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bone turnover markers than one can achieve with
either drug alone.” The editorial went on to state,
“It remains to be seen whether any of the com-
bination antiresorptive approaches will be associ-
ated with reductions in fracture incidence that are
greater than what can be achieved with mono-
therapy.” Besides that still-open question and the
cost of added medication, “a second potential dis-
advantage to combination antiresorptive therapy
is that bone turnover could be reduced to levels
that adversely affect skeletal mineralization. Under
usual therapeutic circumstances, the percentage of
bone that is mineralized . . . is increased when bone
turnover is reduced,” which, potentially, “causes
bones to become more and more brittle.”
What happens in one patient may not occur in
another. An article in The Journal of Bone and Min-
eral Research pointed out, “In clinical trials, patients
enrolled typically are not a homogenous population
and have different baseline characteristics.” How-
ever, “when conducting meta-analysis using sum-
mary statistics, all patients from the same treatment
group within a study are treated exactly the same.
As a consequence, the information from each indi-
vidual patient is not fully or accurately used in the
analysis.” For example, “several studies have indi-
cated that the short-term decrease of bone turnover
markers, especially those of resorption, is signifi-
cantly associated with the subsequent risk of verte-
bral and nonvertebral fractures in patients treated
with antiresorptive drugs. As pointed out recently,
the mechanisms by which these therapies reduce
skeletal fragility are probably more complex than
initially thought. They induce a marginal increase
in bone mass, which is overestimated by the appar-
ent increase in BMD.”
Questions about bone mineral density (BMD)
and bone quality continue to arise. In an article
for Mayo Clinic Proceedings, Dr. Solomon Epstein of
Mount Sinai School of Medicine in New York wrote,
“Properties related to bone strength include rate of
bone turnover, bone mineral density, . . . microar-
chitecture, and . . . mineralization. These properties
(with or without bone density) are sometimes col-
lectively referred to as bone quality. Antiresorptive
agents may reduce fracture risk by several separate
but interrelated effects on these individual proper-
ties. For example, antiresorptive agents have been
reported to reduce bone turnover, stabilize or
increase bone density, . . . reduce the number or size
of resorption sites, and improve mineralization.” As
Dr. Epstein summarized, “Reductions in fracture
risk are the most convincing evidence of good bone
quality. Data from well-designed randomized clinical
trials with up to 10 years of continuous antiresorp-
tive therapy have shown that certain antiresorptive
agents effectively reduce fracture risk and (together
with extensive preclinical data) suggest no deleteri-
ous effects on bone quality.”
AMA. “Treatment of Osteoporosis in Men,” American
Medical Association. Available online. URL: http://
www.ama-cmeonline.com/osteo_mgmt/module07/
06trea/04.htm#. Downloaded November 8, 2005.
Delmas, P.D., Li Zhengqing, and Cyrus Cooper. “Relation-
ship Between Changes in Bone Mineral Density and
Fracture Risk Reduction With Antiresorptive Drugs:
Some Issues With Meta-Analysis,” The Journal of Bone
and Mineral Research 19, no. 2 (February 2004): 330–
337.
Epstein, Solomon, M.D. “The Roles of Bone Mineral Den-
sity, Bone Turnover, and Other Properties in Reducing
Fracture Risk During Antiresorptive Therapy,” Mayo
Clinic Proceedings 80, no. 3 (March 2005): 379–388.
Ettinger, Bruce and John P. Bilezikian. “Editorial: For
Osteoporosis, Are Two Antiresorptive Drugs Bet-
ter Than One?” The Journal of Clinical Endocrinology &
Metabolism 87, no. 3 (March 2002): 983–984.
Harvard Health Publications. “Update on Osteoporosis
Drugs,” Harvard Medical School. Available online. URL:
http://www.health.harvard.edu/newsweek/Update_
on_osteoporosis_drugs.htm. Downloaded November
9, 2005.
Merck.com. “Osteoporosis, Prognosis and Treatment,”
The Merck Manual of Geriatrics. Available online.
URL: http://www.merck.com/mrkshared/mmg/sec7/
ch49/ch49b.jsp. Downloaded November 8, 2005.
National Osteoporosis Foundation. “Medications to Pre-
vent & Treat Osteoporosis,” NOF. Available online.
URL: http://www.nof.org/patientinfo/medications.htm.
Downloaded November 8, 2005.
arachnoiditis As one of three coverings around
the spinal cord and nerves, the arachnoid mem-
brane is normally thin and pliable. When inflam-
16 arachnoiditis
mation causes the delicate tissue to thicken and
swell, arachnoiditis compresses the spinal nerves,
producing
CHRONIC BACK PAIN, leg pain, or SCIATICA.
If the condition worsens, scarring and stickiness
can bind the spinal nerves and the sheath around
the spinal cord, producing the debilitating disorder
known as adhesive arachnoiditis.
Symptoms and Diagnostic Path
Initially, inflammation can begin for various rea-
sons. For example, arachnoiditis can result from a
trauma to the
SPINE, a side effect of SURGERY, or SPI-
NAL INFECTION brought on by a virus, a fungus, or
a complication of
SPINAL TUBERCULOSIS. More com-
monly, an allergic reaction to a medication, preser-
vative, or dye introduced through a
SPINAL INJECTION
can inflame the sensitive arachnoid membrane.
As inflammation continues, back pain becomes
the strongest complaint. Other symptoms vary,
depending on the location and severity of the spi-
nal nerve involvement. For example, stabbing pain
may plunge deeply into the lower back. Joints may
ache.
