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McLain, Robert F., M.D. and Carlos Isada, M.D. “Spinal
Tuberculosis Deserves a Place on the Radar Screen,”
Cleveland Clinical Journal of Medicine 71, no. 7 (July
2004): 537–549.
Ramani, Premanand S., Alok Sharma, Sunil Jituri, and
Dattatraya P. Muzumdar. “Anterior Instrumentation
for Cervical Spine Tuberculosis: An Analysis of Surgi-
cal Experience with 61 Cases,” Neurology India 53, no.
1 (March 2005): 83–89.
spinal tumor Normally, cells reproduce, then begin
their individual but cooperative work of building and
repairing bones, organs, and soft tissue. If that cel-
lular production goes wild, the new growth finds no
place in the body, even if each cell remains harm-
less or benign. These wayward cells may cluster
around
DISCS or between VERTEBRAE, forming a pri-
mary spinal tumor that does not destroy bone but
may put pressure on the
SPINAL CORD and nerves. In
similar random but rampant events, gangs of unruly
cells can become hostile and attack healthy cells to
establish a primary
CANCER site. Unless stopped,
the malignancy may spread, tumultuously produc-
ing tumors at secondary sites in the
SPINE or other
regions of the body.
An information page from the National Institute
of Neurological Disorders and Stroke (NINDS) said,
“In a small number of individuals, primary tumors
may result from specific genetic disease (e.g., neu-
rofibromatosis, tuberous sclerosis) or from exposure
to radiation or cancer-causing chemicals.” G
ENETIC
FACTORS and ENVIRONMENTAL INFLUENCES may trigger
malignant growth, but “the cause of most primary
tumors remains a mystery. They are not contagious
and, at this time, not preventable.”
Symptoms and Diagnostic Path
Depending on the locale, spinal tumors may pro-
duce
CERVICOGENIC HEADACHE, NECK PAIN, LOW BACK
PAIN, or severe BACKACHES that hinder normal daily
ACTIVITY and SLEEP. As the North American Spine
Society Web site stated, “The symptoms associated
with spinal cord tumors may also vary depend-
ing on the level of involvement. Cervical (neck)
tumors may cause weakness or numbness in the
arms or legs. Thoracic (mid-back) and lumbosacral
(low-back) tumors may cause weakness or numb-
ness in the chest area or legs. Difficulty walking is
sometimes a complaint.”
A medical history, family history, physical exam-
ination, and appropriate diagnostic tests will be
needed. For instance, the doctor may order a biopsy
to obtain a tissue sample for microscopic assess-
ment of the conditions in the affected cells. Also,
the physician may request X-
RAY, POSITIVE EMISSION
TOMOGRAPHY (PET) SCAN, or other imaging tests. If a
benign tumor bears watching or a malignant tumor
cannot be removed,
MAGNETIC RESONANCE IMAGING
(MRI) can be used to detect changes.
Treatment Options and Outlook
An article published in The Journal of Bone & Joint
Surgery discussed the value of a biopsy in reaching
an accurate diagnosis of the specific cancer in order
to determine the most appropriate treatment. For
instance, chordoma, a rare type of tumor, consists of
growths in or around the spine, whereas a plasma-
cell tumor involves the cells of such body liquids as
blood plasma or lymph. As the article explained,
“Depending on the circumstance, treatment based
on assumptions of tumor type may lead to under-
treatment (e.g., radiation therapy for chordoma,
or hormonal treatment for parathyroid cancer) or
overtreatment (e.g., corpectomy for plasma-cell
tumor).” Also, “biopsy should be considered when
a new spinal lesion appears in a patient with a
previous or existing malignant lesion. This seems
particularly important for patients who have had a
lengthy disease-free interval, those who have soli-
tary lesions, those who have low-grade or slowly
progressive primary tumors, or those whose lesions
have occurred in an atypical manner.” In such
instances, “needle biopsy would have revealed the
true nature of these lesions in each case, without
appreciable additional expense or risk.” Further-
more, “biopsy should be strongly considered for
such patients before initiating definitive . . . care,
which usually involves high-dose irradiation or
tumor-specific chemotherapy.”
In discussing various treatments, the Cervical
Spine Research Society (CSRS) said, “Some tumors
of the spine may be treatable non-surgically. Treat-
ment options include . . . radiation, . . . radiosur-
gery, and chemotherapy. Whether the tumor of
the spine can be treated with radiation depends on
276 spinal tumor
several factors, including the size of tumor and the
type of cells the tumor contains. Generally speak-
ing, the smaller the tumor is, the more amenable
it is to radiotherapy,” which uses high-energy
radiation to destroy cancer cells and reduce the
tumor. “If the histology” or microscopic study “of
the tumor is already known (either by biopsy or
because of metastases), and the tumor is radiosen-
sitive,” thus responding to radiation, then “radia-
tion therapy may be the only treatment necessary.”
Radiation can also be combined with
SURGERY,
such as
CERVICAL LAMINAPLASTY, LAMINECTOMY,
or
VERTEBROPLASTY, “either to shrink the tumor
pre-operatively or to treat remaining tumor after
surgery. . . . Generally speaking, chemotherapy is
reserved for patients with systemic metastases, or
as an adjunct to surgical resection of malignant spi-
nal cord tumors.”
One rare, and often inoperable, malignant tumor
may occur in the remnants of the notochord or rod of
cells in unborn
INFANTS that normally develops into
the spinal vertebrae of the axial or central skeleton.
