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cervical spine In the upper SPINE, seven little
neck bones come together as the C1 through C7
VERTEBRAE to uphold the head, direct the eyes and
ears, and offer a way for the brain to connect the
senses and good sense with action. For the con-
nection, tiny foramine open on either side of each
neck bone to give numerous spinal nerves a place
to exit the spinal cord and burrow into the muscles
to which they are assigned.
To connect neck vertebrae, small pedicles in the
front (anterior) and back (posterior) fasten each
bone to the one above and the one below. Thus
joined, the cervical spine aligns not in a straight
line, but in a gentle forward curve. To secure the
area more and yet provide
RANGE OF MOTION, facet
joints join one vertebra to another on the posterior
side of the spinal column, forming a row of bony
projections that can be felt down the
BACK. Those
connective bones can make way for
FACET JOINT
DISORDER problems, but bigger problems come if
anything hinders a neck from doing its many jobs.
Risks and Complications
In writing for the Cervical Research Society, Dr.
Jamie Baisden identified three potential factors for
complications in the neck: mechanical problems,
nerve root problems, and spinal cord problems.
Mechanical problems involve the bones and
DISCS,
for instance, in
DEGENERATIVE DISC DISEASE, bone
FRACTURE, HERNIATED DISC, or problems with POS-
TURE as occur in KYPHOSIS, LORDOSIS, and SCOLIOSIS.
Regarding nerve root problems, Dr. Baisden said,
“When a disc herniation, bone spur, or tumor press
on a nerve root, it produces what is called a radicu-
lopathy. Since each nerve root supplies a specific
muscle group and sensory area, a physician can
often interpret the patient’s symptoms and physi-
cal findings and determine which nerve root is
irritated. Irritation of a nerve root (radiculopathy)
typically produces pain, weakness, numbness, tin-
gling and possibly decreased reflexes, depending on
which nerve root is irritated.” Dr. Baisden further
explained, “If disc or bone push on the spinal cord,
the symptoms are called myelopathy. The signs of
myelopathy are variable, but typically are also asso-
ciated with decreased motor and sensory functions,
sometimes involving arms and legs, and sometimes
altering bowel and bladder control. There may also
be increased reflexes or potentially absent reflexes
if the cord injury is severe.”
Treatment Options and Outlook
Treatments for neck pain often begin with home
remedies, such as the RICE
METHOD of rest, ice,
compression, and elevation. N
ONSTEROIDAL ANTI-
INFLAMMATORY DRUG (NSAID) THERAPY and other
OVER-THE-COUNTER PRODUCTS, such as HOMEOPATHIC
MEDICINE, may prove useful too. When home treat-
ments do not ease a cervical spine problem,
ACU-
PRESSURE, ACUPUNCTURE, or MASSAGE THERAPY may
be performed by a licensed therapist. If the neck
has lost its curve, an osteopath or chiropractor can
often reestablish this natural position within a few
weeks through
SPINAL MANIPULATION. To manage
ACUTE PAIN or CHRONIC PAIN, a physician may pre-
scribe medication. Later, the doctor may recommend
X-
RAY to assess bones or discs and MRI (MAGNETIC
RESONANCE IMAGING) or COMPUTED TOMOGRAPHY
SCAN to get a clearer picture of soft tissue, tendons,
and ligaments. If a doctor suspects disc herniation,
a
DISCOGRAM may be needed, but for spinal nerve
involvement, a neurologist may be called to review
results of a
NERVE CONDUCTION STUDY. With SURGERY,
a neurosurgeon or orthopedic surgeon may relieve
spinal compression and other conditions affecting
spinal nerves with procedures such as
ANTERIOR
CERVICAL DISCECTOMY, CERVICAL LAMINAPLASTY, or
various types of
MINIMALLY INVASIVE SURGERY that
may or may not require a
BONE GRAFT.
Statistics and Studies
Writing for the Hospital Practice Web site, Dr. David
G. Borenstein of The George Washington Univer-
sity Medical Center in Washington, D. C., said, “A
common complaint evaluated by primary care phy-
sicians, neck pain affects about 10% of the popula-
tion of the United States every year.” With causes
ranging from neck
STRAIN to CERVICAL SPONDYLOSIS,
“most biomechanical disorders of the cervical spine
have a natural history of improvement. More than
50% of patients will have decreased pain in two
to four weeks; 80% will be asymptomatic in two
to three months, and most will improve without
requiring diagnostic x-rays or laboratory tests. Such
studies are reserved for patients with histories or
physical findings that suggest cord or nerve root
56 cervical spine
compression or systemic illness. These disorders are
uncommon causes of neck pain but require thor-
ough evaluation and immediate treatment.”
Immediate evaluation is also needed after an
accident or injury. As an eMedicine.com article
said, “Cervical spine injuries cause an estimated
6000 deaths and 5000 new cases of quadriplegia
each year.” With a ratio of four males to one female
injured, “approximately 80% of patients are aged 18–
25 years.” About 5 to 10 percent of the unconscious
patients who receive emergency care “as the result of
a motor vehicle accident or fall have a major injury to
the cervical spine.” To be more precise, “most cervical
spine fractures occur predominantly at 2 levels. One
third of injuries occur at the level of C2, and one half
of injuries occur at the level of C6 or C7. Most fatal
cervical spine injuries occur in upper cervical levels,
either at craniocervical junction C1 or C2.”