PARASPINAL MUSCLES may twitch or cramp.
Skin may crawl or itch, making clothing feel bur-
densome or annoying. In some people, shooting
pain darts down both legs. Others feel tingling or
numbness in the limbs with less control of the lower
part of the body. In rare instances, patients with
severe cases of adhesive arachnoiditis may become
paralyzed. Diverse causalities make the disorder
difficult to detect, especially in the presence of a
pre-existent spinal condition. Nevertheless, spinal
injections or other invasions of the sensitive area
beneath the delicate arachnoid membrane provide
a strong diagnostic clue.
Treatment Options and Outlook
Since no cure exists, primary care aims for
PAIN
MANAGEMENT. Surgical repair seldom provides long-
term relief, since the surgery itself may cause addi-
tional scarring. However,
EXERCISE and other types
of therapy, such as
COLD THERAPY, HEAT THERAPY,
HYDROTHERAPY, and MASSAGE, may help a patient
to manage daily
ACTIVITY with greater ease. Ste-
roid injections, electrical stimulation, and treat-
ment with
TRANSCUTANEOUS ELECTRONIC NERVE
STIMULATION (TENS) may be useful, but more
CLINICAL TRIALS are needed to investigate the pos-
sibilities and establish protocol. For information
about current studies recruiting patients, Clini-
calTrials.gov offers updates on http://clinicaltrials.
gov/search/term=Arachnoiditis.
Risk Factors and Preventive Measures
Within the human body, the most delicate balance
exists just below the arachnoid membrane. Yet
this space has become a virtual subway system for
medical transport. In the 1950s, for example, medi-
cal personnel washed reusable needles with deter-
gent before injecting anesthesia into the spine of
a surgical patient. Unfortunately, traces of cleanser
shot into the spine too, causing many patients to
develop permanent paralysis. Disposable needles
washed away that causative factor, but other prob-
lems surfaced. For instance, the dyes developed to
enhance X-
RAY images often damaged spinal nerves.
Although water-soluble agents now greatly reduce
that particular risk, The Burton Report cautioned,
“When water-soluble dyes are used appropriately
their risk is low and the benefit to the patient can be
high. When they are used inappropriately (wrong
agent, wrong concentration, etc.) they continue to
have the potential of being highly toxic to the tis-
sues of the nervous system. The unknown factor
in all cases of introducing a foreign body substance
into the subarachnoid space is the nature of any
given individual’s auto immune response to it.”
Since areas of sensitivity vary from one person to
the next, each should be aware of his or her level of
tolerance to preservatives, dyes, and medications.
Such information should also be provided to a pri-
mary physician, surgeon, gynecologist, and others
who may need emergency access to the spine.
Burton Report®, “The Anatomy of Adhesive Arachnoidi-
tis.” Available online. URL: http://www.burtonreport.
com/InfSpine/AdhesArachAnatomy.htm. Downloaded
November 10, 2005.
Circle Of Friends With Arachnoiditis, COFWA. “Arach-
noiditis Information and Support.” Available online.
URL: http://www.cofwa.org/. Downloaded November
10, 2005.
Dawson, Edgar G., M.D. “Arachnoiditis,” SpineUniverse.
Available online. URL: http://www.spineuniverse.
arachnoiditis 17
com/displayarticle.php/article180.html. Last updated
August 12, 2005.
National Institute of Neurological Disorders and Stroke.
“NINDS Arachnoiditis Information Page,” National
Institutes of Health. Available online. URL: http://
www.ninds.nih.gov/disorders/arachnoiditis/arach-
noiditis.htm. Last updated May 6, 2005.
arthritis As its Greek name denotes, arthritis
refers to joint inflammation, which, for about 43
million Americans, spells
PAIN. Of those diagnosed,
nearly 300,000 patients are
CHILDREN with JUVENILE
ARTHRITIS, JUVENILE RHEUMATOID ARTHRITIS, or other
conditions that affect the
BACK or joints of the VER-
TEBRAE. Another 20 million or more people of all
ages, sex, and ethnic backgrounds have arthritis but
do not know it.
Symptoms and Diagnostic Path
Since this rheumatic condition appears in over 100
forms, the symptoms vary widely. For most peo-
ple with arthritis, joints characteristically inflame,
producing swelling that impedes flexibility. Stiff-
ness often occurs in fingers, weight-bearing joints,
and vertebral joints, resulting in mild to severe dis-
comfort. Occasionally, other symptoms arise too.
For example, the
RANGE OF MOTION may decrease
as
OSTEOARTHRITIS affects the SPINE. With the pro-
gression of
ANKYLOSING SPONDYLITIS, bones in the
back fuse together, producing rigid
POSTURE. If an
auto-immune disease such as
RHEUMATOID ARTHRI-
TIS (RA) affects the internal organs, symptoms may
include fever and pain in corresponding areas of
soft tissue.
If a rheumatologist suspects RA, blood tests and
a urinalysis can aid a diagnosis. For most types of
arthritis, an X-
RAY or other imaging device may
be needed to examine the vertebral joints. In mild
cases, a family history and physical examination
may provide enough information for the rheuma-
tologist, pediatrician, or other physician to deter-
mine which type of arthritis to treat.
