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22 degrees.” In addition to this disconcerted effort,
the span of coccyx bones varies among individuals
with a total of one to four inches being the typical
length. People with longer tailbones have a greater
risk of sustaining injuries, such as
COCCYDYNIA or a
tailbone
FRACTURE.
Statistics and Studies
Most studies agree that the odds of a bone injury
lessen with
BONE BUILDING efforts such as adequate
NUTRITION, daily ACTIVITY, and STRENGTH TRAIN-
ING or other EXERCISE. For example, registered
nurse Debra Wood recommended these sensible
steps: “Eat a diet rich in calcium and vitamin D.
Do weight-bearing exercises to build strong bones.
Build strong muscles to prevent falls.”
Special Aids and Adaptations
Whether a person has a bone fracture or a bruised
tailbone, a “doughnut” cushion can relieve coc-
cygeal pressure.
ERGONOMIC FACTORS bear consid-
eration, too, as a person can often avoid an achy
tailbone by sitting correctly—or not at all.
coccyx.org. “The Normal Coccyx.” Available online. URL:
http://www.coccyx.org/whatisit/normal.htm. Down-
loaded December 16, 2005.
Wood, Debra. “Coccyx Fracture,” Holy Cross Hospital,
EBSCO Publishing. Available online. URL: http://
healthychoice.epnet.com/GetContent.asp?siteid=holy
cross&docid=/dci/coccyxfracture. Downloaded Decem-
ber 16, 2005.
cold therapy Sometimes known as cryotherapy,
cold therapy can involve something as simple as
a bag of frozen peas on a bruise. For swelling and
inflammation, cold therapy provides an instinctive
and effective treatment, especially after
SURGERY or
injuries. A cold compress also slows bleeding and,
when applied to pulse points on the forehead and
wrists, can help to bring down a fever.
Procedure
Whether packaged in cubes, chilled water, or state-
of-the-art equipment, this therapy applies some-
thing cold to an area of heat and swelling. As a
general rule, 20 minutes on and 20 minutes off the
inflamed spot provides the recommended treatment
for two to four days. If numbness begins at, say, ten
minutes though, the session should abruptly end.
For most bone-chilling needs, 15 minutes every
two hours for a day or two will suffice.
Risks and Complications
Ice constricts blood flow, so anyone with circula-
tory problems should avoid cold therapy. Some
people have an allergic response to cold, but almost
everyone reacts adversely to icy treatments of the
heart or chest. In an online article for the Univer-
sity of Michigan Health System, Dr. Pierre Rouzier
cautioned, “Certain parts of the body (including the
elbow, the knee, and the foot) can be injured by
cold more easily because they don’t have as much
padding or insulation.”
To avoid the risk of frostbite at any site, ice should
not be applied directly to the skin for more than a
minute or two. Even then, damp skin can stick and
stay when an ice cube is pulled away. Besides caus-
ing an unnecessary ouch, skin damage can easily
occur in
INFANTS, CHILDREN, or ELDERLY patients who
cannot convey their discomfort.
Assuming a person can tolerate cold, a commer-
cial product from a reputable manufacturer pro-
vides a good option with certain precautions taken.
For instance, the chemicals or dyes in some packs
can seep into the body or cause skin irritation. Also,
most store-bought ice packs have enough cooling
power to last two hours or more but must still be
used for only 10- to 20-minute intervals. However,
improvised cold packs have drawbacks too. A pack
of peas will defrost too quickly but not refreeze in
time for the next cooling session, while crushed ice
rolled into a towel can be messy or slide around the
inflamed area like a car on an icy hill.
Outlook and Lifestyle Modifi cations
Prior to
EXERCISE or a sports event, HEAT THERAPY
can literally help a patient or
ATHLETE to warm up.
Conversely, an ice pack promptly applied to dry
skin can prevent pain and swelling after intense
ACTIVITY. In the Internet article mentioned above,
Dr. Rouzier gave an example of a cool form of
MASSAGE THERAPY, saying, “To do ice massage, first
freeze water in a paper or Styrofoam cup. Then tear
away the top lip of the cup and rub the ice over
66 cold therapy
the injured area for 5 to 10 minutes. Ice massage
works very well for overuse injuries.” The doctor
did not mention this, but if an injured person does
not have time to freeze ice water, a sacrificial pop-
sicle just might suffice.
Roach, Louise. “The Power of Ice,” Mamashealth.com.
Available online. URL: http://www.mamashealth.
com/bodyparts/coldtherapy.asp. Downloaded Decem-
ber 19, 2005.
