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bone scan To assess SPINAL TUMORS, SPINAL INFEC-
TIONS, FRACTURES, CANCER, or other bone conditions
of the
SPINE, this type of radionuclide imaging offers
a more accurate image than an X-
RAY usually pro-
vides. A scan can also detect
OSTEITIS DEFORMANS,
ARTHRITIS, RICKETS, and other sources of bone PAIN.
Procedure
With no preparation but the removal of jewelry
and other metals, a patient undergoes a proce-
dure as described on the Spine Institute of New
York Web site: “during a bone scan, a radioactive
chemical is injected into the bloodstream.” In about
three hours, “this chemical adheres to parts of the
bone which are undergoing rapid changes. After a
gamma camera scans the area, these parts show up
as dark areas on the film.”
A full body scan takes less than an hour. Once
the affected area has been located, additional tests
may be recommended. For example, Spine-health.
com said, “Bone scans . . . cannot distinguish what
a lesion represents, and therefore cannot differen-
tiate between a tumor, an infection or a fracture.
Therefore, this type of imaging study usually needs
to be followed by a CT scan and/or MRI scan to bet-
ter characterize the lesion.”
Risks and Complications
With radiation lower than the amount in an X-ray,
a bone scan carries a minimal risk of exposure. This
does, however, present risks to an unborn child,
so women must avoid this test during
PREGNANCY.
Also, some patients may experience an allergic
reaction to use of the dye.
Outlook and Lifestyle Modifi cations
To wash the unused radioactive material from the
system, patients should drink several glasses of
water after the test. According to MayoClinic.com,
radioactivity disappears in one to three days, during
which time new mothers should refrain from nurs-
ing their
INFANTS. Otherwise, most patients expe-
rience no side effects nor need for additional care
except individual treatment of the condition.
MayoClinic.com. “Bone Scan: Using Nuclear Medicine
to Look for Bone Abnormalities,” Mayo Clinic Health
Information. Available online. URL: http://www.
mayoclinic.com/health/bone-scan/CA00020. Updated
October 27, 2005.
Spinasanta, Susan. “Bone Scan,” SpineUniverse.com.
Available online. URL: http://www.spineuniverse.
com/displayarticle.php/article245.html. Last updated
June 2, 2004.
Spine-health.com. “Bone Scan.” Available online. URL:
http://www.spine-health.com/topics/diag/diag09.
html. Downloaded December 2, 2005.
Spine Institute of New York. “Bone Scan,” Beth Israel
Medical Center. Available online. URL: http://www.
spineinstituteny.com/conditions/bonescan.html. Down-
loaded November 29, 2005.
bone spur See OSTEOPHYTE.
brace, back See ORTHOTICS.
brace, neck See ORTHOTICS.
brachial plexus injury The seven bones of the CER-
VICAL SPINE accommodate the brachial plexus nerves
that travel down the neck and into the shoulder. If
an injury occurs in that area, the condition may be
referred to as a burner or stinger, mainly because
that describes the type of pain typically felt.
Symptoms and Diagnostic Path
When the head has been shoved or the neck pushed
aside too quickly, burning or stinging pain may
shoot down the arms. After performing a physical
examination, a physician may request an X-
RAY,
COMPUTED TOMOGRAPHY (CT) SCAN, or MAGNETIC
RESONANCE IMAGING (MRI) to rule out a FRACTURE.
If the arms or hands feel weak or numb, an
ELEC-
TROMYOGRAM (EMG) or a NERVE CONDUCTION STUDY
may be needed to detect any damage to the muscles
or nerves.
Treatment Options and Outlook
Until a doctor has confirmed a brachial plexus
injury, the area should be immobilized and precau-
tions taken as for a suspected
SPINAL INJURY. After
a diagnosis, an ice pack can be applied for about
46 bone scan
20 minutes every three to four hours. When pain
subsides in two to three days,
HEAT THERAPY gen-
erally replaces
COLD THERAPY, especially if the neck
muscles feel stiff and achy. A physician may also
prescribe
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
(NSAID)
THERAPY or other PAIN RELIEVER. If the
injury caused
VERTEBRAL SUBLUXATION with no bone
fracture, a chiropractor or osteopath may perform
SPINAL MANIPULATION to ease neck VERTEBRAE into
place.
MASSAGE THERAPY may lessen the discomfort
too.
Risk Factors and Preventive Measures
STRENGTH TRAINING acts as a preventive and
addresses the spinal concerns of
ATHLETES who
engage in contact sports.
EXERCISE designed to
strengthen the neck can reduce the risk of a bra-
chial plexus injury, but a helmet will not prevent
one when contact comes head-on. If a stinger does
occur, rest and prompt treatment score the quick-
est goal of recovery.
Rouzier, Pierre, M.D., for McKesson Provider Technolo-
gies. “Brachial Plexus Injury (Stinger/Burner),” Univer-
sity of Michigan Health System. Available online. URL:
http://www.med.umich.edu/1libr/sma/sma_stinger_
sma.htm. Last modified April 19, 2005.