Treatment Options and Outlook
With more investigation needed, researchers in
Australia have discovered that the ADAMTS5
enzyme, present in all persons, can become over-
active, thus provoking an attack on the cartilage
molecule known as aggrecan. Reportedly, this phe-
nomenon activates arthritis and may also activate
future research in developing appropriate drugs.
At present, conservative medication usually
begins with
NONSTEROIDAL ANTI-INFLAMMATORY
DRUG (NSAID) THERAPY, which includes ASPIRIN,
NAPROXEN, and IBUPROFEN but not ACETAMINOPHEN.
Since the latter has no impact on inflammation,
acetaminophen does not belong in the NSAID cat-
egory but may be preferred for pain and fever in
patients with gastrointestinal sensitivity. Unlike
an NSAID, acetaminophen does not restrain the
inflammation-producing cyclooxygenase (COX)
that protects the stomach from bleeding and also
reduces tissue swelling.
Eventually, researchers identified and isolated
COX-2, which has little influence on bleeding but
still provokes inflammation. This discovery led
to the development of COX-2 inhibitors, such as
Vioxx and Celebrex, which soon became the norm
for arthritis treatment. Over time though, serious
adverse events, such as heart attack and stroke,
were noted in some patients, which resulted in
voluntary recall of Vioxx and warnings about Cele-
brex. Around the same time, the Food and Drug
Administration (FDA) also issued a public health
advisory for NSAIDs, which left arthritis patients
wondering what to do.
Since no two patients are the same, a rheumatol-
ogist or primary physician can advise each patient,
individually, on the most appropriate treatment.
Patients whose family history and medical tests
show no inclination toward cardiovascular condi-
tions may be prescribed a COX-2 inhibitor. P
AIN
MANAGEMENT may also rely on various forms of
COMPLEMENTARY AND ALTERNATIVE MEDICINE, such as
HERBAL THERAPY or HOMEOPATHIC MEDICINE. Indeed,
so many arthritis patients have opted for herbal
alternatives that, in November 2005, the FDA
issued a warning letter to manufacturers who claim
their products offer curative benefits not substanti-
ated by research.
Studies of alternative treatments, of course, had
already begun. In an article for Clinical Psychiatry
News, Doug Brunk recounted the findings of Dr.
Robert Bonakdar, the director of pain management
at the Scripps Center for Integrative Medicine in
18 arthritis
La Jolla, California. Reportedly, willow bark, the
forerunner of aspirin, reduced pain scores in osteo-
arthritis patients by 40 percent. Another favorite
herb, devil’s claw, was given to patients with osteo-
arthritis and low back pain for three to eight weeks
in dosages of 50–100 mg. With only minimal side
effects, “the treatments significantly improved the
pain level and joint mobility in study participants.”
Other natural herbs such as ginger and turmeric
“also demonstrated anti-inflammatory activity in
preliminary basic research of human trials.”
Similarly, Kerry Bone reported in the Townsend
Letter for Doctors and Patients that a trial showed
“standardized willow bark compared well with a
conventional treatment for arthritis.” After consid-
ering “evaluation of functional capacity, evaluation
of pain intensity during different activities, impair-
ment of daily activity, estimation whether pain was
localized or diffuse, . . . and time of stiffness of the
observed joint,” the trial indicated a 48 percent pain
reduction in participants who received NSAIDs.
Two other groups experienced a 31.3 to 39.5 per-
cent reduction in pain after taking the lower to
higher recommended dosages of willow bark.
Some may wonder though, if arthritis treat-
ments have been barking up the wrong tree. Finn-
ish researchers, for example, located groups of
anti-inflammatory compounds (phonemics) in the
Scotch pine commonly known as the Christmas
tree. Apparently its bark gives forth an extract with
strong anti-inflammatory properties. Although
studies still need to establish the optimal dose and
identify potential side effects, the bark of Christmas
or other pines brighten prospects for body tissue
wrapped in inflammation.
Meanwhile,
COLD THERAPY offers relief when
inflammation flares, while
HEAT THERAPY, a warm
bath, or a
MASSAGE with warmed oil may ease stiff-
ness. T
OPICAL ANALGESICS often relieve mild dis-
comfort, but a
CORTICOSTEROID INJECTION may be
needed for severe or chronic joint pain. To ease
spinal nerve pain, a physician or therapist may rec-
ommend electrical treatment with
TRANSCUTANEOUS
ELECTRONIC NERVE STIMULATION (TENS).
For spinal instability, a back brace, neck brace, or
other
ORTHOTIC may help temporarily. Some arthri-
tis patients also respond well to
ACUPUNCTURE or SPI-
NAL MANIPULATION. If the condition progresses into
DEGENERATIVE DISC DISEASE, the patient may need
ARTHRODESIS or other type of SURGERY on one or
more vertebrae in the neck or back.
Risk Factors and Preventive Measures
According to current statistics, women acquire
arthritis more often than men. Indeed, 25 mil-
lion women but fewer than 17 million men in the
United States have been diagnosed by a physician.
Reportedly, however, another 20 million patients
have not asked a doctor for directions in locating
the source of their pain, so one might wonder if
men predominantly comprise that group. Regard-
less, half of the people who have been medically
diagnosed think nothing can be done to help.
Language also presents a barrier in obtaining
a prompt diagnosis and beginning effective treat-
ment. According to a report in The Journal of Mus-
culoskeletal Medicine, “Early intervention in patients
with arthritis is crucial to slowing or halting dis-
ease progression . . . , but Hispanic patients often
do not talk about pain and may not visit a physician
when it occurs.” While the same might be said for
patients from other cultures, information in Span-
ish has recently become available, notably from the
Arthritis Foundation.