Rouzier, Pierre, M.D. “Ice Therapy,” University of Michi-
gan Health System, McKesson Provider Technolo-
gies. Available online. URL: http://www.med.umich.
edu/1libr/sma/sma_itherapy_sma.htm. Downloaded
December 19, 2005.
complementary and alternative medicine (CAM)
Traditionally, allopathic medicine strives to
restore and preserve health. Complementary
and alternative medicine (CAM) has the same
goal, but the method can dramatically differ. For
example, instead of prescribing drug therapy for
a musculoskeletal complaint, CAM often takes a
hands-on approach with
ACUPRESSURE, ACUPUNC-
TURE, MASSAGE THERAPY, SPINAL MANIPULATION,
or
TRIGGER POINT THERAPY. Some conditions also
respond to
HEAT THERAPY, HYDROTHERAPY, HERBAL
THERAPY, HOMEOPATHIC MEDICINE, or ULTRASOUND
THERAPY. Besides treating BACKACHE or spinal
pain, CAM practitioners may use
BIOFEEDBACK or
other methods to alter mechanisms that affect the
central nervous system, produce tension, or cause
problems with
SLEEP.
Risks and Complications
Even a simple form of therapy has risks. For
example, patients with circulatory problems must
avoid
COLD THERAPY, such as applying an ice pack
to a bruised shin. People with
SPINAL INFECTION,
OSTEOPOROSIS, VERTEBRAL COMPRESSION FRACTURE,
or other type of bone
FRACTURE should avoid spi-
nal manipulation, while people with food allergies
must be cautious about trying herbal treatments.
Complications also arise if patients refuse appro-
priate allopathic tests and treatments, using CAM
as a soloist instead of a natural accompaniment in
orchestrating their medical care. For instance, some
herbs can ease the side effects of chemotherapy yet
not provide the sole treatment for
CANCER.
Statistics and Studies
Consumer Reports magazine surveyed 34,000 readers
then announced, “Chiropractic was ranked ahead
of all conventional treatments, including prescrip-
tion drugs, by readers with back pain. . . . Deep tis-
sue massage was found to be especially effective in
treating osteoarthritis and fibromyalgia, a painful
musculoskeletal syndrome that conventional medi-
cine often remains at a loss to treat.” Interestingly,
“our new survey found that for readers who recently
used alternative medicine, nearly 75 percent told
their doctors about it. Most doctors approved,” and
“25 percent of those readers said their doctor sug-
gested the alternative in the first place.” In addition,
“Consumer Reports subscribers, who tend to be older,
wealthier, and better educated than the population
at large, are enthusiastic users of alternative medi-
cine not only to treat specific problems but also to
maintain overall health. Forty-seven percent of
respondents had tried an alternative remedy during
the past two years, a higher percentage than that
found by other large-scale surveys.” Furthermore,
“readers were much more likely to try alternative
remedies for conditions that don’t have effective
conventional treatments.” Although readers lauded
chiropractic treatment of
CERVICAL SPINE pain, the
magazine did not recommend it because, “a Uni-
versity of California, San Francisco, study of stroke
victims published in 2003 found that chiropractic
manipulation of the neck significantly increased the
risk of stroke by causing the lining of a neck artery
to break off and block blood flow to the brain. Other
studies have echoed that concern.”
With a similar warning, an article in Patient Care
said, “For any patient, neck maneuvers demand
caution, particularly exercises that involve exten-
sion and rotation. . . . Overall, patients receiving
manual therapy for the treatment of neck pain have
a 1–2% risk of increased symptoms as a result. . . .
Dizziness is most likely to worsen,” but “the risk of
serious complications or death from neck manipu-
lation is estimated at about 0.0001%.” Regarding
the likelihood of being that one person in one-
ten-thousandth of one percent, the article also
said, “The prospect of injury to the cervical spine
complementary and alternative medicine 67
increases when the practitioner is not a physician,
is not well-versed in diagnostic techniques, uses
inappropriate force, or is unaware of contraindica-
tions to cervical treatment.”
Mistrust, conflicting opinions, or lack of informa-
tion can influence people to treat their own vertebral
pain. According to an article in USA Today, “When
adults experience back pain, they most commonly
use self-help methods like resting or lying down
(55%). Others try to alleviate discomfort by taking
an over-the-counter medication (52%) or using a
heating pad (38%). A much smaller number go to a
trained medical professional to get treated, such as
visiting their primary care doctor (23%), chiroprac-
tor (20%), or spine specialist (10%).”
The report “Complementary and Alternative
Medicine Use Among Adults: United States, 2002”
said that, “the majority of people use CAM as a
complement to conventional medicine, not as an
alternative.” However, this choice comes with a
price. As the report stated, “It has been estimated
that the U.S. public spent between $36 billion and
$47 billion on CAM therapies in 1997. Of this
amount, between $12.2 billion and $19.6 billion
was paid out-of-pocket for the services of profes-
sional CAM health care providers such as chiro-
practors, acupuncturists, and massage therapists.