Unfortunately, not every neck injury will be
readily apparent. As reported in a ScienceDaily arti-
cle, “Study authors found that x-rays failed to detect
secondary injuries in 81 of the 224 patients identi-
fied with cervical spine injuries or 36 percent.”
Special Aids and Adaptations
An injury in the upper cervical vertebrae can result
in paralysis or even death. Therefore, a
SPINAL
INJURY must be treated promptly with care taken to
immobilize the victim until a medical specialist can
evaluate the trauma and provide appropriate treat-
ment. Often, severe injuries can be prevented with
the aid of properly fitted athletic equipment and
other safety devices, such as a seat belt or sturdy car
seat to protect the spines of
INFANTS and CHILDREN.
A thin little bathing cap, however, does nothing to
protect a swimmer who dives into rock-infested
waters or the shallow end of a pool.
If a head trauma occurs for any reason, a neck
injury should be suspected. In the book Health At
Home, presented in part on the Internet, Don R.
Powell suggested, “Tell the victim to lie still and not
move his or her head, neck, back, etc.” Then, “place
rolled towels, articles of clothing, etc. on both sides
of the neck and/or body. Tie and wrap in place, but
don’t interfere with the victim’s breathing. If neces-
sary, use both of your hands, one on each side of
the victim’s head, to keep the head from moving.”
If a victim must be moved before the ambulance
arrives, the flat surface of a board or door can be
used as a transporting device, but “several people
should carefully lift and move the person onto the
board, being very careful to align the head and neck
in a straight line with the spine. The head should
not rotate or bend forward or backward.”
Rotating, bending, and stretching the neck of
someone with a cervical spine injury can be fatal.
In everyday life though, that same range of motion
allows a healthy neck to function well and remain
flexible. Everyday assistance also comes through
foods rich in
CALCIUM and other elements of good
NUTRITION. Although vitamin and mineral supple-
ments can be added for special needs, sunlight aids
a body in producing
VITAMIN D, while daily ACTIVITY
and
EXERCISE assist BONE BUILDING.
Usually, people think of
STRENGTH TRAINING as
a means of pumping arm muscles. However, spe-
cific exercises strengthen the neck and, sometimes,
relieve pain. For example, an article in Harvard
Women’s Health Watch offered this exercise: “1. Sit
in a neutral position and look straight ahead. Allow
your head to protrude slightly forward. 2. Slowly
glide your head backward, tucking in your chin
until you have pulled your head and chin as far
back as they will go. Keep your head level. Move
your head slowly back and forth 10 times between
this position and the neutral position. 3. For a stron-
ger stretch, gently apply pressure to your chin with
your fingers and release. Repeat every two hours
as needed.” However, the article cautioned, “if this
exercise increases your pain, try it lying on your
back with your head on a pillow. If pain increases
or numbness develops, stop and contact your cli-
nician.” This particular article did not say so, of
course, but anyone with cervical spine problems
might also refrain from sticking out their necks,
racing neck-to-neck, hanging the head, or adher-
ing to the often-lauded advice of holding a chronic
“chin up” position.
Baisden, Jamie, M.D. “Patient Information Sheet on
Introduction to the Cervical Spine,” Cervical Spine
Research Society. Available online. URL: http://www.
csrs.org/patientinfo/introtocspine.htm. Downloaded
December 6, 2005.
Barrett, Tyler W., M.D., Jerome R. Hoffman, M.D., and
Michael I. Zucker, M.D. “UCLA Study Helps ER
cervical spine 57
Physicians Identify Previously Undetectable Spinal
Injuries,” ScienceDaily. Available online. URL: http://
www.sciencedaily.com/releases/2005/09/050907100
756.htm.
Belaval, Emilio, M.D. and Simon Roy, M.D. “Fractures,
Cervical Spine,” eMedicine.com. Available online. URL:
http://www.emedicine.com/emerg/topic189.htm. Last
updated January 19, 2005.
Borenstein, David G. “Management of Neck Pain: A Primary
Care Approach,” Hospital Practice. Available online.
URL: http://www.hosppract.com/issues/1998/10/boren.
htm. Downloaded December 10, 2005.
Ghanayem, Alexander, M.D. “Patient Information Sheet
on Conservative Care for Cervical Spine Disorders,”
Cervical Spine Research Society. Available online. URL:
http://www.csrs.org/patientinfo/conservativecare.htm.
Downloaded December 10, 2005.
Powell, Don R. Health At Home, ©1999, American Insti-
tute for Preventive Medicine. “Neck/Spine Injuries,
Chapter 23. Emergency Conditions,” Saints Self-Care
Medical Library. Available online. URL: http://www.
saintsok.com/pages/medicallibrary/NECKSPIN.HTM.
Downloaded December 10, 2005.
Staff. “Oh, My Aching Neck,” Harvard Women’s Health
Watch 12, no. 3 (November 2004): 7.
cervical spondylosis Normal wear and tear even-
tually wear down vertebral
DISCS and BACK bones,
causing this condition. Also, aging and
ARTHRI-
TIS can deposit hardened minerals where cushy
discs should be. Adding insult to that non-injury,
OSTEOPHYTES (bone spurs) can also form. According
to National Institutes of Health statistics reported
on the MedlinePlus Web site, “By age 60, 70% of
women and 85% of men show changes consistent
with cervical spondylosis on X-ray.”