For peoples of all languages and body types,
preventive strategies include
EXERCISE, ample fresh
water, adequate
SLEEP, and wholesome NUTRITION.
For example, the omega-3 fatty acids in such cold
water fish as salmon, cod, and mackerel have anti-
inflammatory properties not found in the saturated
fats of other meat products. Whether for cooking or
massaging, olive oil or oils with
VITAMIN E can lubri-
cate and soothe dry skin, parched cells, and achy
joints. Drinking several glasses of filtered water a
day can cleanse the body of toxins and hydrate cells.
Strengthening
PARASPINAL MUSCLES, flexing joints,
and stretching vertebrae can also help, even if just
to get a sedentary body up and moving toward feel-
ing better overall.
Arthritis Foundation. “The Facts About Arthritis.” Avail-
able online. URL: http://www.arthritis.org/resources/
gettingstarted. Downloaded November 10, 2005.
Bone, Kerry. “Willow Bark versus NSAID,” Townsend Let-
ter for Doctors and Patients 265–266 (August–September
2005): 46–47.
arthritis 19
Brunk, Doug. “Patients Seek Natural Alternatives to
NSAIDs,” Clinical Psychiatry News 33, no. 7 (July 2005):
52–53.
CDC. “Arthritis: Data and Statistics,” Centers for Disease
Control and Prevention (CDC), National Center for
Chronic Disease Prevention and Health Promotion.
Available online. URL: http://www.cdc.gov/arthritis/
data_statistics. Last reviewed August 22, 2005.
Mooney, Vert, M.D. “Spinal Arthritis Complete Treatment
Guide,” Spine-health.com. Available online. URL:
http://www.spine-health.com/topics/conserv/osteo
arthtreat/osteoarthtreat01.html. Downloaded Nov-
ember 12, 2005.
Nader, Carol. “All Smiles at Arthritis Find for Young
and Old,” Australasian Business Intelligence (March 31,
2005).
Rados, Carol. “Helpful Treatments Keep People with
Arthritis Moving,” FDA Consumer 39, no. 2 (March–
April 2005).
Shiel, William C. Jr., M.D. “Arthritis,” MedicineNet.com.
Available online. URL: http://www.medicinenet.com/
arthritis/article.htm. Last reviewed June 4, 2005.
Staff. “Bark Has Bite,” Better Nutrition 67, no. 3 (March
2005): 22–23.
Staff. “The Arthritis Foundation Addresses a Grow-
ing Need for Better Information—Helping Hispanic
Patients Manage Arthritis,” The Journal of Musculoskel-
etal Medicine (September 1, 2005): 430.
arthrodesis Commonly known as spinal fusion,
arthrodesis surgically joins two or more
VERTEBRAE
to stabilize, repair, or straighten joints marred by
injury, deformity, or disease. If a
DISCECTOMY or
DISC REPLACEMENT does not offer a viable option for
a patient with a
HERNIATED DISC or DEGENERATIVE
DISC DISEASE, arthrodesis may be performed. This
procedure fuses the vertebrae together, strengthens
that area of the
SPINE, and avoids the pain that inev-
itably follows whenever bones rub against bones.
Arthrodesis can fuse joints in the neck or
CERVI-
CAL SPINE, but more often the procedure performs
LUMBAR SPINAL FUSION in the lower back. To redi-
rect or align bone growth throughout the spine,
arthrodesis can also be used to surgically treat
patients with
KYPHOSIS, SCOLIOSIS, or other vertebral
disorder affecting
POSTURE. Damage from a verte-
bral
FRACTURE may benefit from the procedure too.
Procedure
In making an incision, the surgeon uses either an
anterior (front) or posterior (back) approach. For
MINIMALLY INVASIVE SURGERY, the opening may be no
longer than an inch. Regardless of size, the opening
then makes way for a stabilizing metal device to be
implanted. Traditionally, a surgeon would insert a
BONE GRAFT to promote bone growth during healing,
but now BONE MORPHOGENETIC PROTEIN (BMP) may
be used in place of or in conjunction with a graft.
Either way, BMP introduces a synthetic form of a
naturally-produced body chemical into the surgical
site. When used alone, BMP avoids the pain associ-
ated with a graft, yet this procedure has been shown
to be as effective as using a patient’s own bone to
heal a fusion site. With effects similar to a bone graft,
BMP stimulates cells into making new bone to com-
plete the spinal fusion in a healing process that con-
tinues long after the hospital stay.
The length of hospitalization depends, in part,
on the location of the SURGERY since each area has
specific needs. If, for example, anterior arthrodesis
fuses joints in the THORACIC SPINE, a drainage tube
will be inserted into the chest and left in place for
one to three days. Patients having surgery on the
LUMBAR SPINE may require a urinary catheter and,
possibly, intravenous feeding until the lower body
functions normally again. Because of this, fusion in
the lower back may require two or three days in
the hospital.
Risks and Complications
After arthrodesis, most patients experience pain
severe enough to require medication for the first
few days. Some respond poorly to that medication
or preoperative anesthesia, and all patients risk
infection and bleeding after surgery of any type.
If a bone graft comes from the patient’s hip
or other area, that site also requires an incision,
which can produce lingering discomfort. However,
patients receiving bone grafts from their own bod-
ies have a more successful recovery than occurs
when a donor graft has been used. If multiple joints
require fusion, the rate of success declines.