These fees are more than the U.S. public paid
out-of-pocket for all hospitalizations in 1997 and
about half that paid for all out-of-pocket physician
services.” Explanations for this growth include
“marketing forces, availability of information on
the Internet, the desire of patients to be actively
involved with medical decision-making, and dis-
satisfaction with conventional . . . medicine.”
More than one-third of the adults in the United
States will at least investigate complementary or
alternative treatments. As the National Center for
Health Statistics said, these helps range from mas-
sage therapy (5 percent) to prayer for oneself or
others (67 percent) with medicinal herbs (19 per-
cent) sprinkled between like parsley.
Special Aids and Adaptations
CAM itself offers an adaptation or aid to conven-
tional medical treatment, particularly for
CHIL-
DREN, people sensitive to pharmaceutical drugs,
and those who cannot be helped by
SURGERY. How-
ever, the need for CAM and traditional medical
treatments can often be prevented by tending to
basic necessities with greater care. Although easy
to overlook, a body just naturally prescribes to the
need for ample fresh water, healthful
NUTRITION,
regular
EXERCISE, good POSTURE, and restorative
sleep. Ultimately, this could make CAM mean
“Caring About Myself.”
Barnes, Patricia M., Eve Powell-Griner, Kim McFann, and
Richard L. Nahin. “Complementary and Alternative
Medicine Use Among Adults: United States, 2002,”
Advance Data From Vital and Health Statistics, National
Center for Complementary and Alternative Medicine,
National Institutes of Health, Centers for Disease Con-
trol and Prevention (CDC) no. 343 (May 27, 2004):
p. 1–20.
Bower, Peter J., Beverly Rubik, Steven J. Weiss, and
Cynthia Starr. “Manual Therapy: Hands-on Healing,”
Patient Care 31, no. 20 (December 15, 1997): 69–81.
National Center for Health Statistics. “More Than One-
Third of U.S. Adults Use Complementary and Alter-
native Medicine, According to New Government
Survey.” Available online. URL: http://www.cdc.gov/
nchs/pressroom/04news/adultsmedicine.htm. Last re-
viewed May 27, 2004.
Staff. “Sufferers Prefer Home Remedies,” USA Today Mag-
azine 133, no. 2,717 (February 2005): 11.
Staff. “Which Alternative Treatments Work?” Consumer
Reports (August 2005): 39–41.
complex regional pain syndrome (CRPS) See
REFLEX SYMPATHETIC DYSTROPHY SYNDROME.
compression fracture See VERTEBRAL COMPRES-
SION FRACTURE.
computed tomography (CT) or computerized axial
tomography scan (CAT scan) When X-RAYS met
computer technology, it was lovely at first sight. As
more seriously explained by the American Acad-
emy of Orthopaedic Surgeons (AAOS) Web site, “A
CT scan (computed tomography) is a modern imag-
ing tool that combines X-rays with computer tech-
nology to produce a more detailed, cross-sectional
68 complex regional pain syndrome
image of your body. A CT scan lets your doctor see
the size, shape and position of structures that are
deep inside your body, such as organs, tissues or
tumors.”
The Radiology Society of North America (RSNA)
added, “CT is able to depict internal bleeding and
fractures in trauma victims shortly after they arrive
at the hospital.” Painless and noninvasive, “spi-
nal CT scanning is a rapid procedure and offers an
accurate evaluation of bone and most soft tissues.
Using the latest equipment, the spine may be dis-
played in multiple planes, and three-dimensional
imaging is an option.” Also, “CT is less expensive
and more cost-effective than MRI” (
MAGNETIC RESO-
NANCE IMAGING). “In addition, it is less sensitive to
patient movement. Unlike MRI, CT may be carried
out in patients who have an implanted device of
any kind.”
Procedure
For a memorable interior portrait, the patient must
be as still as needed for a photo-shoot. However,
this painless outpatient procedure seems less glam-
orous and more like being engulfed by a doughnut-
shaped camera lens. As a cylindrical tube encircles
the reclining person, X-rays shot from many angles
appear on a computer screen. In some cases, a
contrast is injected into the vein of the patient to
enhance CT pictures with colorization and show a
troublesome area for what it really is. For example,
a CT scan may be used to detect a
HERNIATED DISC,
hairline
FRACTURE, SPINAL TUMOR, or other abnor-
mality in the
BACK or SPINE. To get a clear picture
in about one hour or less, the procedure involves
a barium sulfate injection or a special dye to drink,
which may seem like downing food coloring with-
out the juicy benefits.
Risks and Complications
Some patients react to the dye with a rash or stom-
ach upset. Although rare, the contrast medium can
cause anaphylactic shock in people who take cer-
tain medications or are highly sensitive to iodine.