Smith, Carrie Myers. “Burner or Stinger (Brachial Plexus
Injury),” Holy Cross Hospital. Available online. URL:
http://healthychoice.epnet.com/GetContent.asp?site
id=holycross&docid=/dci/burner. Last reviewed Sep-
tember 2005. Downloaded December 2, 2005.
brittle bone disease See OSTEOGENESIS IMPERFECTA.
bulimia See EATING DISORDERS, BONE LOSS CAUSED BY.
bulimia 47
48
calcitonin
This naturally occurring hormone
regulates bone metabolism and
CALCIUM absorp-
tion throughout the body. The manufactured form
of calcitonin offers a type of
ANTIRESORPTIVE DRUG
therapy and provides an older alternative to the
BISPHOSPHONATE drugs commonly prescribed to
treat bone loss.
An article on the Web site of the American Med-
ical Association (AMA) explained, “Continuous use
of calcitonin is associated with a persistent decrease
in the rate of bone resorption,” thus reducing the
loss of bone mass. “Calcitonin is also thought to
have an analgesic effect on bone pain associated
with vertebral fractures. For this reason, calcitonin
is often used to treat the pain associated with acute
vertebral fragility fractures.”
Dosage and Potential Side Effects
Doses vary, depending on the form of calcitonin
and the age of the patient. Originally designed as
an injection, approval later arrived for a nasal spray
of salmon calcitonin to treat
OSTEOPOROSIS and pre-
vent
VERTEBRAL COMPRESSION FRACTURE. While the
spray can irritate sensitive sinus passages, an injec-
tion brings potential side effects of an upset stomach
or nausea. Rare side effects of a severe nosebleed,
chills, fever, weakness, or respiratory problems
should be reported to a doctor right away.
Statistics and Studies
According to the AMA article, “the largest random-
ized controlled trial of nasal calcitonin . . . demon-
strated a reduction in vertebral fractures for those
individuals taking 200 IU/d, but there was no sig-
nificant decline for those receiving 100 or 400 IU”
per day. Although the drug may lessen the risk
of bone
FRACTURES in general, the AMA reported,
“Intranasal calcitonin has not been shown to sig-
nificantly decrease nonvertebral fracture rates after
5 years.”
E
LDERLY patients often receive calcitonin, but
specific studies of that age group have not been
made, nor have studies of
CHILDREN or unborn
INFANTS. If studies of animals provide an indicator
though, an infant’s birth weight may be slightly
lower when the mother takes calcitonin. Never-
theless, pregnant women with conditions such as
OSTEITIS DEFORMANS or patients who cannot take
bisphosphonates or
HORMONE REPLACEMENT THERAPY
may need calcitonin to strengthen bones and assist
BONE BUILDING.
American Medical Association. “Antiresorptive Therapy:
Calcitonin,” AMA. Available online. URL: http://www.
ama-cmeonline.com/osteo_mgmt/module05/06anti/
index.htm. Downloaded December 2, 2005.
Thompson MICROMEDEX. “Calcitonin (Systemic),” Med-
linePlus Drugs, National Institutes of Health. Available
online. URL: http://www.nlm.nih.gov/medlineplus/
druginfo/uspdi/202106.html. Last updated October
27, 2005.
calcium Can milk give a person backbone? Maybe.
Whether from milk or other natural sources, cal-
cium builds bones that, in turn, store the mineral
for use throughout the body. In the
BACK, SPINE, or
elsewhere, bones do not provide a warehouse so
much as a “where-housed?” In other words, bone
calcium acts as a distribution center to provide
whatever the body consumes. As with any item a
consumer needs, the demands can be high.
Besides bone formation, a body needs calcium
to maintain a regular heartbeat, appropriately clot
the blood, prevent muscle cramps, and activate
nerves for movement. Calcium also offers a calm-
C
ing effect that soothes aching joints and enables a
body to
SLEEP, unless something disrupts the pro-
cess. For example, caffeine, alcohol, table salt, and
white flour can cause calcium loss, while sugars,
fat, and protein interfere with calcium absorption.
With too many disruptions or too low a calcium
intake, the body robs calcium from wherever it is
housed, which, about 99 percent of the time, will
be in bones.
Dosage and Potential Side Effects
Adequate calcium intake has particular impor-
tance during the
BONE BUILDING years of childhood.
For
CHILDREN, the Milk Matters Web site from the
National Institute of Child Health and Human
Development listed these requirements: From birth
to six months, 210 mg; six months to one year, 270
mg; one- to three-year-olds, 500 mg; four- to eight-
year-olds, 800 mg; and children nine to 18, 1,300
mg. With dairy products a primary source of cal-
cium, one cup of milk or three slices of American
cheese have 300 mg. A cup of child-favored mac-
aroni and cheese holds about 100 mg of calcium,
and a nice slice of cheese pizza, 200.