Outlook and Lifestyle Modifi cations
During hospitalization, the patient will be taught
to move and turn the body as a unit to avoid spinal
20 arthrodesis
twisting. Depending on the location of surgery, a
neck brace, back brace, or other type of
ORTHOTIC
may be prescribed during the recovery period to
stabilize the site and allow new bone time to form.
This ongoing process of bone growth completes the
spinal fusion in about six to nine months.
Fusing a vertebral joint can straighten and
strengthen an area but also reduce the
RANGE OF
MOTION in that section of the spine. Since most
bending occurs in the hip and not the spine, flex-
ibility will be limited only if several joints need
fusion. Regardless, most patients prefer to sacrifice
some litheness in favor of less pain.
American Academy of Orthopaedic Surgeons (AAOS.)
“Spinal Fusion,” AAOS. Available online. URL: http://
orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=1
56&topcategory=Spine. Downloaded November 14,
2005.
Chen, Andrew L., M.D. “Spinal Fusion,” MedlinePlus,
National Institutes of Health. Available online. URL:
http://www.nlm.nih.gov/medlineplus/ency/arti-
cle/002968.htm. Updated July 4, 2004.
Medtronic Sofamor Danek. “Modern Spinal Fusion,”
Back.com. Available online. URL: http://www.back.
com/articles-modern_spinal_fusion.html. Updated July
7, 2005.
Spine Institute of New York. “Spinal Fusion,” Beth Israel
Medical Center. Available online. URL: http://www.
spineinstituteny.com/treatments/spinalfusion.html.
Downloaded November 14, 2005.
arthroplasty See DISC REPLACEMENT.
artificial disc See DISC REPLACEMENT.
ascorbic acid See VITAMIN C.
aspirin Technically known as acetylsalicylic acid
or salicylate, this
NONSTEROIDAL ANTI-INFLAMMA-
TORY DRUG (NSAID) not only thwarts inflammation
but acts as a
PAIN RELIEVER and fever reducer. All
NSAIDs have similar actions, but, unlike the oth-
ers, aspirin hinders blood platelets from clotting.
This reduced clotting action has an adverse effect
in patients with bleeding problems, but it can save
lives, especially of those in danger of a clot-induced
event such as a heart attack or stroke.
The effects of this century-old drug may vary
dramatically from one person to the next. In
everybody’s body, however, hormone-like sub-
stances signal
PAIN to the brain. That alarm system
triggers production of cyclooxygenase (COX) and
prostaglandins that cause pain, inflammation, and
fever. Despite the bad press, such symptoms do not
always produce ill effects. For instance, pain indi-
cates something is wrong. Fever burns off infection.
Inflammation assists the body’s circulatory efforts
toward healing. Each of those natural reactions
has curative value until that individually-derived
moment when too much just becomes too much.
When that happens, aspirin intercepts the pain,
calms the inflammation, reduces the fever, and
thins blood clots within minutes.
Dosage and Potential Side Effects
Aspirin slows inflammation caused by prostaglan-
dins, but this can be a problem if those same sub-
stances need to be left alone to do their other jobs
of shielding the stomach and keeping down gastric
acid. By hindering the protective action of prosta-
glandins, aspirin irritates a sensitive digestive track.
Although this happens most often in
CHILDREN or
ELDERLY patients, too much aspirin can cause stom-
ach bleeding in anyone.
To avoid stomach irritation, buffered aspirin can
be taken with milk or food. Taking a lower dose
also helps, especially since a maintenance dosage
of only 81 mg provides the amount usually recom-
mended to avoid blood clots. However, up to 1,000
mg a day may be prescribed for patients at high
risk for a cardiovascular event. A doctor may pre-
scribe even higher doses to inhibit
ARTHRITIS pain,
but at any dosage, aspirin should not be taken with
a
HOMEOPATHIC MEDICINE, pharmaceutical drug, or
herb that thins the blood unless a physician says
otherwise.
Taken by itself, a toxic dose of aspirin depends on
the person’s body weight, but depending on sensi-
tivity, toxicity can occur above 150 mg/kg to 300
mg/kg. In the event of an overdose, symptoms can
vary widely. For instance, the ears may ring, the
aspirin 21
mouth get dry, and the pulse rate increase. The per-
son may also feel nauseated or drowsy. Large quan-
tities of water, milk, or other beverage may dilute
the toxic effect, but a sharp drop in respiration or
blood pressure signals a medical emergency.
Statistics and Studies
An April 2005 health advisory from the Food and
Drug Administration (FDA) warned of the danger-
ous side effect of cardiovascular events that NSAIDs
can produce. As the only NSAID able to reduce
blood clotting, however, aspirin was omitted from
the list, which came as good news for patients with
arthritis and
CHRONIC BACK PAIN.
More good news arrived in 2005 from Brigham
and Women’s Hospital in Boston. As reported in
the AORN Journal published by the Association of
Operating Room Nurses, “Researchers have dem-
onstrated in a randomized clinical trial that low-
dose aspirin (i.e., 81 mg) triggers the human body
to generate its own anti-inflammatory compounds
that help fight unwanted inflammation. . . . The
finding has implications for people with heart dis-
ease, arthritis, and many other diseases that are
known to be associated with inflammation. The
study demonstrated that unlike COX-2 inhibitors,
aspirin—a COX-1 inhibitor—also generates ‘good’
anti-inflammatory compounds necessary to fight
disease.”