Symptoms and Diagnostic Path
Typical symptoms include neck pain radiating into
the arms and shoulders, neck stiffness, or a
CER-
VICOGENIC HEADACHE stemming from the CERVICAL
SPINE. The RANGE OF MOTION may decrease, but less
frequently, pressure on the spinal nerves affects
balance and movement of the lower body. X-
RAYS
can show evidence of this degenerative condition,
but a
COMPUTED TOMOGRAPHY SCAN will usually be
needed to clarify the extent of damage.
Treatment Options and Outlook
Besides
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
(NSAID)
THERAPY or other types of PAIN MANAGE-
MENT, typical treatments include TRACTION, SPINAL
MANIPULATION, HEAT THERAPY, COLD THERAPY, corti-
sone injection, and, temporarily, an
ORTHOTIC device
or neck brace. For neck spasm, a
MUSCLE RELAXANT
may be prescribed. If, however, bone overgrowth
or pressure on the
VERTEBRAE affect the spinal cord,
prompt
SURGERY may be needed to prevent nerve
damage and permanent disability.
Risk Factors and Preventive Measures
A previous neck injury puts a person at higher risk
for cervical spondylosis. According to an article in
The Practitioner, “Men are affected as often as women
overall, though they seem to be affected at a slightly
younger age.” To prevent the condition from wors-
ening, “most patients who have recurrent episodes
of pain can be managed successfully with gentle
physiotherapy and NSAIDs.” In addition, neck and
shoulder
EXERCISES can be strengthening.
Spinal manipulation can relieve pressure on
spinal nerves that travel through tiny openings
between the vertebrae, but an article for The Jour-
nal of Manual & Manipulative Therapy lamented that,
“the majority of articles published related to serious
anatomical injury seen in association with cervical
manipulation.” Minimal risks of vertebral damage
or a stroke do exist, but as a preventive measure,
“the therapist . . . verbally directs how a particular
spinal movement is to take place. Performed in this
fashion, active cervical movement testing allows
the patient to do what he feels able to.”
Regarding surgical risks, a team of doctors from
the Department of Orthopaedic Surgery at Yale
University joined with a group of physicians from
Germany to research the results of cervical disc
replacement in treating spondylosis. As reported
in the Journal of Neurosurgery: Spine, adverse out-
comes included less range of motion (ROM),
BONE
GRAFT failure, and complications with the stabiliz-
ing devices surgically inserted into the neck. The
researchers said, however, “Recent advances in
material and implant design have enabled the devel-
opment of a novel implant design . . . , which fol-
lows the principles of providing immediate implant
stability, ease and safety of insertion . . . and opti-
mization of functional ROM.”
58 cervical spondylosis
A.D.A.M., MedlinePlus. “Cervical Spondylosis,” U.S.
National Library of Medicine, National Institutes
of Health. Available online. URL: http://www.nlm.
nih.gov/medlineplus/ency/article/000436.htm. Last
updated November 9, 2005.
Bertagnoli, Rudolf, M.D., James J. Yue, M.D., Frank
Pfeiffer, M.D., Andrea Fenk-Mayer, M.D., James P.
Lawrence, M.D., Trace Kershaw, and Regina Nanieva.
“Early Results after ProDisc-C Cervical Disc Replace-
ment,” Journal of Neurosurgery: Spine, no. 2 (April
2005): 403–410.
Creighton, Douglas S., James Viti, and John Krauss. “Use
of Translatoric Mobilization in a Patient with Cervical
Spondylotic Degeneration: A Case Report,” The Jour-
nal of Manual & Manipulative Therapy 13, no. 1 (2005):
12–26.
Ross, Alistair. “Managing Cervical Spondylosis,” The Prac-
titioner, no. 11 (November 10, 2005): 762–769.
cervical spondylotic myelopathy (CSM) Some-
times
OSTEOPHYTE (bone spur) formation, FACET
JOINT DISORDER, ARTHRITIS, SPINAL STENOSIS, or other
problems can cause neck
VERTEBRAE to become nar-
row enough to squeeze the spinal cord. In a Spine-
health.com article, Dr. Thomas M. Wascher said this
compression commonly occurs at the C4 to C7 ver-
tebrae of the
CERVICAL SPINE. As he described, “The
end result is chronic compression of the spinal cord
and nerve roots leading to impaired blood flow and
. . . frank damage within the spinal cord itself.”
In an article for the Internet Journal of Neurol-
ogy, M. Hochman explained, “At the C1 level the
spinal cord occupies just one half of the canal. It
occupies three quarters of the canal at the C5-C7
levels, however, which helps to explain why CSM
predominately occurs in the lower cervical spine.”
The article also pointed out, “Cervical spondylotic
myelopathy (CSM) is the most common cause of
spinal cord dysfunction in older patients.”
Symptoms and Diagnostic Path
According to the familydoctor.org Web site, “Symp-
toms of CSM may develop slowly. Some symptoms
of CSM may include neck stiffness, arm pain, numb-
ness in the hands and weakness of the arms and
legs. A person with CSM may have stiff legs. CSM
may make it difficult for a person to use his or her
hands or to walk steadily.” To assist a diagnosis, the
physician may recommend
MAGNETIC RESONANCE
IMAGING and refer the patient to a neurologist or
neurosurgeon.
Treatment Options and Outlook
Surgical treatment of CSM includes
ANTERIOR CER-
VICAL DISCECTOMY or disc decompression. If instabil-
ity occurs in neck joints,
ARTHRODESIS will likely be
used to fuse those vertebrae. A
BONE GRAFT, special
hardware,
BONE MORPHOGENETIC PROTEIN, or a com-
bination of implants may be inserted to aid spinal
fusion. In milder cases,
TRACTION and temporary use
of an
ORTHOTIC device offer alternatives to surgery.
