sci-
atic pain, but the condition commonly known as
sciatica most often is a symptom. As a single disor-
der though, sciatica might be more accurately called
LUMBAR RADICULOPATHY, which exhibits radiating
pain caused by pressure, inflammation, or damage
to the sciatic nerve. This large nerve exits the spinal
column between the lowest
VERTEBRA of the LUM-
BAR SPINE and the uppermost bone of the SACRAL
VERTEBRAE then runs down the middle of each hip
and leg. Consequently, sciatica can begin with
LOW
BACK PAIN or numbness that radiates into one or
both legs and feet.
As information from the Sciatica.org Web site
explained, “Sciatica arises from injury to the fibers
of the sciatic nerve. The injury can occur in one of
four places: inside the spinal canal (cauda equina);
where bundles of sciatic nerve fibers pass through
bony openings in the spine (neuroforamina); in the
pelvis (lumbrosacral plexus); where the sciatic nerve
exits the pelvis, below the piriformis muscle in the
buttock (Piriformis Syndrome), or along the leg.”
Symptoms and Diagnostic Path
Danger signs requiring immediate medical atten-
tion include lower body weakness and loss of blad-
der or bowel control. In such cases, a fever may also
occur. More commonly, radiant pain, tingling, or
numbness accompanies persistent
BACK pain. Dur-
ing a physical examination, the doctor may test the
RANGE OF MOTION or simply ask the patient to walk
across the room. If nerve involvement is suspected,
MAGNETIC RESONANCE IMAGING or X-RAYS can be
used to locate the source of inflammation.
Treatment Options and Outlook
According to the American Academy of Orthopaedic
Surgeons (AAOS), “About 80–90 percent of people
with sciatica get better, over time, without sur-
gery. . . . In rare cases, a herniated disk may press on
nerves that cause you to lose control of your bladder
or bowel. If this happens, you may also have numb-
ness or tingling in your groin or genital area.” Like
CAUDA EQUINA SYNDROME, “this is an emergency situ-
ation that requires surgery.” Otherwise, treatments
generally include bed rest,
NONSTEROIDAL ANTI-
INFLAMMATORY DRUG THERAPY, and COLD THERAPY. If
no swelling exists,
HEAT THERAPY may bring more
comfort. The AAOS also said, “Sometimes, your doc-
tor may inject your spine area with a cortisone-like
drug. As soon as possible, start physical therapy with
stretching exercises to help you resume your physi-
cal activities without sciatica pain. To start, your doc-
tor may want you to take short walks.”
Risk Factors and Preventive Measures
Regular daily
ACTIVITY and EXERCISES to strengthen
the
PARASPINAL MUSCLES or increase vertebral flex-
ibility may help to avoid sciatic pain. Patients who
must sit for long periods of time should move
around often, stretch like a cat, and consider sup-
portive
ERGONOMIC FACTORS in their choice of chairs.
Prompt treatment of
DISC problems or a short but
healing bed rest may ease sciatica too.
In Vancouver, British Columbia, a group of sur-
geons considered the impact of surgical delays. After
studying 92 patients whose lumbar disc herniation
caused sciatica, they reported their findings in the
Journal of Neurosurgery: Spine: “The only relevant
different between our study and others appears to
be in the mean time between symptom onset and
surgery. The mean of 49 weeks was considerably
longer than that in most comparable studies.” Yet,
despite these surgical delays, “the mean number of
days to return to work was 73.” Of the patients who
did not return to work after recovery, one was a
student who needed no employment; three did not
respond to a request for information, and one could
not find a job.
sciatica 251
American Academy of Orthopaedic Surgeons. “Sciatica,”
AAOS. Available online. URL: http://orthoinfo.aaos.
org/fact/thr_report.cfm?Thread_ID=167&topcategory
=Spine. Downloaded April 21, 2006.
Fisher, Charles, M.D., Vanessa Noonan, Paul Bishop,
M.D., Michael Boyd, M.D., David Fairholm, M.D.,
Peter Wing, and Marcel Dvorak, M.D. “Outcome Eval-
uation of the Operative Management of Lumbar Disc
Herniation Causing Sciatica,” Journal of Neurosurgery:
Spine 100, no. 4 (April 2004): 317–324.
Sciatica.org. “Frequently Asked Questions,” Manhattan
Physical Medicine & Rehabilitation. Available online.