Also in 2005, Dr. Victor L. Serebruany reported
the results of a study involving over 192,000
patients. As quoted in Family Practice News, Dr.
Serebruany told attendees at the American College
of Cardiology annual meeting in Orlando, “We do
not know if 75 mg/day of aspirin is better or worse
than 325 mg in terms of efficacy, because there has
been no direct comparative trial. However, now
we know for sure that the lower the dose, the less
the bleeding risk.” Dr. Serebruany also said, “If you
give 25 mg of aspirin, you have complete platelet
inhibition within 10 minutes. This is a fact.”
In some instances, patients may need more aspi-
rin to address severe back pain or rheumatologic
issues such as gout. Others may be relieved to hear
of studies on willow bark, the forerunner of aspirin,
that has provided successful treatment for
ARTHRI-
TIS. Recent findings emphasize the importance of an
individual assessment for each patient. Neverthe-
less, no one concerned about health should exceed
the dose recommended on the label without the
say-so of a personal care physician.
Center for Drug Evaluation and Research. “FDA Public
Health Advisory,” U.S. Food and Drug Administra-
tion. Available online. URL: http://www.fda.gov/cder/
drug/advisory/COX2.htm. Downloaded November
15, 2005.
Jancin, Bruce. “Aspirin Below 100 mg/day Is Safest,
Metaanalysis Shows.” Family Practice News 35, no. 10
(May 1, 2005): 8.
MedlinePlus. “Aspirin Overdose,” U.S. Library of Medi-
cine. Available online. URL: http://www.nlm.nih.
gov/medlineplus/ency/article/002542.htm. Updated
November 9, 2005.
MedlinePlus. “Drug Information: Aspirin,” U.S. Library
of Medicine. Available online. URL: http://www.
nlm.nih.gov/medlineplus/print/druginfo/medmaster/
a682878.html. Downloaded on November 15, 2005.
Staff, Association of Operating Room Nurses, Inc. “Low-
dose Aspirin Offers Adults Inflammation Protection,”
AORN Journal 81, no. 2 (February 2005): 428.
athletes, spinal concerns of With or without con-
tact and competition, a chosen sport can strengthen
the
VERTEBRAE and PARASPINAL MUSCLES or add
undue stress. Although usually thought of as recre-
ational, an athletic activity can be occupational too.
Regardless of the goal, sports generally gain positive
support for the
BACK and SPINE.
Risks and Complications
An article posted on the Spine-health.com Web site
reported that up to 20 percent of all sports injuries
involve either the neck or the lower back. As the
article explained, “Sports that use repetitive impact
(e.g., running) or weight loading at the end of a
range-of-motion (e.g., weight lifting) commonly
cause damage to the lumbar spine (lower back).
Sports that involve contact (e.g., football) place the
cervical spine (neck) at risk of injury. The thoracic
spine (mid portion of the spine at the level of the
rib cage) is less likely to be injured in sports because
it is relatively immobile due to the rib cage.” Failing
to warm up, exceeding physical limits, and using
poor equipment, such as improperly fitted shoes,
22 athletes, spinal concerns of
increase the risk of back injury, as can too much
loading.
An article in the Journal of Athletic Training focused
on neck injuries caused by overloading the
CERVI-
CAL SPINE: “Because of the potentially catastrophic
and life-altering nature of cervical spine injury
(CSI), much concern exists regarding the prehos-
pital management of the cervical spine-injured ath-
lete. This is evidenced by a multiprofessional task
force effort initiated by the National Athletic Train-
ers’ Association to establish general guidelines for
the acute care of the spine-injured athlete. Major
CSIs, although rare compared with sprain and strain
injuries to the extremities, are troubling because of
mortality rates, and the potential permanent loss
of neural function. A CSI requires an immediate
and deliberate, yet sensitive, response. The highest
rate of severe neck injuries has occurred in Ameri-
can football and rugby. Other sports and activities
that contribute to a high rate of CSI are wrestling,
diving, recreational diving, ice hockey, gymnastics,
and horseback riding.” For example, “when contact
is applied to the crown of the head or helmet in
the football player, the cervical spine experiences
a compressive load from the torso. As the padding
provided by the helmet reaches its absorptive lim-
its, the head then reverses direction, resulting in an
increased compressive load as the cervical spine is
compressed between the head and torso. When this
compressive force exceeds the spine’s absorption
capabilities, soft and hard tissue components fail.”
Besides the possibility of a broken bone, that type
of injury often results in a wryneck (
TORTICOLLIS) or
a
FLEXION-EXTENSION INJURY similar to a whiplash.
An article in American Family Physician discussed
stingers as the most common cervical spine-related
injury in football. Over half of the players who
experience one such injury will have another,
but previous conditions such as
SPINAL STENOSIS
increase the likelihood. As the article said, “In older
athletes, about 94 percent of persistent stingers are
associated with disc degeneration or other pathol-
ogy.” Since the injury must be taken seriously, “full
evaluation and exclusion from play are indicated
if stingers persist longer than 24 hours or recur.
Any evidence of neurologic deficit, persistent pain,
loss of motion, or cervical myelopathy requires full
investigation for cervical pathology.”
Statistics and Studies
The article “Preventing Severe Head and Neck Inju-
ries in High School and Collegiate Athletes,” posted
online by the American Academy of Orthopaedic
Surgeons (AAOS), stated that college athletes expe-
rience more injuries than do high school students.