This type of spinal tumor or chordoma can occur in
CHILDREN but typically develops in ELDERLY patients,
occurring twice as often in men. As the Bonetu-
mor.org Web site explained, “Due to their origin in
the notochord, chordomas occur in the mid-line of
the axial skeleton. One half of cases occur in the
sacrococcygeal region,” around the sacrum and coc-
cyx or tailbone, “and one third occur at the base
of the skull.” If located in the
SACRAL VERTEBRAE or
upper
CERVICAL SPINE, this type of tumor can seldom
be removed. For instance, “with sacrococcygeal
tumors, sexual function and sphincter control may
be compromised after surgery. Radiation is used if
complete resection is impossible. Chordomas metas-
tasize to lymph nodes, lungs, liver and bone. Che-
motherapy can be used for late stage disease.”
Presenting a more hopeful outlook for cancer
treatments, the Thomas Jefferson University Hos-
pital in Pennsylvania announced an innovative
procedure that wraps radiation around the spine.
According to that 2005 news release, “the technol-
ogy, called shaped beam surgery, relies on sophis-
ticated computers to tailor the shape and intensity
of radiation beams to fit the exact size and shape
of the tumor—all while sparing healthy tissue. It
enables doctors to treat a range of hard-to-reach
benign and malignant tumors in the brain and spine
they couldn’t treat before, often avoiding invasive
surgery and speeding the patient’s recovery.”
As
RESEARCH continues in hospitals, universi-
ties, and government agencies, researchers aim
to find additional treatments and preventives to
improve the outlook. For example, the NINDS
reported, “Researchers are studying brachytherapy
(small radioactive pellets implanted directly into
the tumor) and advanced drugs and techniques
for chemotherapy and radiation therapy. In gene
therapy for brain and spinal cord tumors, scientists
insert a gene to make the tumor cells sensitive to
certain drugs, to program the cells to self-destruct,
or to instruct the cells to manufacture substances
to slow their growth. Scientists are also investigat-
ing why some genes become cancer-causing. Since
tumors are more sensitive to heat than normal tis-
sue, research scientists are testing hyperthermia
as a treatment by placing special heat-producing
antennae into the tumor region after surgery. In
immunotherapy, scientists are looking for ways to
duplicate or enhance the body’s immune response
to fight against brain and spinal cord cancer.”
Risk Factors and Preventive Measures
With new possibilities forthcoming, ancient ones
provide options too. For instance, the article “Acu-
puncture in Cancer Treatment” posted by the
American Academy of Medical Acupuncture and
written by an oncologist said, “Most oncologists
have experienced the patients who start vomiting
at the thought of their next clinic visit.” Besides
preventing such nauseating side effects, “acupunc-
ture is effective for control of pain, of local swelling
post-operatively, for shortening the resolution of
hematoma and tissue swelling and for minimizing
use of medications and their attendant side effects.
Energetic acupuncture, an approach consisting of
the use of needles with electricity and moxibustion
(a form of local heating with herbs) imparts a sense
of well-being and accelerates patients’ recovery. In
conjunction with nutritional support, its use is rou-
tinely employed in some cancer institutions.”
Regarding
NUTRITION, an emphasis on fruits,
vegetables, grains, and such protective nutrients as
VITAMIN A, VITAMIN C, and VITAMIN E can aid recov-
ery, boost energy, and enhance the quality of life.
spinal tumor 277
Some studies even indicate that healthful dietary
choices, including ample fresh
WATER, may prevent
or reduce cancer cells. To avert the spread of an
existing malignancy, early detection remains cru-
cial. Therefore, regular medical examinations con-
tinue to decrease patient risk and provide optimal
measures for stopping the growth of spinal tumors.
Arnold, Paul M., M.D. “Patient Information Sheet on
Tumors Involving the Cervical Spine,” Cervical Spine
Research Society. Available online. URL: http://www.
csrs.org/patientinfo/tumors.htm. Downloaded May 2,
2006.
DeGroot, Henry III, M.D. “Chordoma,” Bonetumor.org.
Available online. URL: http://bonetumor.org/tumors/
pages/page101.html. Downloaded May 2, 2006.
Lewandrowski, Kai-Uwe, M.D., Daisure Togawa, M.D.,
Thomas W. Bauer, M.D., and Robert E. McLain, M.D.
“A Role for Vertebral Biopsy in Selected Patients with
Known Malignancy,” The Journal of Bone & Joint Sur-
gery, 87-A, no. 6 (June 2005): 1,348–1,353.
Mak, Eugene, M.D. “Acupuncture in Cancer Treatment,”
American Academy of Medical Acupuncture. Available
online. URL: http://www.medicalacupuncture.org/
acu_info/articles/cancertreatment.html. Downloaded
May 2, 2006.
National Institute of Neurological Disorders and Stroke.
“NINDS Brain and Spinal Tumors Information Page,”
National Institutes of Health. Available online. URL:
http://www.ninds.nih.gov/disorders/brainandspinal
tumors/brainandspinaltumors.htm. Last updated March
17, 2006.
North American Spine Society. “Spinal Tumor,” NASS.
Available online. URL: http://www.spine.org/fsp/
prob_action-injury-tumor.cfm. Last updated March 3,
2005.
Thomas Jefferson University Hospital. “Jefferson Neu-
rosurgeons, Radiation Oncologists Wrap Radiation
Around Spine to Provide Cancer Pain Relief,” News
Release, Jefferson Health Systems. Available online.