In either case, advanced CSM may necessitate the
use of a cane or walker.
Risk Factors and Preventive Measures
Regarding other concerns associated with CSM, Dr.
William F. Young wrote, “The presence of myelopa-
thy on neurologic examination is not unique to CSM.
Therefore, it is important to exclude other diagnoses
that present in a similar fashion. In one study, it was
found that 14.3 percent of patients who underwent
surgery for CSM were later found to have other diag-
noses.” For example,
SYRINGOMYELIA, SPINAL TUMOR,
and
VITAMIN B deficiency reportedly mimic CSM.
If CSM has been confirmed and surgery needed,
ELDERLY patients with OSTEOPOROSIS present a par-
ticular challenge. After researching a combination
of therapies, doctors from the Israel Spine Center
in Tel Aviv reported their results in the Journal of
Neurosurgery: Spine, saying, “Our hybrid decompres-
sion fixation technique allows multilevel anterior
decompression, avoids bone graft donor site mor-
bidity, and provides a basis for stable mechanical
reconstruction.” These combined procedures may
fail in 4 percent of the cases, but for most patients,
stability in the neck can be achieved.
Ashkenazi, Ely, M.D., Yossi Smorgick, M.D., Nah-
shon Rand, M.D., Michael A. Millgram, M.D., Yigal
Mirovsky, M.D., and Yizhar Floman, M.D. “Anterior
Decompression Combined with Corpectomies and
Discectomies in the Management of Multilevel Cervi-
cal Myelopathy: a Hybrid Decompression and Fixation
Technique,” Journal of Neurosurgery: Spine 3 (Septem-
ber 2005): 205–209.
cervical spondylotic myelopathy 59
familydoctor.org. “Cervical Spondylotic Myelopathy
(CSM),” American Academy of Family Physicians.
Available online. URL: http://familydoctor.org/622.
xml. Downloaded December 12, 2005.
Hochman, M. and S. Tuli. “Cervical Spondylotic Myelop-
athy: A Review,” Internet Journal of Neurology 4, no. 1
(2005): 24–42.
Wascher, Thomas M., M.D. “Understanding Cervical
Spondylotic Myelopathy,” Spine-health.com. Available
online. URL: http://www.spine-health.com/topics/cd/
undermy/undermy01.html. Downloaded December
12, 2005.
Young, William F., M.D. “Cervical Spondylotic Myelop-
athy: A Common Cause of Spinal Cord Dysfunction
in Older Persons,” American Family Physician, Sep-
tember 1, 2000, American Academy of Family Phy-
sicians. Available online. URL: http://www.aafp.
org/afp/20000901/1064.html. Downloaded December
12, 2005.
cervicogenic headache In describing this type
of headache, Dr. Daniel J. Hurley of the Chicago
Institute of Neurosurgery and Neuroresearch
wrote, “Whether from chronic tension or acute
whiplash injury, intervertebral disc disease or pro-
gressive facet joint arthritis, the neck can be a hid-
den and severely debilitating source of headaches.
Such headaches are grouped under the term ‘cer-
vicogenic headache,’ indicating that the primary
contributing structural source of the headache is
the cervical spine.” Since upper neck
VERTEBRAE
support the weight and movement of the head,
“fatigue, postural malalignment, injuries, disc prob-
lems, joint degeneration, muscular stress and even
prior neck surgeries all can compound the wear
and tear on this critical region of the human skel-
etal anatomy.”
Symptoms and Diagnostic Path
While potential causes may be visible on X-
RAY,
COMPUTED TOMOGRAPHY SCAN, or MAGNETIC RESO-
NANCE IMAGING, a cervicogenic headache itself can
not be shown. As an alternative method of diagno-
sis, Mitchell Elkiss from the Department of Neurol-
ogy at Wayne State University wrote, “A thorough
history with particular attention to the quality of
the pain, its severity . . . and particularly its localiza-
tion is mandatory. Pain sensitive structures include
the eyes, ears, nose, and mouth.” The doctor may
also ask a patient about
TENSION or depression and
assess biomechanical problems caused by
CERVICAL
SPONDYLOSIS, DEGENERATIVE DISC DISEASE, or spinal
imbalances.
Treatment Options and Outlook
Depending on the cause of the headache, treat-
ments vary from
PAIN RELIEVERS to ACUPRESSURE to
orthopedic correction of
POSTURE. As an article in
the American Journal of Pain Management said, “The
ideal treatment approach is to address the underly-
ing neck disorder, but this is not always possible,”
since cervicogenic headache “can be mistaken for
other forms of . . . headache, especially . . . com-
mon migraine. . . . Therefore, the best approach is
to start with conservative treatments and move to
more invasive ones if necessary.”
Often, a whiplash or
FLEXION-EXTENSION INJURY
shifts the neck vertebrae, rearranging the natu-
ral C-curve into a straight line. This can make the
head feel as if it sits on a rigid pole. Assuming no
FRACTURE exists, an osteopath or chiropractor may
be able to ease the vertebrae back into place with
SPINAL MANIPULATION done over a few weeks. Ther-
apeutic
EXERCISE commonly follows this course of
treatment with
STRENGTH TRAINING added after the
neck has healed. Other treatment options include
TRIGGER POINT THERAPY, radiofrequency treatment,
SPINAL INJECTION, ACUPUNCTURE, or in extreme
instances,
SURGERY. In any case, the outlook may
depend on whether a treatment successfully rees-
tablishes the neck curve.