In both groups, “the number-one sport responsible
for female direct catastrophic injuries” is cheerlead-
ing, “with approximately two direct catastrophic
injuries per year.” The sport increasingly includes
gymnastic stunts, with the greatest threats occur-
ring in the pyramid and in the basket toss. Often,
the frequency and extent of injuries depend on the
number of cheerleaders involved and the height
attained. Adverse conditions, such as a wet floor
or the lack of floor mats and spotters, have a dra-
matic impact too. The AAOS added, “However, the
physical, mental and social benefits of team sports
significantly outweigh the risks involved: only one
out of every 100,000 athletes suffers from a direct
catastrophic injury.”
In another online report, “A Guide to Safety for
Young Athletes,” the AAOS provided statistics on
the number of annual injuries in children under
15: basketball, 574,000; football, 448,200; baseball,
252,665; soccer, 227,100; hockey, 80,700; gym-
nastics, 75,000; volleyball, 50,100. These injuries
involve various bones, muscles, ligaments, and
tendons, commonly resulting in a
SPRAIN, STRAIN,
or
FRACTURE. Such injuries may only temporarily
remove athletes from play, but others can cause
permanent damage to growing bones.
For
ELDERLY athletes, another AAOS report stated,
“The most common injuries among aging athletes
are chronic, overuse injuries such as muscle strains
and tendinitis. These types of injuries result from a
decrease in musculoskeletal flexibility and partici-
pation in endurance sports, such as long-distance
running, which promote muscle fatigue and pre-
disposition to injury. Chronic and overuse injuries
account for approximately 70 percent of injuries in
veteran athletes age 60 and older, whereas only 41
percent of younger athletes ages 21–25 are affected
by these same injuries.” Such injuries aside, the
AAOS also reported positive outcomes for older
participants in sports. For instance, “with regu-
lar, intensive muscle training, aging athletes well
athletes, spinal concerns of 23
into their 80s can minimize or reverse age-related
declines in muscle mass.”
Athletes of all ages may be more concerned
about muscle spasm. As Dr. Norman L. Epstein
reported in the Canadian Medical Association Journal,
“Many patients arrive in the emergency depart-
ment with acute lumbar and cervical muscle spasm
. . . that occurs either spontaneously or secondary
to nonimpact axial injuries (i.e., lifting and twist-
ing).” Although these injuries can happen to any-
one, athletes encounter such problems with greater
frequency. When this happens, “current treatment
options, such as opioids, NSAIDs and anxiolytics,
provide either minimal or no relief or precipitate
undesirable side effects.” However, Dr. Epstein
decided to study the effects of Benztropine, a drug
used to treat Parkinson’s, in relieving muscle spasm
and providing pain relief. While more studies will be
needed to corroborate the findings and their appli-
cation for athletes, this particular study showed,
“Every patient experienced substantial relief and
improved range of motion.”
Special Aids and Adaptations
The American Academy of Orthopaedic Surgeons
warned that over half of golfers twist their lower
backs when they make contact with the ball or fol-
low through with high velocity. In reporting on
these AAOS findings, the American Council on
Exercise (ACE) explained, “Unfortunately, while
your stance may be beneficial to your golf score, it
could result in the wearing of the disc in the spine.
An alternative stance, such as standing up straighter
on the follow-through, could help eliminate the
back pain, but send your handicap skyrocketing.”
What constitutes a handicap remains a matter of
perception, as shown each year by young athletes
who compete in the Special Olympics (SO). This
international nonprofit organization offers year-
round training and events in 25 sports for athletes
eight and older who have been diagnosed with
varying degrees of mental retardation. Many of the
athletes also have physical disabilities that make a
sport more challenging. For example, the person
may have poor muscle tone,
SCOLIOSIS, a musculo-
skeletal condition, or a problem affected by
WEIGHT,
making properly fitted equipment and shoes espe-
cially important in preventing injuries.
As an added precaution, the Special Olympics
requires medical approval for each participant.
According to an article by Linda Platt, “Athletes
who have abnormal radiographs are eliminated
from contact sports such as diving, gymnastics,
floor hockey, and soccer and are limited to non-
contact competition such as bowling, swimming,
cross-country skiing, figure skating, and distance
running. Swimmers who have abnormal radio-
graphs are restricted from starting on the blocks
and required to start in the pool.” Besides these
special concerns, the Special Olympics offered sen-
sible instructions for bone health in general. For
instance, “athletes need to be reminded often to
continue to hydrate before, during, and after com-
petition and practice.”
ACE, acefitness.org. “Golf Is a Pain in the Back for Some,”
American Council on Exercise. Available online. URL:
http://www.acefitness.org/fitfacts/fitbits_display.
aspx?itemid=115. Updated November 15, 2005.
American Academy of Orthopaedic Surgeons. “Aging
Athletes Require Tailored Exercise Regimen to Avoid
Overuse Injuries: Orthopaedic Surgeons Study Most
Common Bone, Joint and Muscle Problems in Mature
Athletes,” Newsroom. Available online. URL: http://
www6.aaos.org/pemr/news/press_release.cfm?
PRNumber=402. Downloaded November 16, 2005.
American Academy of Orthopaedic Surgeons. “A Guide
to Safety for Young Athletes,” AAOS, Sports/Exer-
cise. Available online. URL: http://orthoinfo.aaos.org/
brochure/thr_report.cfm?ThreadID=34&topcategory=
Sports%20%2F%20Exercise. Downloaded November
16, 2005.