URL: http://www.jeffersonhospital.org/news/2005/
article10954.html. Published May 30, 2005.
spine Rings of irregularly shaped VERTEBRAE, gel-
cushioning
DISCS, muscle-linking tendons, and
bone-strapping ligaments come together to form the
spine. This stack of components shapes the curva-
ceous
CERVICAL SPINE, THORACIC SPINE, and LUMBAR
SPINE then connects with the less flexible bones of
the
SACRAL VERTEBRAE and COCCYGEAL SPINE. These
five regions of the backbone have unique qualities
that cooperate to maintain upright
POSTURE, protect
the
SPINAL CORD, and mobilize the body. Even a per-
fectly designed spine, however, must contend with
numerous conditions that oppose the plan, such
as
GENETIC FACTORS, BIRTH DEFECTS OF THE SPINE,
ENVIRONMENTAL INFLUENCES, ERGONOMIC FACTORS,
degenerative conditions, and various types of
BACK
INJURY.
Risks and Complications
Remarkable
RANGE OF MOTION also makes the neck
susceptible to trauma and
NECK PAIN as caused, for
instance, by a
FLEXION-EXTENSION INJURY. Yet spinal
vulnerability increases where the cervical region
meets the thoracic spine, mainly because the neck
bends easily but connects with an area that does
not. Another vulnerable point occurs where the
fairly rigid thoracic region meets the highly mobile
lumbar spine. Adding to those worries, that thora-
columbar connection encounters the added effects
of
WEIGHT. Stress on those vertebral joints can be
compounded by pounds of body fat. Among
CHIL-
DREN and ADOLESCENTS a load of BACK problems
occur with the lack of
BACKPACK SAFETY. Similarly,
adult workers risk exceeding their personal
LOAD
TOLERANCE in LIFTING heavy or awkward objects.
In
ATHLETES, spinal concerns include SPRAIN,
STRAIN, or FRACTURE, but anyone who EXERCISES
without warming up may be prone to muscle
spasm.
ELDERLY persons may encounter knotted
PARASPINAL MUSCLES too, but aging alone raises the
risk of
DEGENERATIVE DISC DISEASE and OSTEOPORO-
SIS. People of all ages, however, gamble with spinal
wear-and-tear by wearing
SHOES that tear the spine
from its proper alignment. Anyone can be plagued
with such posture problems as
SCOLIOSIS, KYPHO-
SIS, or LORDOSIS, but prompt treatment, appropri-
ate
ORTHOTIC bracing, and sometimes SURGERY may
prevent the complications of progressive curvature
or spinal deformity.
Statistics and Studies
The American Association of Neurological Surgeons
posted an online report of over 530,000 spinal pro-
278 spine
cedures performed in a single year. Of this total,
111,488 patients had
ARTHRODESIS or spinal fusion,
and 141,620 had a
LAMINECTOMY involving one or
more discs. Another 14,062 had laminectomies not
involving discs, while 85,876 patients had laminec-
tomies to treat
SPINAL STENOSIS.
Although some patients require surgery to sta-
bilize the spine, accident victims encounter spinal
concerns that extend beyond the hospital or emer-
gency room. According to a study in the February
2006 issue of The Journal of Trauma, “reinjury risk
is highest soon after injury, but persists for at least
5 years after initial injury. Periodic interventions
through 5 years after injury, particularly in cer-
tain high-risk groups, might have lasting effects on
reinjury rates.” Yet the study also said, “any injury
to the face, spine, and extremities were associated
with a decreased risk of reinjury.”
For most people, spine pain occurs in a non-
traumatic event such as the common
BACKACHE. As
the American Academy of Orthopaedic Surgeons
reported, “More than 31 million visits were made
to physician offices in 2003 because of back prob-
lems. . . . Eight out of 10 people will experience
back pain at some point in their lives. Low back
pain is one of the most frequent problems treated
by orthopaedic surgeons.”
Special Aids and Adaptations
To help the spine adapt to the loads often placed
on it, regular daily
ACTIVITY can keep the vertebrae
flexible, while
WEIGHT-BEARING EXERCISE aids BONE-
BUILDING. If bones shift out of place, for instance
after a twisted movement or overextended reach,
SPINAL MANIPULATION may restore alignment. For
achy back muscles,
MASSAGE THERAPY, HYDROTHER-
APY, COLD THERAPY, and, in the absence of swelling
or bleeding,
HEAT THERAPY may ease ACUTE PAIN. For
CHRONIC BACK PAIN, a first course of treatment often
includes
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
(NSAID)
THERAPY, but some people prefer HOMEO-
PATHIC MEDICINE or HERB THERAPY to treat inflam-
mation and pain. Each of those special aids are just
that though: special aids for a special individual
and need. For everyone, however, plenty of fresh
WATER, well-balanced NUTRITION, and restful SLEEP
can strengthen general health and help the back-
bone adapt to the special demands of each day.
American Academy of Orthopaedic Surgeons. “The
Spine,” AAOS. Available online. URL: http://orthoinfo.
aaos.org/fact/thr_report.cfm?Thread_ID=91&
topcategory=Spine. Downloaded May 3, 2006.
NeurosurgeryToday.org. “AANS National Neurosurgical
Statistics Report—1999 Procedural Statistics,” Ameri-
can Association of Neurological Surgeons. Available
online. URL: http://www.neurosurgerytoday.org/
what/stats/spine.asp. Downloaded May 3, 2006.