Risk Factors and Preventive Measures
A diagnostic block may prevent further recurrence
of cervicogenic headaches, especially when the rea-
sons and risks have not been clearly ascertained.
In an article posted by the American Council for
Headache Education, Dr. Nikolai Bogduk of Austra-
lia explained, “A diagnostic block is a procedure in
which needles are used to deliver local anesthetic,
under x-ray control, to any joint suspected of being
the source of pain.” Assuming a physician has the
necessary facilities and training, “the idea is that
if a joint is the source of headache, anesthetizing
that joint should promptly, although temporarily,
60 cervicogenic headache
relieve the pain; much the same way that once a
painful tooth is anesthetized, toothache is promptly
relieved. By testing the upper cervical joints in this
way a doctor can tell if one of them is responsible
for headache, and if so, which one.”
Bogduk, Nikolai, M.D. “ ‘Is It My Neck?’ Cervicogenic
Headache,” American Council for Headache Edu-
cation, ACHE. Available online. URL: http://www.
achenet.org/articles/44.php. Downloaded December
9, 2005.
Elkiss, Mitchell, D.O. “Cervicogenic Headaches: Diagnosis
and Treatment with Osteopathic Manipulative Ther-
apy and Acupuncture,” U.S. Doctor. Available online.
URL: http://www.usdoctor.com/sym9.htm. Down-
loaded December 9, 2005.
Hurley, Daniel J., M.D. “Cervicogenic Headache,” Chicago
Institute of Neurosurgery and Neuroresearch, CINN.
Available online. URL: http://www.cinn.org/news/
cervicogenicheadache.html. Downloaded December
12, 2005.
Ribeiro, S., S. N. Palmer, and F. Antonaci. “Headache.
Cervicogenic Headache,” American Journal of Pain Man-
agement 15, no. 2 (April 2005): 48–58.
children, spinal concerns for From BIRTH DEFECTS
to
SHAKEN INFANT SYNDROME to a vertebral FRACTURE
that breaks a fall along with a growing bone, children
encounter many jolts and, sometimes, give their
parents a few. Most children grow at a similar rate
as shown in the “2000 CDC Growth Charts: United
States” posted by the National Center for Health
Statistics on http://www.cdc.gov/growthcharts/.
However,
NUTRITION, ENVIRONMENTAL INFLUENCES,
GENETIC FACTORS, and a lack of daily ACTIVITY can
make boys and girls from all socio-economic lev-
els prone to such problems as birth defects of the
spine, early onset scoliosis,
GROWTH HORMONE DIS-
ORDERS, JUVENILE ARTHRITIS, JUVENILE OSTEOPOROSIS,
and
OSTEOGENESIS IMPERFECTA.
Risks and Complications
The risk of a spinal problem begins with a poten-
tial
BIRTH INJURY and proceeds to school years when
BACKPACK SAFETY becomes a weighty issue. Being
overweight or having an
EATING DISORDER can
cause problems with young bones as can wear-
ing improperly fitted
SHOES. POSTURE affects the
SPINE, too, particularly if a sedentary child seems
oblivious to
ERGONOMIC FACTORS or slouches dur-
ing prime times of growth. Although bone growth
ceases after adolescence,
BONE BUILDING continues
for adults, including the
ELDERLY. For them, child-
hood offers an ironically optimal time to bank bone
mass and minimize the loss of bone density that
typically occurs as a person ages. However, lack
of
SLEEP, lack of EXERCISE, inadequate water, and a
poor supply of
CALCIUM lower bone quality, placing
the spinal health of a child at risk.
When children experience
ACUTE BACK PAIN and
CHRONIC BACK PAIN, the causes will likely differ from
those adults encounter. For example, “Back Pain
In Children,” posted on the American Academy of
Orthopaedic Surgeons (AAOS) Web site said, “Com-
pared with an adult, a child with a backache is more
likely to have a serious underlying disorder. This is
especially true if the child is 4 years old or younger, or
in a child of any age who has back pain accompanied
by: Fever or weight loss; Weakness, numbness, trou-
ble walking or pain that radiates down one or both
legs; Bowel or bladder dysfunction; Pain that inter-
feres with sleep.” A back
STRAIN should improve with
rest, whereas weakened
PARASPINAL MUSCLES may
need
STRENGTH TRAINING or physical therapy. Accord-
ing to the AAOS, “More serious causes of back pain
need early identification and treatment or they may
become worse. Always see a doctor if your child’s
back pain lasts for more than several days or progres-
sively worsens.” Besides a physical examination, X-
RAY may be needed to diagnose KYPHOSIS, LORDOSIS,
SPONDYLOLISTHESIS, or other postural problems that
commonly require an
ORTHOTIC cast or brace.
If a
SPINAL INFECTION causes back pain, a pediatri-
cian usually prescribes bed rest and an antibiotic.
As the AAOS explained, “In young children, infec-
tion in a disk space (diskitis) can lead to back pain.
Diskitis typically affects children aged 1–5, although
older children and teenagers can also be affected.”
In addition to the risk of
DISCITIS, the AAOS said,
“On rare occasion, tumors can be responsible for
back pain. Spinal tumors usually happen in the
middle or lower back. Pain is constant and progres-
sive; it is unrelated to activity and/or happens at
night.” If a
SPINAL TUMOR exists, a child may also
limp or lean to one side.
children, spinal concerns for 61
Statistics and Studies
An article in The Journal of Musculoskeletal Medi-
cine said the prevalence of
LOW BACK PAIN (LBP) in
children “ranges from 11% to 50%” with “distinct
differences in evaluation and management of LBP
in younger and older patients.” Unlike for adults,
“most causes of LBP in children can be identified.”