URL: http://www.sciatica.org/faq.html. Downloaded
April 20, 2006.
scoliosis A sideways curve of the SPINE greater
than 10 degrees marks this condition, which may
be apparent in
INFANTS or gradually appear in grow-
ing
CHILDREN and ADOLESCENTS. Curves less than 10
degrees are not labeled as scoliosis and are consid-
ered normal anatomic variations. However, the spi-
nal development of a baby born with
DWARFISM or
a
BIRTH DEFECT OF THE SPINE needs to be monitored
as does the bone growth of a child diagnosed with
IDIOPATHIC SCOLIOSIS. Although late onset of scoliosis
seldom troubles the
BACK of an adult, abnormal cur-
vature can begin with an injury, bone loss, or such
conditions as
DEGENERATIVE DISC DISEASE, MARFAN
SYNDROME, MUSCULOSKELETAL DISORDERS, OSTEOGEN-
ESIS IMPERFECTA, OSTEOPOROSIS, RHEUMATOID ARTHRI-
TIS, and VERTEBRAL COMPRESSION FRACTURE.
According to an article posted by the Scoliosis
Research Society, “Scoliosis is defined as a side-to-
side deviation from the normal frontal axis of the
body. Although traditional, this definition is lim-
ited since the deformity occurs in varying degrees
in all three planes: back-front; side-to-side; top-to-
bottom.” Therefore, “scoliosis is a descriptive term
and not a diagnosis. As such, a search is made for
the cause.” However, “in more than 80% of the
cases, a specific cause is not found and such cases
are termed idiopathic, i.e., of undetermined cause.
This is particularly so among the type of scoliosis seen
in adolescent girls.” While
GENETIC FACTORS often
influence spinal formation, including the particu-
lar curvature of the spine, “scoliosis does not come
from carrying heavy things, athletic involvement,
sleeping/standing postures, or minor lower limb
length inequality.” If, however, a child with scoliosis
slouches or does not practice
BACKPACK SAFETY, an
existing condition certainly will not improve.
Symptoms and Diagnostic Path
B
ACKACHE, LOW BACK PAIN, and fatigue frequently
accompany scoliosis, along with such visible signs
as a tilt to the
SACRAL VERTEBRAE or misaligned POS-
TURE that makes one shoulder noticeably higher
than the other. In general though, the location of
the curvature affects the overall symptoms.
An article posted online by the National Insti-
tute of Arthritis and Musculoskeletal and Skin Dis-
eases (NIAMS) explained, “Doctors group curves
of the spine by their location, shape, pattern, and
cause. They use this information to decide how best
to treat the scoliosis.” For example, “to identify a
curve’s location, doctors find the apex of the curve
(the vertebra within the curve that is the most off-
center); the location of the apex is the ‘location’ of
the curve.” Therefore, a thoracic curvature occurs
in the
THORACIC SPINE, while a sideways curve in
the
LUMBAR SPINE will indicate a lumbar curvature.
If the apex happens to be at the point where those
two portions of the spine come together, a thoraco-
lumbar curve results.
Treatment Options and Outlook
For mild cases with less than a 20-degree curve,
SPINAL MANIPULATION may realign the spinal col-
umn, but this remains a controversial topic. Many
scientific papers have refuted the utility or long-
term benefits of this treatment, while patients
claim otherwise. Regardless, in between visits to a
chiropractor or osteopath, at home
EXERCISES may
strengthen the
PARASPINAL MUSCLES enough to hold
the individual vertebrae in place. Growing children
and teens with a curvature of 25 to 40 degrees often
require an
ORTHOTIC cast or brace to prevent further
curving of the spine. As the NIAMS said, “Braces
can be custom-made or can be made from a pre-
fabricated mold. All must be selected for the spe-
cific curve problem and fitted to each patient. . . .
To have their intended effect (to keep a curve from
getting worse), braces must be worn every day for
the full number of hours prescribed by the doctor
until the child stops growing.”
252 scoliosis
While a back brace will not correct the spine
of an adult, such an orthotic may be beneficial for
temporary use, such as to minimize pain during an
activity. At any age though, a worsening curve or
spinal instability can indicate a need for
SURGERY. If
so, the type of procedure will depend on the age of
the patient, degree of curve, stage of bone devel-
opment, and causative factor. Commonly, surgery
involves spinal fusion,
BONE GRAFT, and the implan-
tation of a device designed to stabilize the spine.