Worrell, S. S., T. D. Koepsell, D. R. Sabath, L. M. Gentilello,
C. N. Mock, and A. B. Nathens. “The Risk of Reinjury
in Relation to Time since First Injury: a Retrospective
Population-based Study,” The Journal of Trauma 60, no.
2 (February 2006): 379–384.
spondylitis See ANKYLOSING SPONDYLITIS.
spondyloepiphyseal dysplasia (SED) This group
of disorders affects the
VERTEBRAE and produces
abnormal bone growth. The congenital type of
spondyloepiphyseal dysplasia (SED) may be quickly
apparent in
INFANTS with DWARFISM, disproportion-
ately large hands and feet, a barrel chest, and a
shortened
CERVICAL SPINE. Later, SED tarda, a milder
form of SED, may be detected in growing
CHILDREN
or
ADOLESCENTS with short stature or with aver-
age height except for a shortened trunk. Although
GENETIC FACTORS differ, either type of SED involves a
collagen defect and progressive change in the
SPINE.
However, SED tarda occurs only in males.
Symptoms and Diagnostic Path
X-
RAYS confirm the condition in newborns with
SED. A characteristic appearance may include flat
cheekbones, cleft palate, and skeletal deformity. As
POSTURE disorders of SCOLIOSIS, KYPHOSIS, or LORDO-
SIS worsen, a child may encounter CHRONIC BACK
PAIN. Problems in the LUMBAR SPINE may also delay
motor development.
According to the Greenberg Center for Skeletal
Dysplasias at Johns Hopkins, “Myopia (near-
sightedness) is present in 40%. Retinal detachment
can occur so careful ophthalmologic follow-up is
important to treat small retinal tears. Close oph-
thalmologic follow-up is important to monitor for
retinal problems.” To monitor skeletal changes,
spondyloepiphyseal dysplasia 279
MAGNETIC RESONANCE IMAGING and neurological
exams may be required, for instance, to assess a
potential
SPINAL CORD involvement.
An article in The Indian Journal of Radiology and
Imaging evaluated symptoms in six SED patients
then reported, “The first symptoms are usually back
pain of a vague pattern, while at a later stage osteo-
arthritis of the large proximal joints” nearest the
source of pain may develop. “In the present series
the most common type of presentation was back
ache (3 patients), gait abnormalities (2 patients)
and pain in the hip and difficulty in walking (1
patient).”
Treatment Options and Outlook
The Genetics Home Reference page posted by the
U.S. National Library of Medicine said that in con-
genital SED, “adult height ranges from 3 feet to
just over 4 feet. Abnormal curvature of the spine
(kyphoscoliosis and lordosis) becomes more severe
during childhood and can cause problems with
breathing. Instability of the spinal bones (verte-
brae) in the neck may increase the risk of spinal
cord damage. Other skeletal features include flat-
tened vertebrae (platyspondyly), an abnormality
of the hip joint in which the upper leg bones turn
inward (coxa vara), and a foot deformity called a
clubfoot.”
In cases of skeletal deformity,
SURGERY, such as
ARTHRODESIS, may be needed to fuse and stabilize
the spine. However, persons with bone deformities
in the
THORACIC SPINE may have poor respiratory
function that makes anesthesia inadvisable. Before
any surgical procedure, the condition of the neck
must also be assessed with care taken to support
the
VERTEBRAE, especially if SED produces ATLANTO-
AXIAL INSTABILITY.
Risk Factors and Preventive Measures
In choosing an appropriate daily
ACTIVITY, protec-
tive measures should be taken to lessen the risk of
head and neck trauma. Since SED carries the risk of
early development of
ARTHRITIS, DEGENERATIVE DISC
DISEASE, and OSTEOARTHRITIS, low-impact EXERCISES
can be particularly important, but only as recom-
mended by the primary care physician or therapist.
A dietician or nutritionist can suggest supportive
NUTRITION, perhaps emphasizing fresh blue-black
or red-black fruits that aid the body in producing
collagen.
Genetics Home Reference. “Spondyloepiphyseal Dyspla-
sia Congenital,” U.S. National Library of Medicine.
Available online. URL: http://ghr.nlm.nih.gov/condit
ion=spondyloepiphysealdysplasiacongenita. Published
April 28, 2006.
Greenberg Center for Skeletal Dysplasias. “Type II Col-
lagen Conditions,” Johns Hopkins Hospital Center for
Genetics. Available online. URL: http://www.hopkins
medicine.org/greenbergcenter/SED.htm. Downloaded
May 4, 2006.
Lakhar, B. N. and R. Raphael. “Spondyloepiphyseal Dys-
of Radiology and Imaging 13, no. 2 (May 2003): 199–
203.
spondylolisthesis This spinal condition may occur
because of
GENETIC FACTORS, SPONDYLOLYSIS, degen-
eration of the
DISCS and SPINE, or an injury brought
on by overextension or overuse. As also happens
in
VERTEBRAL SUBLUXATION, one or more of the spi-
nal
VERTEBRAE can become involved as a bone slips
out of alignment. Characteristically, this slippage
causes the vertebra located above to shift forward,
but sometimes backward shifting may occur.
Symptoms and Diagnostic Path
B
ACKACHES and LOW BACK PAIN may extend into the
hips and outer thighs. This dull
BACK pain may be
accompanied by tightness in the hamstrings and
muscle spasms in the calf muscles of the legs. To
confirm a diagnosis, a physician will usually request
a medical history, physical examination,
RANGE OF
MOTION tests, and X-RAYS or other imaging tools.