American Academy of Orthopaedic Surgeons. “Prevent-
ing Severe Head and Neck Injuries in High School and
Collegiate Athletes: Orthopaedic Research Reveals
Benefits of Enhanced Protective Gear, Preventive
Strategies, Rule Revisions,” Newsroom. Available
online. URL: http://www6.aaos.org/pemr/news/press_
release.cfm?PRNumber=408. Downloaded November
16, 2005.
Epstein, Norman L., M.D. “Benztropine for Acute Muscle
Spasm in the Emergency Department,” Canadian Medi-
cal Association Journal 164, no. 2 (January 23, 2001):
203–204.
Hyde, Thomas E. “Sports Injuries and Back Pain,”
Spine-health.com. Available online. URL: http://www.
24 athletes, spinal concerns of
spine-health.com/topics/cd/sports/spsp/spsp01.html.
Downloaded November 15, 2005.
Platt, Linda S. “Medical and Orthopaedic Conditions in
Special Olympics Athletes,” Journal of Athletic Training
36, no. 1 (March 2001): 74–80.
Swartz, Erick E., R. T. Floyd, and Mike Cendoma. “Cervi-
cal Spine Functional Anatomy and the Biomechanics
of Injury Due to Compressive Loading,” Journal of Ath-
letic Training 40, no. 3 (July 2005): 155–161.
Walling, Anne D., M.D. “Cervical Spine Conditions in
Athletes,” American Family Physician 71, no. 11 (June
1, 2005): 2,194.
atlantoaxial instability The Greek god Atlas did
not actually carry the weight of the world on his
shoulders, but the first bone of the
CERVICAL SPINE
carries his name and the weight of a globe-shaped
head. Just below the atlas or C1 vertebra sits the
axis (C2) on which the head rotates. Connecting
those two
VERTEBRAE, a tooth-shaped bone known
as the dens acts as a pivotal device. However, a
trauma such as a
FLEXION-EXTENSION INJURY (whip-
lash) can dislodge the vertebrae, jiggle the “tooth,”
or loosen the supportive ligaments. In addition,
atlantoaxial instability can result from spinal condi-
tions or disorders, such as
ANKYLOSING SPONDYLITIS,
OSTEOGENESIS IMPERFECTA, RHEUMATOID ARTHRITIS,
or
SCOLIOSIS. SPINAL INFECTION and SPINAL TUMOR
can be causative factors too.
Symptoms and Diagnostic Path
Instability in the neck commonly produces pain,
occasionally with
CERVICAL RADICULOPATHY, often
indicating a pinched nerve. If symptoms include
TORTICOLLIS, the head tilts to one side, which can
increase pain or cause muscle spasm. Some patients
also experience vertigo and, in severe cases, may
have trouble with movement and mobility.
If vertebrae have shifted out of alignment, X-
RAY
may show this
VERTEBRAL SUBLUXATION. However,
an article in Postgraduate Medicine warned, “Radio-
graphs obtained in neutral position may fail to show
the instability.” To provide a clearer diagnosis and
also assess any soft tissue involvement, a
MAGNETIC
RESONANCE IMAGING (MRI) or a COMPUTED TOMOG-
RAPHY (CT) SCAN may be needed.
Treatment Options and Outlook
A Southern Medical Journal (SMJ) article said, “It is
well known that the atlantoaxial segment is the
most mobile region of the entire vertebral column.
Approximately 50% of the rotation of the cervical
spine occurs at the C1-C2 joint. The average rota-
tion at the C1-C2 joint has been calculated to be
43 degrees (range, 32 to 50 degrees). When desta-
bilized, its range of motion increases significantly,
with consequent risk of severe neurological dam-
age.” If neurological damage does occur, the person
may have difficulty walking or lose bladder or bowel
control over the lower part of the body. In such
cases, prompt
SURGERY will usually be needed.
Regarding surgery, the SMJ article discussed the
use of a device known as a transarticular screw to
stabilize the area. According to the article, “C1–C2
posterior transarticular screw fixation is a biome-
chanically superior fixation technique that provides
immediate rigid stability without the use of rigid
external orthosis.” However, “meticulous preop-
erative planning and precise operative techniques
are required for successful transarticular screw fixa-
tion, because the tolerance for error in this region
of the spine is very limited. Ultimately . . . it is up to
the surgeon to weight the advantages of this tech-
nique against the possible risk of screw malposition
and neural or vascular injury, and to choose the
technique most appropriate for each patient.”
In discussing atlantoaxial instability among
CHIL-
DREN, a group of doctors from the Department of
Neurosurgery at the Medical College of Georgia
reported in Neurosurgical Focus, “Atlantooccipital
injuries are commonly seen among pediatric spine
injuries. When surgical intervention is indicated,
we have used different fusion methods—all with
excellent outcomes.” If patients present a wry neck
or torticollis, “diagnosis is controversial, however,
most cases resolve with the use of cervical brac-
ing for time periods shorter than 6 weeks.” With
trauma causing 83 percent of the cases of atlanto-
axial instability in children and infection 17 per-
cent, the article further stated, “Most cases . . .
reduced spontaneously with the use of a rigid cer-
vical collar (50%) or with 48 to 72 hours of traction
followed by the use of a collar (33%).” Regardless
of whether an
ORTHOTIC device or SURGERY pro-
vides the best option, “dynamic imaging is critical
atlantoaxial instability 25
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