A dietary fact sheet from the National Institutes
of Health (NIH) recommended 1,000 mg of calcium
for adults, 19 to 50, with 1,300 mg for pregnant
women and 1,200 mg for adults over 50. People
who do not tolerate milk may do fine with a cup
of yogurt, which has the same calcium as a cup of
milk, but a cup of calcium-fortified orange juice
has even more. Other food sources to rival a cup of
milk include one and a half cups of kale, two and
a quarter cups of cooked broccoli, or four ounces
of canned salmon with the soft bones crushed into
the fish. Although most people would not object
to three cups of ice cream, calcium does not have
to come in one food at one time. Each milligram
counts, whether milk goes into pudding, pancakes,
mashed potatoes, or cereal. Cheese chunks atop
chili or grated over pasta add flavor, color, and cal-
cium too.
Natural sources of calcium usually incur no side
effects other than food allergies or lactose intoler-
ance. Often, the latter can be remedied by using
soured dairy products, such as sour cream, yogurt,
and the buttermilk great for plumping biscuits, but
other foods can thwart calcium use. For instance,
VITAMIN D increases absorption, whereas the oxalic
acid found in beans, greens, and sweet potatoes
hinders calcium uptake. Foods high in phytate,
such as fiber or wheat bran, also interfere with cal-
cium absorption. “However, the effect of fiber on
calcium absorption is more of a concern for indi-
viduals with low calcium intakes,” according to NIH
information, because “the average American tends
to consume much less fiber per day than the level
that would be needed to affect calcium absorption.”
Similarly, “the effect of dietary phosphorus on cal-
cium is minimal. Some researchers speculate that
the detrimental effects of consuming foods high in
phosphate such as carbonated soft drinks is due to
the replacement of milk with soda rather than the
phosphate level itself.” In addition, food and bever-
ages low in calcium but high in protein, potassium,
sodium, and caffeine can affect
MINERAL BALANCE.
Statistics and Studies
In Food Chemical Toxicology, R. P. Heaney reported,
“Human physiological studies and controlled bal-
ance studies show a clear but only a very small
depressant effect of caffeine itself on intestinal cal-
cium absorption,” with no effect on calcium excre-
tion during a 24-hour period. If a person ingests
the recommended daily dose of calcium, caffeine
usually has no harmful effects on bone status.
However, “low calcium intake is clearly linked to
skeletal fragility, and it is likely that a high caffeine
intake is often a marker for a low calcium intake.”
The solution? For coffee-drinkers concerned about
bone health, “the negative effect of caffeine on cal-
cium absorption is small enough to be fully offset
by as little as 1–2 tablespoons of milk.”
Heaney, R. P. “Effects of Caffeine on Bone and the Cal-
cium Economy,” Food Chemical Toxicology 40, no. 9
(September 2002): 1,263–1,270.
Milk Matters. “Tweens and Teens Need Calcium Now
More Than Ever,” National Institutes of Health,
National Institute of Child Health and Human Devel-
opment. Available online. URL: http://www.nichd.nih.
gov/milk/milk.cfm. Downloaded December 2, 2005.
Office of Dietary Supplements. “Dietary Supplement Fact
Sheet: Calcium,” National Institutes of Health. Available
online. URL: http://ods.od.nih.gov/factsheets/calcium.
asp. Updated September 23, 2005.
calcium 49
cancer Healthy growth in INFANTS, CHILDREN, and
ADOLESCENTS counts on cells’ dividing in an orderly
fashion and staying within the boundaries of a
functional design. In all age groups, normal repairs
throughout the body depend on systematic cel-
lular division. If cells rampantly divide, however,
disorderly growths or tumors appear, eventually
displacing healthy bone and tissue. These benign
growths may not be life-threatening, but they can
cause
PAIN by invading vertebral spaces and press-
ing spinal nerves. If malignant cells begin to form
anywhere in the body, cancer can spread to the
VERTEBRAE and other bones.
Less often, cancerous cells originate in bone or
as
SPINAL TUMORS. As the American Cancer Soci-
ety (ACS) said, “In 2005, about 2,570 new cases
of cancer of the bones and joints will be diagnosed,
and about 1,200 deaths from these cancers are
expected,” but, “primary cancers of bones account
for less than 0.2% of all cancers.”
Symptoms and Diagnostic Path
For early detection, the ACS recommended routine
testing and regular physical examinations. Prompt
attention must be given to such signs as gradu-
ally increased pain, swelling, or the presence of a
lump or knot. A spontaneous or easily occurring
FRACTURE can be a symptom, too, but this usually
happens in a limb that has been achy or painful
for weeks. More often, patients experience weight
loss and fatigue, especially if cancerous cells have
spread into bones or body organs.
To expose cancer in a bone, an X-
RAY may detect
a hole-like appearance or other irregular shape. An
oncologist or other physician will also recommend
a urinalysis, blood test, and needle biopsy to con-
firm or rule out a malignancy. Additional tests may
include a
BONE SCAN, COMPUTED TOMOGRAPHY (CT)
SCAN, MAGNETIC RESONANCE IMAGING (MRI), or POSI-
TIVE EMISSION TOMOGRAPHY (PET) SCAN to determine
the site of origin and see if spreading has occurred.