Treatment Options and Outlook
Conservative treatments begin with rest,
PAIN
RELIEVERS or NONSTEROIDAL ANTI-INFLAMMATORY
DRUG THERAPY, and sometimes the temporary use
of an
ORTHOTIC device. A doctor may also prescribe
traditional or
COMPLEMENTARY AND ALTERNATIVE
MEDICINE, such as COLD THERAPY, HEAT THERAPY,
HYDROTHERAPY, MASSAGE THERAPY, SPINAL MANIPULA-
TION, or ULTRASOUND THERAPY. Sometimes SURGERY
may be needed to stabilize the spine.
280 spondylolisthesis
According to an article in Neurosurgical Focus,
“treatment options for spondylolisthesis are plen-
tiful,” with surgical choices ranging from recon-
struction during open back surgery to various
types of
MINIMALLY INVASIVE SURGERY. Also, “in the
rapidly evolving field of spinal neurosurgery, . . .
techniques have been developed that allow for the
placement of . . . screws and interbody devices”
between the affected vertebrae. For newer pro-
cedures, a long-term outlook has not yet been
established. Nevertheless, “there are an assort-
ment of methods that are acceptable for the treat-
ment of spondylolisthesis, which may vary based
on the age of the patient, the type of abnormality,
and the experience and comfort of the treating
surgeon.”
Risk Factors and Preventive Measures
Active
CHILDREN, ADOLESCENTS, and ATHLETES may
be particularly at risk for vertebral slippage. As an
article in the March 2006 issue of Massage Today
explained, “Individuals engaged in certain sports or
occupations are particularly susceptible to spondy-
lolisthesis, especially if it involves repetitive flexion
and extension of the spine. It is common in gym-
nastics, rowing, diving, swimming (especially the
butterfly), tennis, wrestling, weightlifting and foot-
ball. An increased incidence also has been identified
in loggers and soldiers carrying heavy backpacks.
The condition is prevalent in adolescents due to the
extremes of physical exertion in athletics and bones
that are not fully formed.”
Despite those risks,
EXERCISE provides an impor-
tant preventive means of strengthening the
PARA-
SPINAL MUSCLES, thus reducing the risk of vertebral
slippage. As the North American Spine Society
explained, “At first, the exercises you learn may
be gentle stretches or posture changes to reduce
the back pain or leg symptoms. When you have
less pain, more vigorous aerobic exercises (such as
stationary bicycling or swimming) combined with
strengthening/stretching exercises will likely be
used to improve flexibility, strength, endurance,
and the ability to return to a more normal lifestyle.
Developing your back and stomach muscles will
help stabilize your spine and support your body.
Exercise instruction should start right away and be
modified as recovery progresses.”
Heary, Robert F., M.D. “Spondylolisthesis: Introduction
and Illustrative Cases,” Neurosurgical Focus 13, no. 1
(July 2002).
Lowe, Whitney. “Spondylolisthesis: An Elusive Cause of
Low Back Pain,” Massage Today 6, no. 3 (March, 2006).
North American Spine Society. “Adult Isthmic Spondylo-
listhesis (Slipped Vertebra),” NASS. Available online.
URL: http://www.spine.org/articles/spondylolisthesis.
cfm. Downloaded May 4, 2006.
spondylolysis This type of stress FRACTURE may
result from exceeding
LOAD TOLERANCE or receiv-
ing repeated trauma to the
SPINE. Most often, the
break involves the L5
VERTEBRA of the LUMBAR SPINE
with most incidents occurring in males. Among
older women and
ELDERLY patients, spondylolysis
may not result from stress so much as degenerative
conditions such as
OSTEOARTHRITIS. That type of the
condition may involve the
CERVICAL SPINE, THORACIC
SPINE, or lumbar region and affect the intervertebral
DISCS, possibly causing FACET JOINT DISORDER.
With
SPONDYLOLISTHESIS, vertebral shifting may
also be involved. To explain the difference between
that condition and spondylolysis, the Spine Institute
of New York said, “Spondylolisthesis . . . most com-
monly occurs in the lowest lumbar vertebra on the
bony ring formed by the pedicle and lamina bones,
which protects the spinal cord and spinal nerves.
The bone is weakest in an area called the ‘pars
interarticularis,’ which joins the upper and lower
joints. This pars defect or fracture is called spon-
dylolysis and is believed to be a stress fracture that
results from repeated strain on a bone. At first, the
body can heal the damage produced by strain on
the bone. However, if repeated strains occur faster
than the body can respond, the bone will eventu-
ally fracture. If the pars is fractured, the condition
is called spondylolysis.”
Symptoms and Diagnostic Path
While
NECK PAIN indicates involvement of the cervi-
cal spine, lumbar spondylolysis produces
LOW BACK
PAIN. In the upper back, CHRONIC BACK PAIN suggests
thoracic spine involvement. Regardless of the spi-
nal region, the diagnostic path includes a medical
history, physical examination, and X-
RAYS or other
type of imaging tests.
spondylolysis 281
Treatment Options and Outlook
According to the American Academy of Orthopae-
dic Surgeons (AAOS), “initial treatment for spon-
dylolysis is always conservative. The individual
should take a break from the activities until symp-
toms go away, as they often do. Anti-inflammatory
medications such as ibuprofen may help reduce
back pain. Occasionally, a back brace and physical
therapy may be recommended.”