Although “treatment of children with LBP can be
confounded by their relative lack of descriptive
terminology,” their back pain “can be divided into
5 general categories: developmental, inflamma-
tory, mechanical, neoplastic, and psychosomatic.”
For example, spondylosis can be categorized as
developmental,
JUVENILE RHEUMATOID ARTHRITIS as
inflammatory, a
HERNIATED DISC as mechanical, and
CANCER as neoplastic. For cancer, “the spine is the
most common site of skeletal metastasis, account-
ing for 80% of all metastatic skeletal lesions.” How-
ever, the article added, “Spinal tumors rarely occur
in children or adolescents.”
Far more likely is a playground injury. In a fact
sheet on that topic, the National Center for Injury
Prevention and Control posted statistics from vari-
ous studies, stating, “Each year in the United States,
emergency departments treat more than 200,000
children ages 14 and younger for playground-related
injuries.” Of these, “about 45% of playground-
related injuries are severe—fractures, internal inju-
With girls (55 percent) sustaining more injuries
than boys, “children ages 5 to 9 have higher rates of
emergency department visits for playground inju-
ries than any other age group. Most of these inju-
ries occur at school.” In addition, “a study in New
York City found that playgrounds in low-income
areas had more maintenance-related hazards than
playgrounds in high-income areas. For example,
playgrounds in low-income areas had significantly
more trash, rusty play equipment, and damaged fall
surfaces.”
Unfortunately, some children cannot come
out to play at all. According to statistics posted by
ChildStats.gov, “In 2003, approximately 8 percent
of children ages 5–17 were reported by parents to
have activity limitations due to chronic conditions.
Six percent were identified as having activity limi-
tation solely by their participation in special educa-
tion. Two percent had limitations in their ability to
walk, care for themselves, or participate in other
activities.”
Disease, injuries, and other factors can keep a
child from walking, but disabling accidents can
often be prevented. As the online article “Child
Passenger Safety: Fact Sheet” by the Centers for
Disease Control and Prevention (CDC) reported,
“A survey of more than 17,500 children found that
only 15% of children in safety seats were correctly
harnessed into correctly installed seats,” thus plac-
ing growing spines at unnecessary risk.
Special Aids and Adaptations
Besides the protective aid of properly fitted car
seats for
INFANTS and young children, a child’s spi-
nal needs may necessitate special aids such as a
crawler, walker, handrail, ramp, or wheelchair to
aid age-appropriate mobility.
Since children with spinal problems often
require special tests or treatments, these too must
be adapted to fit. For instance, most children want
to know what to expect, how long it will take, and
whether it will hurt. If the child is old enough to
ask questions, a helpful response will usually offer
simple, direct, brief, and matter-of-fact statements.
Taking a quick tour of a medical facility or leafing
through a picture book about a procedure may
also ease fears, as can truthful but light words to
explain. For example, “That machine is noisy, but
it will not hurt you.”
Often, children with spinal problems can be
aided by various forms of
COMPLEMENTARY AND
ALTERNATIVE MEDICINE. Special adaptations may then
include child-appropriate treatments of
ACUPRES-
SURE, BIOFEEDBACK, HERBAL THERAPY, HOMEOPATHIC
MEDICINE, or SPINAL MANIPULATION. Some specialists
have been trained in
MASSAGE THERAPY techniques
for children, including infants, but parents may also
find a good massage for themselves can help to ease
chronic worries about a child.
American Academy of Orthopaedic Surgeons. “Back Pain
In Children,” AAOS. Available online. URL: http://
orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=3
29&topcategory=Spine. Downloaded December 14,
2005.
ChildStats.gov. “America’s Children: Key National Indica-
tors of Well-Being 2005, Activity Limitation,” Forum
62 children, spinal concerns for
on Child and Family Statistics. Available online. URL:
http://childstats.gov/americaschildren/hea2.asp.
Downloaded December 14, 2005.
National Center for Injury Prevention and Control.
“Child Passenger Safety: Fact Sheet,” Centers for Dis-
ease Control and Prevention (CDC). Available online.
URL: http://www.cdc.gov/ncipc/factsheets/childpas.
htm. Last reviewed February 14, 2005.
———. “Playground Injuries: Fact Sheet,” Centers for Dis-
ease Control and Prevention (CDC). Available online.
URL: http://www.cdc.gov/ncipc/factsheets/playgr.
htm. Downloaded December 14, 2005.
Rooney, Richard C., M.D. and John G. Devine, M.D.
“Evaluating and Managing Back Pain in Children and
Adolescents,” The Journal of Musculoskeletal Medicine 22,
no. 6 (June 2005): 284–293.
chordoma See SPINAL TUMOR.
chronic back pain Unlike the abrupt arrival of
ACUTE BACK PAIN, chronic pain hangs around a
while, ambles off, then frequently returns. Since
this unwelcome caller keeps on calling, one might
wonder what a particular pain wants.
To explain some reasons for pain, a Spine-health.
com article by Dr. Ralph Rashbaum said, “With
acute pain, the severity of pain directly correlates
to the level of tissue damage. This provides us with
a protective reflex, such as the reflex to move your
hand immediately if you touch a sharp object. This
type of pain is a symptom of injured or diseased tis-
sue, so that when the underlying problem is cured
the pain goes away.” However, “in chronic pain,
the pain does not have the same meaning as with
acute pain—it does not serve a protective or other
biological function. Rather, the nerves continue to
send pain messages to the brain even though there
is no continuing tissue damage.”