Regarding the success of various treatments and
improvement in the overall outlook, a retrospec-
tive review of 24 cases appeared in Spine. According
to that report, “The patients were assessed for the
amount of correction obtained in the main curve,
and for the spontaneous correction of the compen-
satory curves above and below.” With the ages of
the patients ranging from 10 to 43 years, “correc-
tion of the major curve at follow-up assessment was
54%.” Instead of a back or posterior approach, the
spinal fusions involved a frontal (anterior) approach
with
RODDING SURGERY to stabilize approximately
two to five vertebral segments. After following up
with their patients for an average of 3.6 years, the
doctors concluded, “Anterior correction and fusion
using solid rod instrumentation constitute effec-
tive and safe treatment of thoracolumbar scoliosis.
As compared with posterior systems, it provides
correction and rebalance of the trunk through a
shorter fusion segment.”
Risk Factors and Preventive Measures
According to the National Scoliosis Foundation Web
site, “The primary age of onset for scoliosis is 10–15
years old, occurring equally among both genders.
However, females are eight times more likely to
progress to a curve magnitude that requires treat-
ment.” Six million people in the United States have
scoliosis. “Each year scoliosis patients make more
than 600,000 visits to private physician offices, and
an estimated 30,000 children are put into a brace
for scoliosis, while 38,000 patients undergo spinal
fusion surgery.” There is no known cure and, for 80
to 85 percent of the cases, no known cause. “Con-
sequently, a scoliosis patient’s life is exacerbated
by many unknowns and treatments . . . that are
often ineffective, invasive, and/or costly. Scoliosis
patients also have increased health risks due to fre-
quent x-ray exposure.” That exposure poses little
risk for most people since the dangers of X-
RAYS can
usually be kept to a minimum. Nevertheless, expo-
sure may be hazardous for scoliosis patients who
frequently require radiographs to monitor the pro-
gression of their conditions. In addition, risks may
increase for patients who have certain sensitivities
or who have cause to question cumulative expo-
sure from
ENVIRONMENTAL INFLUENCES.
Information posted online by the Scoliosis Asso-
ciation reported, “Approximately 10% of all teens
have some degree of scoliosis. Usually only 1%
have severe enough curves to require some kind of
medical attention beyond the normal 6 months or
yearly observations.” Quite likely, X-rays will not be
required at each annual or semi-annual checkup,
but some type of monitoring will be needed. Some-
times, this can be as simple as noticing a misshapen
pattern on a T-shirt.
Since growing teens and children have the high-
est risk of developing a spinal deformity, aware-
ness and early treatment can often prevent a slight
curve from becoming an extreme postural problem.
In most cases, good
NUTRITION with ample CALCIUM
and daily
ACTIVITY, such as swimming and rowing,
can aid
BONE BUILDING and build up spinal health.
Bitan, Fabien D., M.D., Michael G. Neuwirth, M.D.,
Paul L. Kuflik, M.D., Andrew Casden, M.D., Norman
Bloom, M.D., and Sid Siddiqui, M.D. “The Use of Short
and Rigid Anterior Instrumentation in the Treatment
of Idiopathic Thoracolumbar Scoliosis: A Retrospec-
tive Review of 24 Cases,” Spine 27, no. 14 (July 15,
2002): 1,553–1,557.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases. “Questions and Answers about Scoli-
osis in Children and Adolescents,” NIAMS, National
Institutes of Health. Available online. URL: http://
www.niams.nih.gov/hi/topics/scoliosis/scochild.htm.
Downloaded April 21, 2006.
National Scoliosis Foundation. “Information and Sup-
port,” NSF. Available online. URL: http://www.scoliosis.
org/info.php. Downloaded April 21, 2006.
Scoliosis Association, Inc. “Types of Scoliosis.” Available
online. URL: http://www.scoliosis-assoc.org/default.
tpl?PageID=55&cart=11290570424484307&PageNa
me=TYPES%20OF%20SCOLIOSIS&sec_id=55&sec_
status=main. Downloaded April 21, 2006.
scoliosis 253
Scoliosis Research Society. “In Depth Review of Scolio-
sis: Introduction,” SRS. Available online. URL: http://
www.srs.org/patients/review/default.asp?page=2.