Risk Factors and Preventive Measures
To explain the ongoing risks, the Mount Sinai
Medical Center said, “Pinched or irritated nerves
produce compressive symptoms. This occurs in
spondylolysis when a lump of tissue forms around
the crack—where the body tries to heal the stress
fracture. The lump can cause pressure on the spinal
nerves where they leave the spinal canal.” In such
instances, “pressure on the nerve can produce pain
that radiates down to the foot. It can also cause
numbness in the foot and weakness in the muscles
supplied by the nerve.”
Simply resting the area provides opportunity for
the spine to heal, especially if the person has the
NUTRITION, WATER, and SLEEP needed for restoration.
As the AAOS said, “In most cases, activities can be
resumed gradually and there will be few complica-
tions or recurrences. Stretching and strengthening
exercises for the back and abnormal muscles can
help prevent future recurrences of pain.”
American Academy of Orthopaedic Surgeons. “Spon-
dylolysis and Spondylolisthesis,” AAOS. Available
online. URL: http://orthoinfo.aaos.org/fact/thr_report.
cfm?Thread_ID=155&topcategory=Spine. Downloaded
May 5, 2006.
Mount Sinai Medical Center, The. “Spondylolysis and
Spondylolisthesis.” Available online. URL: http://www.
mountsinai.org/msh/msh_frame.jsp?url=clinical_
services/orthospine_spondylolysis.htm. Downloaded
May 5, 2006.
Spine Institute of New York. “Spondylolisthesis,” Beth
Israel Medical Center. Available online. URL: http://
www.spineinstituteny.com/conditions/spondylolis-
thesis.html. Downloaded May 5, 2006.
sports injury See ATHLETES, SPINAL CONCERNS OF;
SPINAL INJURY.
sprain A fall, a twisting motion, or a blow to the
body can quickly cause a vertebral joint to get out
of joint. Bones sometimes pop back into place with-
out medical treatment, but they might not. Either
way, a sudden, sharp movement can stretch, tear,
or put a hurt on the surrounding ligaments.
Symptoms and Diagnostic Path
A
CUTE PAIN, swelling, and, occasionally, bruising
characterize a sprain, but similar symptoms can
occur with a
STRAIN or muscle tearing. If a sprain
affects joint function, the
RANGE OF MOTION will be
limited.
In explaining the three types of sprains, the
National Institute of Arthritis and Musculoskel-
etal and Skin Diseases (NIAMS) said, “In general, a
grade I or mild sprain is caused by overstretching or
slight tearing of the ligaments with no joint insta-
bility.” A mild sprain can often be treated at home,
but a grade II or III sprain may require an X-
RAY to
rule out a
FRACTURE. As the NIAMS said, “A grade
II or moderate sprain is caused by further, but still
incomplete, tearing of the ligament and is charac-
terized by bruising, moderate pain, and swelling.
A person with a moderate sprain usually has more
difficulty putting weight on the affected joint and
experiences some loss of function.” By contrast,
“people who sustain a grade III or severe sprain
completely tear or rupture a ligament. Pain, swell-
ing, and bruising are usually severe, and the patient
is unable to put weight on the joint.” In such cases,
MAGNETIC RESONANCE IMAGING may be needed to
assess the damage.
Treatment Options and Outlook
Initially, the RICE
METHOD of rest, ice, compression,
and elevation reduces swelling with the addition of
NONSTEROIDAL ANTI-INFLAMMATORY DRUG THERAPY to
ease
BACK pain. A moderate sprain may require the
temporary use of an
ORTHOTIC brace for the NECK
or back to minimize movement during recovery.
If a ligament has been completely torn, however,
restorative
SURGERY will often be required.
When
LOW BACK PAIN and muscle spasms involve
stress but no tearing of the ligaments, the American
Association of Neurological Surgeons said, “The pain
is worsened by activities and bed rest is an absolute
necessity for a short period of time—one to three
282 sports injury
days.” Assuming there is no lower body weakness,
“the pain is typically limited to five to ten days and
does not involve either leg.” During this time, how-
ever, “patients are typically bent over and unable
to straighten up or maintain a normal posture. Any
particular activity is impossible, including sitting,
standing, walking, driving, etc.”
If a sprain involves the
CERVICAL SPINE, the
American Academy of Orthopaedic Surgeons said,
“Usually, neck sprains, like other sprains, will grad-
ually heal, given time and appropriate treatment.
You may have to wear a soft cervical collar to help
support the head and relieve pressure on the neck
so the ligaments have time to heal.” If the sprain
resulted from a
FLEXION-EXTENSION INJURY, other
treatment options include
MASSAGE THERAPY, TRAC-
TION, or ULTRASOUND THERAPY.
Risk Factors and Preventive Measures
Too much
WEIGHT adversely affects the LUMBAR
SPINE, yet good NUTRITION can keep down body
pounds and aid all regions of the back. Also, ade-
quate
WATER intake and warm-ups before EXERCISE
can keep the vertebral ligaments flexible and better
able to stretch. With the approval of a doctor, daily
ACTIVITY to limber up and exercises to strengthen
the
PARASPINAL MUSCLES can gradually be increased
to improve health and lower the risk of future
injuries.
American Academy of Orthopaedic Surgeons. “Neck
Sprain,” AAOS. Available online. URL: http://orthoinfo.
aaos.org/fact/thr_report.cfm?Thread_ID=141&
topcategory=Neck. Downloaded May 5, 2006.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases. “Questions and Answers About Sprains
and Strains,” NIAMS, National Institutes of Health.