Treatment Options and Outlook
The article “Metastatic Bone Disease” posted by the
American Academy of Orthopaedic Surgeons (AAOS)
summarized: “The skeleton is the third most com-
mon site of spread of cancers that arise from organs
or carcinomas. Metastases to the lung and liver are
often not detected until late in the course of dis-
ease because patients experience no symptoms. On
the contrary, bone metastases are generally painful
when they occur. The vast majority of bone metas-
tases originate from cancers of the breast, lung, and
prostate, followed by the thyroid and kidney. The
most common sites of spread in the skeleton include
the spine, pelvis, ribs, skull, upper arm and leg long
bones. Interestingly, these sites correspond to areas
of bone marrow that demonstrate high levels of red
blood cell production, the cells responsible for carry-
ing oxygen to tissues in the body.”
Treatment depends on the patient and the type
and stage of cancer, but questions can be asked
and specific information found on numerous Web
sites. For example, http://www.curesearch.org/
offers help on Ewing’s sarcoma and other cancers
that affect the
BACK and SPINE. The U.S.A. Children’s
Cancer Resource Directory is located on http://www.
cancerindex.org/ccw/guide2us.htm. For
PAIN MAN-
AGEMENT in children, the Texas Cancer Council offers
suggestions on http://www.childcancerpain.org/. For
information about dealing with pain, mood swings,
medications, and side effects experienced in all age
groups, The National Pain Foundation provides helps
on http://www.nationalpainfoundation.org. Also,
the U.S. Government hosts a Cancer Information
Service with hotline (800) 4–CANCER (6237) and
Web site http://cis.nci.nih.gov/. Contacts for other
relevant and reliable organizations appear in the
appendixes of this book.
With the diagnosis of a tumor, the most com-
mon outlook is fear. However, facts often overcome
fears and feelings of hopelessness. For example,
information from the AAOS said that most bone
tumors are benign and may just need to be watched,
whereas others may disappear with medication. If
a tumor becomes invasive or develops cancer cells,
SURGERY can generally remove the growth. Surgi-
cal procedures may also be combined with radia-
tion therapy, which uses high levels of X-rays to kill
cancer cells. To explain another option, the AAOS
said, “Systemic treatment (chemotherapy) is often
used to kill tumor cells when they have spread
into the blood stream but cannot yet be detected
on tests and scans. Chemotherapy is generally used
when cancerous tumors have a very high chance
of spreading.”
50 cancer
If medical treatment does not prove effective,
some patients elect various types of
COMPLEMEN-
TARY AND ALTERNATIVE MEDICINE to delay progres-
sion, manage
CHRONIC PAIN, or improve mental
outlook. Many patients also have the option of par-
ticipating in
CLINICAL TRIALS to contribute to future
resources and receive the latest treatments. Often,
cancer centers, universities, and pharmaceutical
companies sponsor relevant
RESEARCH too, some-
times with significant results.
For example, a study headed by J. R. Ross
evaluated
BISPHOSPHONATES as a treatment option.
Reporting on that study in “Bisphosphonates and
Skeletal Morbidity in Patients with Metastatic Can-
cer,” Mohit Bhandari explained, “Cancer patients
with bone metastases can suffer from hypercalce-
mia,” an excess of calcium released from the bones
into the blood, and also experience “fractures, spi-
nal cord compression, reduced mobility and pain.”
Although “a completely satisfactory therapeutic
option has yet to be found . . . analyses confirm the
efficacy of bisphosphonates—potent medications
that inhibit bone resorption—in increasing bone
mineral density and reducing fracture rates.” The
treatment does not extend rate of survival but does
increase quality of life by delaying the “first skeletal
event,” such as a
VERTEBRAL COMPRESSION FRACTURE.
Therefore, “bisphosphonate therapy should be ini-
tiated when skeletal metastases are identified and
continued for at least 6 months for clinical benefit.”
Since those findings first appeared, however, The
International Myeloma Foundation (IMF) warned,
“Be alert and aware that bisphosphonate use can
be associated with jaw or dental problems, includ-
ing pain, bone loss, and poor healing. Problems are
more likely with longer periods of bisphosphonate
use (e.g., several years) and possibly more potent
bisphosphonates.” To avoid complications, the IMF
suggested taking “conservative measures such as
antibiotic treatment and mouth rinses” and hav-
ing regular dental checkups. Despite potential side
effects, the IMF said, “Bisphosphonates remain a
critical element of care to reduce bone destruction.”
Therefore, each patient must be assessed by both a
doctor and a dentist to avoid the impact of a dental
crisis. Difficulties with chewing and eating not only
affect the outlook and quality of life, but the length
of life, particularly if weight has begun to decline.