Symptoms and Diagnostic Path
A precise description of pain provides an impor-
tant diagnostic tool. As explained on the Back.com
Web site, “Neuropathic pain is caused by damage to
nerve tissue. It is often felt as a burning or stabbing
pain. One example of neuropathic pain is a pinched
nerve.” Conversely, “nociceptive pain is caused by
an injury or disease outside the nervous system. It is
often an ongoing dull ache or pressure, rather than
the sharper, trauma-like pain more characteristic
of neuropathic pain.” To find out which is which,
diagnostic tests, such as
MAGNETIC RESONANCE IMAG-
ING or nerve function tests, may be needed.
Treatment Options and Outlook
If conservative treatments, such as
NONSTEROIDAL
ANTI-INFLAMMATORY DRUG (NSAID) THERAPY or
prescription
PAIN RELIEVERS, do not ease chronic
back pain, Back.com suggested another approach.
As the article explained, “Neurostimulation is the
stimulation of the spinal cord by tiny electrical
impulses. An implanted lead (a flexible insulated
wire), which is powered by an implanted battery
or by a receiver, is placed near your spinal cord,”
which then blocks “the pain messages to your
brain.” Reportedly, this therapy “can offer good to
excellent pain relief, and improve your ability to go
about daily activities.”
Without successful intervention, the brain itself
eventually reacts to the effects of chronic pain. To
find out how much, a medical team from North-
western University Feinberg School of Medicine
in Chicago used magnetic resonance imaging in
an innovative study. According to their report in
The Journal of Neuroscience, “Our studies show that
chronic back pain (CBP) (sustained for >6 months)
is accompanied by abnormal brain chemistry” that
resulted in “reduced cognitive abilities.” Besides this
decline in reasoning powers, the article reported,
“the magnitude of brain gray matter atrophy caused
by CBP is equivalent to 10–20 years of aging.”
Undoubtedly, chronic pain stresses the brain,
and makes a
NERVE BLOCK or NEUROSTIMULATION via-
ble options for
PAIN MANAGEMENT. Other possibili-
ties include
ACUPRESSURE, ACUPUNCTURE, or SPINAL
MANIPULATION, assuming no FRACTURE or degenera-
tive conditions, such as
OSTEOGENESIS IMPERFECTA or
OSTEOARTHRITIS, exist. To repair the cause of chronic
pain,
SURGERY often helps, while BIOFEEDBACK can
assist a person in managing pain that does not go
away.
Risk Factors and Preventive Measures
Frequently, chronic pain results from an underlying
medical condition, such as
ARTHRITIS or OSTEOPOROSIS,
chronic back pain 63
with each causative factor having its own course
of treatment. Nevertheless, people can sometimes
avoid painful episodes or decrease the intensity
by becoming aware of what triggers the pain. For
instance, the American Osteopathic Association
(AOA) mentioned improper
LIFTING and poor POS-
TURE in “Prevention: The Best Treatment for Back
Pain.” As the AOA article said, “Prevent back pain
by making a habit of sitting up straight and using
correct form when lifting heavy items or complet-
ing daily tasks. Whether you work construction or
spend your days typing on a computer, the way
you sit, twist, bend, lift things, and even relax may
either cause or prevent back pain.”
Similarly, a fact sheet on “Managing Chronic
Pain” posted by The American Occupational Ther-
apy Association, Inc. (AOTA) explained that an
occupational therapist (OT) can “identify specific
activities or behaviors that aggravate pain and sug-
gest alternatives.” For example, an OT can “rec-
ommend and teach the client how to use adaptive
equipment to decrease pain while performing tasks
such as reaching, dressing, bathing, and performing
household chores.” Such adaptations help patients
avoid the risk of encouraging unwanted pain to
come and stay.
American Occupation Therapy Association, The, Inc.
“Managing Chronic Pain,” AOTA. Available online.
URL: http://www.aota.org/featured/area6/docs/pain.
pdf. Downloaded December 15, 2005.
American Osteopathic Association. “Prevention: The
Best Treatment for Back Pain,” AOA Health and Well-
ness. Available online. URL: http://www.osteopathic.
org/index.cfm?PageID=you_backpain. Downloaded
December 15, 2005.
Apkarian, A. Vania, Yamaya Sosa, Sreepadma Sonty,
Robert M. Levy, R. Normal Harden, Todd B. Parrish,
and Darren R. Gitelman. “Chronic Back Pain Is Asso-
ciated with Decreased Prefrontal and Thalamic Gray
Matter Density,” The Journal of Neuroscience 24, no. 46
(November 17, 2004): 10,410–10,415.
Medtronic Sofamor Danek. “Frequently Asked Ques-
tions,” Back.com. Available online. URL: http://www.
back.com/faqs_chronic_pain.html. Updated July 11,
2005.
Rashbaum, Ralph, M.D. “Types of back pain,” Spine-health.
com. Available online. URL: http://www.spine-health.
com/topics/cd/neuropain/neuropain02.html. Down-
loaded December 15, 2005.
clinical trials In defining this important option,
ClinicalTrials.gov said, “A clinical trial (also clinical
research) is a research study in human volunteers
to answer specific health questions. Carefully con-
ducted clinical trials are the fastest and safest way
to find treatments that work in people and ways to
improve health.” More specifically, “interventional
trials determine whether experimental treatments
or new ways of using known therapies are safe and
effective under controlled environments. Observa-
tional trials address health issues in large groups of
people or populations in natural settings.”