Available online. URL: http://www.niams.nih.gov/hi/
topics/strain_sprain/strain_sprain.htm. Downloaded
May 5, 2006.
NeurosurgeryToday.org. “Sprain and Strain,” American
Association of Neurological Surgeons. Available online.
URL: http://www.neurosurgerytoday.org/what/patient_
e/sprain.asp. Downloaded May 5, 2006.
steroid therapy Cortisone-like medicines stem
from the cortisone-like hormones the body pro-
duces to ease pain, swelling, itching, and inflamma-
tion. For instance, an insect bite, food allergen, or
inflammatory condition in the vertebral joints may
trigger a reaction that pumps up natural cortisone
production. If that natural response fails to relieve
the symptoms, then mild drugs, such as antihista-
mines and
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
THERAPY, may initially be prescribed. A severe reac-
tion would, of course, require emergency medical
treatment. Otherwise, a condition that becomes
too intense or too prolonged for the body to handle
on its own may need other types of medication. In
such cases, the patient may be given synthetic cor-
tisone, prednisone, or other form of steroid therapy
to be taken orally or by injection.
Risks and Complications
In an article for SpineUniverse, Dr. Gerald Malanga
wrote, “In the setting of acute low back pain with
radiculopathy,” which has a pattern of pain and
numbness in muscles supplied by the same nerve
root, “oral corticosteroids are typically prescribed in
a quick tapering fashion over one week.” However,
“multiple adverse effects have been associated with
prolonged steroid use, including” suppression of
the immune system,
SECONDARY OSTEOPOROSIS, psy-
choses, gastric ulcers, electrolyte disturbances, “and
impaired wound healing. . . . The severity of these
complications correlates with the dosage, duration
of use, and the potency of the steroid prescribed.”
Extended use of steroids may occur, for example,
in treating
RHEUMATOID ARTHRITIS (RA) or JUVENILE
RHEUMATOID ARTHRITIS, which then incurs the risk
of bone loss. Other risks involved in steroid ther-
apy include muscle weakness, impaired growth in
CHILDREN and ADOLESCENTS, swings in blood pres-
sure and moods,
SLEEP problems, and dry or brit-
tle bones, including the
VERTEBRAE. Also, steroid
therapy may produce the complication of sudden
WEIGHT gain with adverse effects.
“Your Child and Prednisone” explained how ste-
roid therapy can negatively affect the immune sys-
tem. According to the article, “normally, the body
makes approximately 25 mg of cortisol per day.
When ‘stressed’ the body may make over 100 mg.
(Stress in this sense means trauma, such as major
surgery, broken bones, or a major illness.) Predni-
sone has roughly five times the potency of cortisol,
steroid therapy 283
so 5 mg of prednisone is like 25 mg of cortisol.” This
effectively combats inflammation. However, pred-
nisone also “inhibits immune cells that kill other
cells, and it inhibits the secretion of substances
(cytokines) which tend to ‘rev up’ the immune sys-
tem. The result is that all inflammatory processes
are slowed and weakened,” thereby slowing the
natural immune system.
Statistics and Studies
An article published in Pain Medicine reported, “The
only rationale for intra-articular steroids” (injected
between the spinal joints) “appears to be the expec-
tation that they should work. The most commonly
used indication has been back pain, for which no
specific diagnosis has been made. When the results
of observational studies are pooled, they paint a
picture of impressive immediate responses, but a
rapid decay of outcomes by three and six months.
Initial responses, however, are dissonant with the
literature from controlled studies of the prevalence
of lumbar . . . joint pain. Moreover, controlled trials
have shown that there is no attributable effect to
the injection of steroids.”
An article in the BMJ Journal reviewed a study
of the effectiveness of
EPIDURAL INJECTION in treat-
ing
LOW BACK PAIN then reported, “Epidural injec-
tion therapy has not yet been shown to be effective,
nor has it been shown to be ineffective. Side effects
are relatively minor, and a tendency exists towards
an outcome favouring injection therapy. On the
basis of our longstanding clinical experience we
suggest that epidural steroid injection may have
a role in specific clinical situations. Low back pain
that has not resolved within three months leads
to greater long term morbidity. Epidural injection
therapy may provide a useful adjunct to recovery in
patients whose symptoms have extended beyond
three months.” However, “the evidence for and
against epidural steroid injection should be clearly
explained to allow patients to make an informed
choice regarding their treatment.”
In October 2004, the American College of Rheu-
matology (ACR) issued a press release that reported
“between 35 percent and 45 percent of patients with
rheumatoid arthritis currently use prednisone,” a
type of steroid therapy. Prior to that announcement,
a two and a half year study compared the effects of
prednisone to those of biologic drugs prepared from
living organisms and, consequently, less likely to
cause toxicity or allergic reactions in most patients.
As the ACR reported, “While participants who used
biologic drugs were 30 percent more likely to get
pneumonia, those on prednisone were 170 percent
more likely. Therefore prednisone, the corticoste-
roid most often prescribed to treat inflammation,
poses a much larger risk.”
Special Aids and Adaptations
Before beginning long-term use of steroids, various
forms of
COMPLEMENTARY AND ALTERNATIVE MEDI-
CINE (CAM) may offer workable options. Although
many CAM therapies have not been proven effec-
tive, they have seldom been proven ineffective.
Also, each patient responds differently to
ACUPUNC-
TURE, HERBAL THERAPY, and HOMEOPATHIC MEDICINE.