Downloaded April 21, 2006.
secondary osteoporosis Primary OSTEOPOROSIS
characteristically results from bone loss in post-
menopausal women and
ELDERLY patients. For men,
CHILDREN, and ADOLESCENTS, secondary osteoporosis
may be a likely occurrence since a number of medi-
cal conditions and medications, such as
STEROID
THERAPY, can cause bone mass to decline.
Explaining what typically happens, a fact sheet
from the National Institutes of Health (NIH) Osteo-
porosis and Related Bone Disease National Resource
Center said, “As the primary condition, juvenile
rheumatoid arthritis provides a good illustration
of the possible causes of secondary osteoporosis.
In some cases, the disease process itself can cause
osteoporosis. For example, some studies have found
that children with juvenile rheumatoid arthritis
have bone mass that is lower than expected, espe-
cially near the joints affected by arthritis. In other
cases, medication used to treat the primary disorder
may reduce bone mass. For example, drugs such
as prednisone, used to treat severe cases of juve-
nile rheumatoid arthritis, negatively affect bone
mass. Finally, some behaviors associated with the
primary disorder may lead to bone loss or a reduc-
tion in bone formation. For example, a child with
juvenile rheumatoid arthritis may avoid physical
activity, which is necessary for building and main-
taining bone mass, because it may aggravate his or
her condition or cause pain.”
Risks and Complications
High risks particularly occur for inactive people with
active cases of
ANKYLOSING SPONDYLITIS, JUVENILE
RHEUMATOID ARTHRITIS, MARFAN SYNDROME, OSTEO-
GENESIS IMPERFECTA, RHEUMATOID ARTHRITIS, RICKETS,
and
SPINAL CORD injury. Persons with metabolic dis-
orders or medications that interfere with
MINERAL
BALANCE and NUTRITION also have an especially high
risk of developing secondary osteoporosis. In addi-
tion, too much dietary
IRON and too many colas can
interfere with calcium uptake. However, otherwise
healthy individuals who consume high quantities
of alcohol or drugs or low amounts of
CALCIUM,
VITAMIN C, VITAMIN D, and other essential nutrients
will experience varying degrees of bone loss. Also,
males and females with
EATING DISORDERS greatly
increase their risks of acquiring secondary osteo-
porosis. In addition, teenage girls and women may
incur amenorrhea or the loss of their menstrual
cycles. This disruption of the normal hormonal pat-
tern then leads to further loss of bone mass.
Statistics and Studies
According to the NIH, “Individuals with anorexia
restrict their dietary intake and experience weight
loss and amenorrhea to the extent that their skel-
etal health is impaired. Low bone mineral density
(BMD) is a common feature in anorexia nervosa,
and up to two-thirds of affected teens have BMD
values more than two standard deviations below
the norm.”
Regarding studies involving men, an issue of
NIH ORBD-NRC News posted online by the NIH
reported, “The NIH Consensus Development Con-
ference Statement on Osteoporosis Prevention,
Diagnosis and Therapy estimates that 30–60 per-
cent of osteoporosis cases in men can be attributed
to secondary causes,” such as renal disease,
CANCER,
and problems with
PARATHYROID HORMONE (PTH).
Treatments vary according to the cause, but for PTH
problems, the NIH said, “Researchers in Portland,
Oregon, reported on two studies concerning the
use of human parathyroid hormone in men with
osteoporosis. In one study of 437 men, PTH use was
associated with increases in bone mineral density
of up to 9 percent at the spine and up to 3 per-
cent at the hip. In a second study of 355 men, PTH
decreased the risk of vertebral fractures by more
than 80 percent.”
Special Aids and Adaptations
A
BONE MINERAL DENSITY TEST, such as ABSORPTI-
OMETRY, assesses bone loss and helps to determine
which treatment may be needed. This can be trick-
ier for men since the average T-scores that measure
a person’s bone mass have been based on data from
young women. Also, such treatments as
HORMONE
REPLACEMENT THERAPY have been well studied in
women, but not in men. Nevertheless, some treat-
ments remain the same. For instance, the article
254 secondary osteoporosis
“Osteoporosis in Men: Suspect Secondary Dis-
ease First” in the Cleveland Clinic Journal of Medicine
reported, “Alendronate has been shown to increase
skeletal density in men comparably to levels seen
in women.” Furthermore, “it is now approved for
use in men.” In addition to that
BISPHOSPHONATE,
“teriparatide, a parathyroid hormone preparation,
is now approved to increase bone mass in men with
primary . . . osteoporosis at high risk for fracture.”