Risk Factors and Preventive Measures
NUTRITION has a vital role for every individual, not
only to sustain life but to reduce the risk of bone can-
cer and improve the survival rate for those who have
been diagnosed. In the Nutrition Journal, research
scientist Michael S. Donaldson reported, “It has
been estimated by the American Institute for Cancer
Research and the World Cancer Research Fund that
30–40 percent of all cancers can be prevented by
appropriate diets, physical activity, and maintenance
of appropriate body weight.” For example, “obesity
accounted for 14 percent of all cancer deaths in men
and 20 percent of those in women.”
Besides the effects of
WEIGHT, other risk factors
include alcohol consumption, cigarette smoking,
and low intake of
FOLIC ACID. Donaldson further
reported, “The ‘western’ dietary pattern, with its
higher intakes of red meat and processed meats,
sweets, and desserts, French fries, and refined
grains, was associated with a 46% increase relative
risk of colon cancer in the Nurses’ Health Study.”
Conversely, “one of the most important messages
of modern nutrition research is that a diet rich in
fruits and vegetables protects against cancer” of
all types as well as cardiovascular and other life-
threatening diseases. “For most cancers, people
in the lower quartile (¼ of the population) who
ate the least amount of fruits and vegetables had
about twice the risk of cancer compared to those in
the upper quartile who ate the most fruits and veg-
etables. Even in lung cancer, after accounting for
smoking, increasing fruits and vegetables reduces
lung cancer” by 20 to 33 percent. Similarly, “85%
of the studies that queried raw vegetable consump-
tion found a protective effect,” especially in carrots,
green vegetables, garlic, onions, tomatoes, and cru-
ciferous vegetables, such as broccoli, cauliflower,
cabbage, and Brussels sprouts.
Various anticarcinogenic properties have also
been identified in other natural sources, such as fla-
vanol in green tea and proanthocyanidin in grape
seed extract. For cancer prevention,
VITAMIN A,
VITAMIN C, and VITAMIN E may be particularly help-
ful, with supplements supplying the daily require-
ment if needed. As a general principle, though, the
closer a food remains to its natural state, the more
healthful it will be in preventing cancer, building
bone, and strengthening the whole body.
cancer 51
American Academy of Orthopaedic Surgeons. “Bone
Tumor,” AAOS. Available online. URL: http://orthoinfo.
aaos.org/fact/thr_report.cfm?Thread_ID=278&topcate
gory=Tumors. Downloaded December 5, 2005.
———. “Metastatic Bone Disease,” AAOS. Available
online. URL: http://orthoinfo.aaos.org/indepth/thr_
report.cfm?Thread_ID=13&topcategory=Tumors.
Downloaded December 3, 2005.
American Cancer Society. “Detailed Guide: Bone Cancer,”
ACS, Cancer Reference Information. Available online.
URL: http://www.cancer.org/docroot/CRI/CRI_2_3x.
asp?rnav=cridg&dt=2. Last revised May 27, 2005.
Bhandari, Mohit. “Bisphosphonates and Skeletal Mor-
bidity in Patients with Metastatic Cancer,” Canadian
Medical Association Journal 169, no. 10 (November 11,
2003): 1,053.
Donaldson, Michael S. “Nutrition and Cancer: A Review
of the Evidence for an Anti-cancer Diet,” Nutrition
Journal 3, no. 19 (October 20, 2004).
International Myeloma Foundation. “Myeloma Minute:
Special Advisory on Osteonecrosis of the Jaws,” IMF.
Available online. URL: http://www.myeloma.org/
main.jsp?type=article&id=1223. Downloaded Decem-
ber 3, 2005.
capsaicin See TOPICAL ANALGESIC.
carcinoma See CANCER.
CAT scan or CT scan See COMPUTED TOMOGRAPHY
SCAN.
cauda equina syndrome (CES) The bundle of
spinal nerves fanning into the image of a horse’s
tail gave cauda (horse) equina (tail) its amusing
name. However, the syndrome involving those
nerves brings no humor but, instead, shows a
probability of emergency surgery. As an online fact
sheet from the American Academy of Orthopae-
dic Surgeons (AAOS) explained, “Cauda equina
syndrome (CES) occurs when the nerve roots are
compressed and paralyzed, cutting off sensation
and movement. Nerve roots that control the func-
tion of the bladder and bowel are especially vul-
nerable to damage.”
Probable causes of CES include a
HERNIATED DISC,
SPINAL INFECTION, SPINAL TUMOR, SPINAL STENOSIS,
OSTEOPHYTE, or a trauma, such as a severe blow to
the lower back.
BIRTH DEFECTS of the LUMBAR SPINE
can also obstruct cauda equina nerves, as can the
formation of a blood clot following lumbar
SUR-
GERY.
Symptoms and Diagnostic Path
Severe
LOW BACK PAIN radiating into the legs usually
indicates
SCIATICA. If the lower body suddenly loses
the ability to function, however, CES may be more
likely. Specific symptoms include motor weak-
ness, loss of reflexes in the legs, and abrupt onset
of dysfunction in the bladder and bowels.