Almost everyone, though, can benefit from natural
aids, such as ample
WATER intake, well-balanced
NUTRITION, and some type of daily ACTIVITY. Besides
those natural aids, short-term steroid therapy may
be just what the doctor orders to ease pain and
inflammation long enough to adapt to a long-range
course of appropriate
EXERCISE.
American College of Rheumatology. “Prednisone May
Prove to Be a High Risk Factor for Pneumonia in
Patients with Rheumatoid Arthritis,” Press Release
October 17, 2004. Available online. URL: http://www.
rheumatology.org/press/2004/wolfe_pneumonia.asp.
Downloaded May 5, 2006.
Bogduk, N. “A Narrative Review of Intra-articular Corti-
costeroid Injections for Low Back Pain,” Pain Medicine
6, no. 4 (July–August 2005): 287–296.
Malanga, Gerald, M.D. “Corticosteroids in the Treatment
of Acute Low Back Pain,” SpineUniverse. Available
online. URL: http://www.spineuniverse.com/display-
article.php/article1835.html. Last updated February
13, 2006.
Punch, Jeffrey D., M.D. “Your Child and Prednisone,”
C.L.A.S.S., Children’s Liver Association for Support
Services. Available online. URL: http://www.classkids.
org/library/pred.htm. Downloaded May 5, 2006.
Samanta, Ash and Jo Samanta. “Is Epidural Injection of Ste-
roids Effective for Low Back Pain?” BMJ Journal (June
2004). Available online. URL: http://bmj.bmjjournals.
com/cgi/content/full/328/7455/1509. Downloaded May
5, 2006.
284 steroid therapy
Still’s disease See JUVENILE RHEUMATOID ARTHRITIS.
stinger See BRACHIAL PLEXUS INJURY.
strain TENSION, improper LIFTING techniques, and
sudden movements can strain
PARASPINAL MUSCLES
to the limit. Too far can stress muscle tissue in the
BACK and connective tendons too.
To differentiate between a strain and a ligament-
stretched
SPRAIN, the National Institute of Arthritis
and Musculoskeletal and Skin Diseases (NIAMS)
said, “A strain is an injury to either a muscle or a
tendon (fibrous cords of tissue that connect muscle
to bone). Depending on the severity of the injury, a
strain may be a simple overstretch of the muscle or
tendon, or it can result from a partial or complete
tear.”
Symptoms and Diagnostic Path
As the NIAMS Web site said, “A strain is caused by
twisting or pulling a muscle or tendon. Strains can
be acute or chronic. An acute strain is associated
with a recent trauma or injury; it also can occur after
improperly lifting heavy objects or overstressing
the muscles. Chronic strains are usually the result
of overuse: prolonged, repetitive movement of the
muscles and tendons.” A
CUTE PAIN, BACKACHE, and
muscle spasms may indicate a muscle strain, but the
same symptoms can occur with other causes of
LOW
BACK PAIN. To find out what precipitated the event,
a doctor will request a medical history in addition
to performing a physical examination.
Treatment Options and Outlook
The RICE
METHOD of rest, ice, compression, and
elevation often offers the first option of home treat-
ment. In discussing
ATHLETES with muscle strain, the
North American Spine Society (NASS) said, “Initial
treatment may require a period of rest, removing
the athlete from sports participation. Treatments
may include medication and special exercise. Ice
can be used along with pain medications, which
should be used sparingly. In addition, other mea-
sures to control pain and restore motion are com-
monly used. Initially, ice and medications such as
nonsteroidal anti-inflammatories can be used. For
persistent symptoms, particularly those associated
with muscle spasm, heat may also be very helpful.”
Besides applying
COLD THERAPY followed by HEAT
THERAPY, the NASS suggested slowly beginning
“sport-specific exercises that mimic activities of ath-
letic competition. . . . It is also always important to
evaluate and correct poor technique and mechanics
that may have predisposed the athlete to the initial
injury.”
Risk Factors and Preventive Measures
The American Academy of Orthopaedic Surgeons
(AAOS) warned, “People at risk for the injury have
a history of sprains and strains, are overweight, and
are in poor physical condition.” Among athletes,
those who engage in sports that involve jumping
or twisting have a higher risk of muscle strain. In
addition, “inadequate rest breaks during intensive
training precipitates a strain.”
If muscle strain immobilizes a person for two
weeks or more, muscles may weaken. Therefore,
when swelling and intense pain have subsided, a
doctor may advise gradually increasing daily
ACTIV-
ITY and conditioning EXERCISE.
American Academy of Orthopaedic Surgeons. “Sprains
and Strains,” AAOS. Available online. URL: http://
orthoinfo.aaos.org/fact/thr_report.cfm?Thread_
ID=45& topcategory=General%20Information. Down-
loaded May 5, 2006.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases. “Questions and Answers About Sprains
and Strains,” NIAMS, National Institutes of Health.
Available online. URL: http://www.niams.nih.gov/
hi/topics/strain_sprain/strain_sprain.htm. Downloaded
May 5, 2006.
North American Spine Society. “Treatment of the Young
Athlete,” NASS. Available online. URL: http://www.
spine.org/articles/young_athlete.cfm. Downloaded May
5, 2006.
strength training Typically, strength training
combines a variety of
EXERCISES, such as weight lift-
ing,
WEIGHT-BEARING EXERCISE, stair-climbing, and
other activities designed to increase balance,
strengthen
PARASPINAL MUSCLES, support POSTURE,
and aid
BONE BUILDING. Energy, endurance, overall
strength training 285
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