This has particular significance since the article
also stated, “Compared with women, men with
hip fractures have higher rates of mortality and
morbidity. More are institutionalized, and 30% to
50% die within a year of fracture vs. about 20%
of women.” Although other potential aids, such as
CALCITONIN, have not been thoroughly studied in
men, “small increases in bone density and a reduc-
tion in vertebral fractures were seen in major stud-
ies in women.”
Other types of
BONE BUILDING therapies appropri-
ate for men, women, and children include
HERBAL
THERAPY, HOMEOPATHIC MEDICINE, and natural forms
of nutrition, such as dairy products, fresh fruit, and
vegetables. Adequate
WATER intake also helps to
hydrate bones and body cells, thus minimizing the
inflammatory conditions that accelerate bone dam-
age. While some patients cannot avoid some drugs
that contribute to bone loss, children and adults
who regularly engage in
WEIGHT-BEARING EXERCISE,
such as jumping rope and running, can continue
to build bone strength. Also, calcium needs to be
ingested regularly and not just once in a while.
Licata, Angelo, M.D. “Osteoporosis in Men: Suspect Sec-
ondary Disease First,” Cleveland Clinic Journal of Medi-
cine 70, no. 3 (March 2003): 247–254.
National Institutes of Health Osteoporosis and Related
Bone Disease National Resource Center, “Juvenile
Osteoporosis,” NIH ORBD-NRC. Available online.
URL: http://www.osteo.org/newfile.asp?doc=r609i.
Downloaded April 21, 2006.
National Institutes of Health (NIH) Osteoporosis and
Related Bone Diseases (ORBD). “Secondary Osteo-
porosis,” NIH ORBD~NRC News 4, no. 1 (December
2001). Available online. URL: http://www.osteo.org/
newfile.asp?doc=n401&doctitle=Secondary+Osteopo
rosis&doctype=HTML+Newsletter. Downloaded April
21, 2006.
selective costimulation modulator See ABATACEPT.
selective endoscopic discectomy (SED) This
MINIMALLY INVASIVE SURGERY uses micro-instru-
ments and a minute incision to remove a
HERNI-
ATED DISC or DISCS damaged by DEGENERATIVE DISC
DISEASE. For some patients, the procedure offers an
option other than
DISCECTOMY and LAMINECTOMY.
The most appropriate treatment option may not
be determined, however, until the disc has been
located and studied with a
DISCOGRAM guided by
FLUOROSCOPY.
Procedure
Since the patient must remain awake for this pro-
cedure, a local anesthetic will be given to dull the
discomfort. Then a thin needle is inserted into
the disc space. A slightly larger probe goes into the
quarter-inch incision, then with the guidance of a
fluoroscope and X-
RAYS, the surgeon uses laser to
shrink or remove the damaged portion of one or
more discs. This out-patient procedure takes about
a half hour, but the patient remains in the clinic
long enough to be monitored.
Risks and Complications
All spinal
SURGERY, including minimally invasive
procedures, carries risks of bleeding, nerve damage,
or
SPINAL INFECTION. In an article for SpineUniverse,
Dr. Elliott Gross wrote, “Prior to the procedure,
patients are provided with outcome statistics. For
example, good to excellent results are expected in
86% of patients if pre-operative pain is primarily
low back pain. If the patient’s pain was back and
leg pain, good to excellent results should approach
92%.” For the remaining patients though,
CHRONIC
PAIN may not subside and may, instead, worsen.
Also, this type of surgery will not be the best choice
for everyone. Patients with
SPINAL STENOSIS, for
example, may need open
BACK surgery, whereas
those with spinal instability may require
ARTHROD-
ESIS with a BONE GRAFT.
Outlook and Lifestyle Modifi cations
Dr. Anthony T. Yeung, who helped to develop
selective endoscopic discectomy (SED), discussed
the evolution of the procedure in The Mount Sinai
selective endoscopic discectomy 255
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