MAGNETIC
RESONANCE IMAGING of the SPINE may indicate nerve
involvement, while a
MYELOGRAM shows the loca-
tion and type of obstruction that must be surgically
tended.
Treatment Options and Outlook
The best outlook comes when surgery can be per-
formed within 48 hours of onset of CES. As a gen-
eral rule, the longer the time lapse, the greater the
likelihood of permanent nerve damage. If nerve
impairment continues, the American Association
of Neurological Surgeons (AANS) warned, “CES
can affect people both physically and emotionally,
in particular if it is chronic. People with CES may
no longer be able to work, either because of severe
pain, socially unacceptable incontinence problems,
motor weakness and sensory loss, or a combination
of these problems.” Sexual dysfunction and urinary
tract infections may become commonplace, while
weakness in the lower body can make walking dif-
ficult. Even so, the AANS said, “There are several
medications prescribed to address pain, bladder and
bowel problems. In addition, some patients find
that physical therapy and psychological counseling
help them cope with CES.”
Risk Factors and Preventative Measures
Staff from the Department of Orthopaedic Sur-
gery at Johns Hopkins University addressed CES in
patients with
ANKYLOSING SPONDYLITIS as having “a
high index of suspicion for this problem,” especially
if a history of incontinence exists. Although
NON-
STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAID) offer
52 capsaicin
some degree of PAIN MANAGEMENT, a PAIN RELIEVER
will not remove a neurologic problem caused by
pressure on the spinal nerves. Prompt surgical inter-
vention, however, will often correct a causal factor
before the nerves sustain permanent damage.
In an article for Neurosurgery Focus, Dr. John P.
Kostuik addressed the postoperative occurrence
of CES as, “a totally preventable complication.”
To keep CES from happening after spinal surgery,
patients should have a full neurological examina-
tion. However, Dr. Kostuik suggested, “It is rec-
ommended that every patient, regardless of the
spinal surgery undergone, have a postoperative
rectal examination . . . to establish a baseline. If
the patient complains of increasing back pain . . .
or increasing numbness, subsequent follow-up data
can be compared with the baseline data.”
Ahn, N. U., U. M. Ahn, L. Nallamshetty, B. D. Springer,
J. M. Buchowski, L. Funches, E. S. Garrett, J. P. Kos-
tuik, K. M. Kebaish, and P. D. Sponseller. “Cauda
Equina Syndrome in Ankylosing Spondylitis (the
CES-AS Syndrome): Meta-analysis of Outcomes after
Medical and Surgical Treatments,” Journal of Spinal
Disorders 14, no. 5 (October 2001): 427–433.
American Academy of Orthopaedic Surgeons. “Cauda
Equina Syndrome,” AAOS. Available online. URL:
http://orthoinfo.aaos.org/fact/thr_report.cfm?thread_
id=285&topcategory=spine. Downloaded December
7, 2005.
Kostuik, John P., M.D. “Cauda Equina Syndrome,” Neuro-
surgery Focus 16, no. 6 (June 2004).
NeurosurgeryToday.org. “Cauda Equina Syndrome (CES),”
American Association of Neurological Surgeons. Avail-
able online. URL: http://www.neurosurgerytoday.org/
what/patient_e/cauda.asp. Downloaded December 7,
2005.
cervical brace See ORTHOTICS.
cervical disc disease See HERNIATED DISC.
cervical foraminal stenosis Spinal nerves exit the
spinal cord through tiny spaces or foramen between
the
VERTEBRAE then connect into muscles to provide
the area with movement. Sometimes, though, nar-
rowing or stenosis makes a tiny foraminal opening
even smaller, thereby producing this condition.
Symptoms and Diagnostic Path
Foraminal stenosis of the
CERVICAL SPINE commonly
occurs between the C5 and C6 neck vertebrae or
between the C6 and C7 level. As spinal nerves
become irritated, pain radiates from the neck into
the shoulders and down the arms. To diagnose the
condition, a physician will usually request
MAG-
NETIC RESONANCE IMAGING or a COMPUTED TOMOGRA-
PHY (CT) SCAN with a MYELOGRAM.
Treatment Options and Outlook
The type of treatment varies with the underlying
problem as well as with the specialty of the phy-
sician or therapist. If joint inflammation causes
foraminal constriction, a doctor may recommend
the RICE
METHOD of rest, ice, compression, and
elevation with
NONSTEROIDAL ANTI-INFLAMMATORY
DRUGS (NSAIDs) to relieve the pain. A chiroprac-
tor or osteopath may perform
SPINAL MANIPULA-
TION and suggest therapeutic EXERCISE, whereas an
orthopedist may recommend an
EPIDURAL INJEC-
TION, NERVE BLOCK, or TRACTION. In severe instances
of unremitting pain,
SURGERY, such as an ANTERIOR
CERVICAL DISCECTOMY, cervical FORAMINOTOMY, CER-
VICAL LAMINAPLASTY, or insertion of a BONE GRAFT,
may be needed to relieve chronic pressure on spinal
nerves.