As a service of the U.S. National Institutes of
Health, information on the ClinicalTrials.gov Web
site discussed what to expect: “In Phase I trials,
researchers test an experimental drug or treatment
in a small group of people (20–80) for the first
time to evaluate its safety, determine a safe dosage
range, and identify side effects. In Phase II trials,
the experimental study drug or treatment is given
to a larger group of people (100–300) to see if it is
effective and to further evaluate its safety. In Phase
III trials, the experimental study drug or treatment
is given to large groups of people (1,000–3,000) to
confirm its effectiveness, monitor side effects, com-
pare it to commonly used treatments, and collect
information that will allow the experimental drug
or treatment to be used safely. In Phase IV trials,
post marketing studies delineate additional infor-
mation including the drug’s risks, benefits, and
optimal use.”
Risks and Complications
Besides the time involved in adhering to the
requirements of a clinical trial, some treatments
cause adverse side effects. Also, not all partici-
pants receive the new treatment but may, instead,
be given a placebo. Other patients simply become
disappointed by not being accepted for a research
trial.
Special Aids and Adaptations
Before participating in a clinical trial, ClinicalTrials.
gov suggested asking pertinent questions, such as:
64 clinical trials
“What is the purpose of the study? . . . What kinds
of tests and experimental treatments are involved?
How do the possible risks, side effects, and benefits
in the study compare with my current treatment?
How might this trial affect my daily life? How long
will the trial last? Will hospitalization be required?
Who will pay for the experimental treatment? . . .
What type of long-term follow up care is part of this
study?” Undoubtedly, the answers will aid a person
in making this potentially life-changing decision.
ClinicalTrials.gov. Home page, a service of the U.S. National
Institutes of Health, developed by the National Library
of Medicine. Available online. URL: http://clinicaltrials.
gov/. Downloaded December 16, 2005.
Medtronic Sofamor Danek. “Could a Clinical Trial be
Right for You?” Back.com. Available online. URL:
http://www.back.com/articles-clinical_trial.html.
Updated February 11, 2005.
coccydynia This pain in the tailbone can occur
during childbirth but more commonly results from
a backward fall. Other causative factors include a
SPINAL TUMOR or a SPINAL INFECTION.
Symptoms and Diagnostic Path
If a medical history gives cause to suspect
CANCER,
bone
FRACTURE, or bone spur (OSTEOPHYTE), a phy-
sician may request X-
RAYS or MAGNETIC RESONANCE
IMAGING (MRI). A pelvic or a rectal examination
may be necessary too. Otherwise, tests may not
be needed so much as
PAIN RELIEVERS and restful
reclining.
Treatment Options and Outlook
According to the coccyx.org Web site, “Coccydynia
can be anything from discomfort to acute pain, vary-
ing between people and varying with time in any
individual. The name describes a pattern of symp-
toms (pain brought on or aggravated by sitting), so
it is really a collection of conditions which can have
different causes and need different treatments.”
While inflammation lasts, at-home treatments
include
COLD THERAPY and NONSTEROIDAL ANTI-
INFLAMMATORY DRUG (NSAID) THERAPY. If no swell-
ing exists,
HEAT THERAPY may be more comforting.
Until the tailbone heals, special devices, such as a
cushion with the center cut out, can avoid painful
aggravation of the problem. Patients with frequent
recurrences can sometimes be helped with
ULTRA-
SOUND THERAPY and, in rare instances, SURGERY.
Risk Factors and Preventive Measures
Online information from Spine-health.com said
coccydynia “is fairly uncommon and probably
accounts for less than 1% of cases of low back
pain.” Men have fewer risks, since “women have
a broader pelvis, which means that sitting places
pressure not only on their ischial tuberosities (‘butt
bone’) but also on the coccyx. (Men tend to sit only
on their ischial tuberosities without a lot of pres-
sure applied to the coccyx).” A member of either
sex with a tendency toward a tender tailbone would
do well to avoid prolonged sitting. For some, the
best position may come in being a fine citizen who
remains upstanding.
coccyx.org. “What Is Coccydynia.” Available online. URL:
http://www.coccyx.org/whatisit/index.htm. Downloaded
December 16, 2005.
Staehler, Richard, M.D. “Coccydynia—a Real Pain in the
Tailbone,” Spine-health.com. Available online. URL:
http://www.spine-health.com/topics/cd/coccydynia/
coc01.html. Downloaded December 12, 2005.
coccygeal spine Commonly known as the tail-
bone, this part of the derriere consists of three to
five vertebral bones designed in a triangular pat-
tern similar to a wall sconce. Unlike the
VERTEBRAE
of the
THORACIC SPINE and LUMBAR SPINE, the bones
of the coccygeal spine have a solid center instead of
a hollow opening, since they do not need to make
room for the spinal cord. Instead, spinal nerves exit
in the lumbar region, fanning across the hips and
down the lower body.
Risks and Complications
The coccygeal spine does not articulate well with
the upper
SPINE and does not have much RANGE OF
MOTION. As the coccyx.com Web site says, “When
you walk or bend over, the coccyx does not move
much in relation to the spine. But when you sit
down, this pushes the flesh of your bottom out of its
normal position, making the coccyx move by up to
coccygeal spine 65
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