Risk Factors and Preventive Measures
As a person stands or walks, spinal vertebrae set-
tle somewhat, reducing the foraminal space even
more. Since stretching has the opposite effect,
patients with cervical foraminal stenosis can some-
times prevent painful episodes by becoming aware
of their movements. For example, most people
turn their heads to one side during a conversation,
yet they can avoid pain by facing the other person
and maintaining a neutral position in the vertebral
joints. Cradling a phone with the neck triggers pain
and inflammation, but using a headset or speaker
phone can prevent that problem. Good
POSTURE,
daily
ACTIVITY, and simply moving around instead of
sitting like an unused appliance can get spinal fluids
flowing. If the neck begins to ache or stiffen, resting
cervical foraminal stenosis 53
on a flat surface with a rolled hand towel or small
pillow cradled into the neck curve may relieve the
pressure enough to prevent a mild discomfort from
becoming an imperial pain.
Ullrich, Peter F. Jr., M.D. “Cervical Foraminal Stenosis,”
Spine-health.com. Available online. URL: http://www.
spine-health.com/topics/cd/overview/cervical/cerv02.
htm. Downloaded December 8, 2005.
Walker, Richard S., M.D. “Sciatic and Brachalgia,” Coventry
Pain Clinic. Available online. URL: http://www.coven-
trypainclinic.org.uk/spinalpain-sciaticaandbrachalgia.
htm. Downloaded December 8, 2005.
cervical laminaplasty By taking the pressure off
the spinal cord and spinal nerves, this surgical pro-
cedure may be referred to as spinal decompression.
Initially, the pressure may come from a
HERNIATED
DISC, FRACTURE, or some type of DEGENERATIVE DISC
DISEASE that affects the lamina or flat bones on the
backs of the
VERTEBRAE.
Procedure
Unlike the frontal access of an
ANTERIOR CERVICAL DIS-
CECTOMY, laminaplasty takes a posterior approach. In
an article posted by SpineSource, Dr. John J. Regan
described the procedure: “An incision is made down
the back of the neck to expose the cervical vertebrae.
On one side of the vertebral column, the lamina are
cut through just far enough to create a hinge-like
movement, much like a door. Then the lamina on
the other side are cut all the way through to, in
effect, open the door.” Once the incision has been
made, “The back portion of the vertebrae, the spi-
nous processes (bumps you feel on the back) are
removed to make more room for the ‘door’ to open.
After gently opening the ‘door’ of each vertebra
to create more room for the spinal cord and nerve
roots behind it, bone wedges are inserted to keep the
‘door’ from totally closing. Then the ‘door’ is closed
securely onto the wedges, resulting in an expanded
‘doorway’ for the nerves.”
Risks and Complications
As occurs with any surgery, risks include damage
to a surrounding area, which, in this case, would
be the larynx, esophagus, or spinal cord. Dr. Brian
R. Subach of The Virginia Spine Institute discussed
other risks of laminaplasty, saying, “Disadvantages
include a slightly reduced range-of-motion and
increased risk of neck pain, as well as potential
injury to the C5 nerve root during the procedure.
This is thought to occur as a result of traction on the
nerve root as the spinal bones shift.”
A study from Japan indicated that
RANGE OF
MOTION may continue to decrease between the third
and fifth postoperative years. To assess “curvature
and range of motion of the cervical spine after lami-
naplasty,” researchers from the Institute of Clinical
Medicine at the University of Tsukuba in Ibaraki
took radiographs of 26 patients before laminaplasty
and again at one, three, and five years later. The
surgery somewhat reduced vertebral flexibility, but
reportedly,
LORDOSIS diminished too.
Outlook and Lifestyle Modifi cations
Overall, laminaplasty effectively treats
SPINAL STE-
NOSIS with less loss of flexibility than occurs with a
cervical fusion. While the procedure may prevent
spinal deformity and preserve neck stability, the
long-term outlook depends on addressing the ini-
tial cause of a neck problem. To do this, lifestyle
changes may be required, including therapeutic
EXERCISE, supportive NUTRITION, MASSAGE THERAPY,
adequate
SLEEP, ORTHOTICS, and SHOES chosen to
aid
POSTURE. Also, ERGONOMIC FACTORS have par-
ticular importance in providing ongoing support
for the
SPINE.
Aita, I., Y. Wadano, and T. Yabuki. “Curvature and Range
of Motion of the Cervical Spine after Laminaplasty,”
Journal of Bone & Joint Surgery, American volume 82-A,
no. 12 (December 2000): 1,743–1,750.
Regan, John J., M.D. “Cervical Disc Herniation,” Spine-
Source. Available online. URL: http://www.spinesource.
com/Back-Pain-Disorders/cervical-disc-herniation.
html. Downloaded December 8, 2005.
Subach, Brian R., M.D. “Cervical Laminaplasty: An
Option for Some Patients with Cervical Myelopathy,”
The Virginia Spine Institute. Available online. URL:
http://www.spinemd.com/laminaplasty.htm. Down-
loaded December 9, 2005.
cervical laminectomy See LAMINECTOMY.
54 cervical laminaplasty
cervical radiculopathy Commonly known as a
pinched nerve, cervical radiculopathy is a pain in
the neck. In the
CERVICAL SPINE, nerves exit the spi-
nal cord through tiny holes or neuroforamen. When
everything works well, those nerves aid movement
in the neck, shoulders, arms, and hands. If pres-
sure on the
VERTEBRAE occurs because of CERVICAL
FORAMINAL STENOSIS, SPINAL STENOSIS, a HERNIATED
DISC, DEGENERATIVE DISC DISEASE, or an OSTEOPHYTE
(bone spur), the compressed spinal nerves may get
irritated enough to complain.
Symptoms and Diagnostic Path
With cervical radiculopathy, the most common com-
plaints are
PAIN, tingling, numbness, or weakness. To
be more specific, Dr. Charles Tuen, a neurologist at
Methodist Medical Center in Dallas, pointed to the
C7 neck vertebra as the most likely suspect if numb-
ness affects the middle finger, with the probable
cause being a herniated
DISC. If pain shoots down
the middle finger, a disc lesion of some kind may be
pressing the C6 to C7 area. If pain extends into the
thumb and index finger, a lesion or
CERVICAL SPON-
DYLOSIS may be affecting C5 or C6. However, pain
radiating down the back of the arm into the little fin-
ger may be coming from a problem at C8 or between
C7 and the T1 vertebra of the
THORACIC SPINE.
Besides inquiring about symptoms, a physician
will evaluate a medical history and
RANGE OF MOTION
in the neck and arms. While X-
RAY will assess verte-
bral bones,
MAGNETIC RESONANCE IMAGING or a COM-
PUTED TOMOGRAPHY SCAN may be needed to evaluate
spinal nerves and soft tissue involvement.
Treatment Options and Outlook
An article posted online by the American Academy
of Orthopaedic Surgeons (AAOS) said, “Initial treat-
ment is usually conservative and aims to reduce the
pain by easing the pressure on the nerves. The treat-
ment consists of three parts: rest, medication and
physical therapy.” The doctor may also prescribe
NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID)
THERAPY to relieve pain and swelling. COLD THERAPY
may be recommended for a swollen neck and
HEAT
THERAPY for stiffness with stretching EXERCISES help-
ful to both. However, “if conservative treatment
doesn’t relieve your pain over the course of 6 to 12
weeks . . . surgery may be an option.”
Regarding the potential need for surgery, infor-
mation from the DynoMed.com Web site stated, “If
significant compression on the nerve exists to the
extent that motor weakness results, surgery may be
necessary to relieve the pressure by either remov-
ing the offending disk material or enlarging the
space where the nerve root exits the vertebrae. This
may be called a laminectomy, because the lamina,
which is a portion of the bone in the vertebra, is
often removed in order to make more room for the
exiting nerve root. If the pressure is more severe
and disc space narrowed more, an anterior discec-
tomy and fusion can be done.”
Risk Factors and Preventive Measures
The type of
SURGERY determines the risks. For
example, an
ANTERIOR CERVICAL DISCECTOMY can
affect swallowing, whereas failed
ARTHRODESIS
can cause vertebral instability. A
BONE GRAFT with
donor bone could be rejected or simply not heal. A
posterior spinal fusion may have a higher rate of
success than an anterior (front) approach, but pain
during recovery can be more intense. In any case,
an orthopaedic surgeon will discuss specific risks
and prescribe appropriate treatments to assist
BONE
BUILDING and healing.
American Academy of Orthopaedic Surgeons. “Cervical
Radiculopathy,” AAOS. Available online. URL: http://
orthoinfo.aaos.org/fact/thr_report.cfm?Thread_
ID=179&topcategory=Neck. Downloaded December
9, 2005.
Bolesta, Michael J., M.D. “Patient Information Sheet
on Surgical Indications and Procedures for Cervical
Myelopathy, Radiculopathy, and Axial Neck Pain,” Cer-
vical Spine Research Society. Available online. URL:
http://www.csrs.org/patientinfo/surgicalindications.
htm. Downloaded December 9, 2005.
DynoMed.com. “Cervical Radiculopathy,” Patient Ency-
clopedia. Available online. URL: http://www.dynomed.
com/encyclopedia/encyclopedia/spine/Cervical_
Radiculopathy.htm. Downloaded December 9, 2005.
Tuen, Charles, M.D. “Cervical Radiculopathy,” Neuro-
land. Available online. URL: http://neuroland.com/
spine/c_radi.htm. Downloaded December 9, 2005.
cervical spinal fusion See ARTHRODESIS.
cervical spinal fusion 55
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