Minimal exposure lowers radiation risks, but preg-
nant women should avoid a CT scan. More likely
complications occur for people in small towns or
rural areas where no CT scanning equipment can
be found to evaluate an injury.
Outlook and Lifestyle Modifi cations
To assess
ELDERLY patients or monitor persons with
OSTEOPOROSIS, a CT scan can be used as a BONE
MINERAL DENSITY TEST every two years or so. Since
the pictures show soft tissue and
DISCS too, a scan
provides an accurate diagnostic tool for a catalog
of spinal problems, each of which may suggest an
appropriate change in lifestyle.
American Academy of Orthopaedic Surgeons. “Diagnos-
tic Imaging,” AAOS. Available online. URL: http://
orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=
212&topcategory=General%20Information. Down-
loaded December 20, 2005.
Radiology Society of North America. “Computed Tomog-
raphy (CT)—Spine,” RSNA. Available online. URL:
http://www.radiologyinfo.org/content/spinect.htm.
Last reviewed August 2, 2005.
seniorhealthchannel. “CT Scan,” Healthcommunities.com,
Inc. Available online. URL: http://seniorhealthchannel.
com/diagnostictests/CTscan.shtml. Last modified Decem-
ber 20, 2005.
spine inc. “CAT Scan,” Extracted from Asia Medicine Net.
Available online. URL: http://www.spine-inc.com/
glossary/c/ct-scan.html. Downloaded December 20,
2005.
congenital anomaly of the spine See BIRTH DEFECTS
OF THE SPINE.
corpectomy A type of ARTHRODESIS, this surgical
procedure often addresses the
CERVICAL SPINE but
sometimes the
THORACIC SPINE and LUMBAR SPINE.
In any case, the operation removes one or more
vertebrae and/or adjacent
DISCS, usually to relieve
pressure on the
SPINE, spare the spinal nerves, or
prevent a
SPINAL CORD injury. If a bone spur has
developed, that
OSTEOPHYTE will also be removed.
Procedure
Similar to an
ANTERIOR CERVICAL DISCECTOMY, the
surgeon makes an incision in the front (anterior)
portion of the neck, removes the offending bone
matter, then fills the space with a
BONE GRAFT. In
addition, information from the All About Back &
Neck Pain Web site said, “Some method of internal
corpectomy 69
fixation to hold the bones and bone graft in place is
normally used. The most common method is to use
metal (titanium) plates and screws. The plate sits
on the front of the remaining vertebrae, covering
the . . . graft. Screws are placed into the vertebral
bodies above and below the graft to hold the plate
in place and keep the bone graft from slipping.”
Risks and Complications
Every
SURGERY involves risks such as bleeding or
infection, but proximity to the spinal cord makes
a corpectomy a delicate and potentially dangerous
operation. Most patients, however, will be released
from the hospital in two to four days. Some experi-
ence immediate relief, but for others, a decrease in
pain may be gradual. Few complications arise, but
cigarette smoking can slow bone growth, hindering
the desired bone fusion.
Outlook and Lifestyle Modifi cations
During the recovery period, an
ORTHOTIC neck brace
or halo device immobilizes the neck until natural
fusion has stabilized the area. If the corpectomy
involves vertebrae in the
BACK, a different type of
orthotic may be needed to keep the person mobile.
When fusion has been established, therapeutic
EXERCISE can begin to strengthen the spine and
PARASPINAL MUSCLES.
All About Back & Neck Pain. “Cervical Corpectomy
and Strut Graft.” Available online. URL: http://www.
allaboutbackpain.com/html/spine_cervical/spine_
cervical_corpectomy.html. Downloaded December
20, 2005.
Mellion, B. Theo, M.D. “Surgical: Cervical Corpectomy,”
Medtronic Sofamor Danek, Neck Surgery.com. Available
online. URL: http://www.neckreference.com/treatment-
surgical-corpectomy.html. Downloaded Dec ember 20,
2005.
corticosteroid injection When other forms of
PAIN MANAGEMENT no longer ease vertebral pain or
swelling in the
BACK and SPINE, cortisone injections
come to the rescue. The tricky part can be finding
the right spot to inject this synthetic version of a
naturally produced hormone. If a patient can iden-
tify the source of pain, so much the better, but pain
radiating from a tendon or joint can be difficult to
pinpoint. If so, an
ELECTROMYOGRAM may confirm
the locale. Also, the doctor may request
MAGNETIC
RESONANCE IMAGING (MRI) or a COMPUTED TOMOG-
RAPHY (CT) SCAN to clarify the site of injection.
Procedure
In an article for eMedicine.com, Dr. Jerrold N.
Rosenberg explained variations in the procedure:
“Some physicians prefer to give one injection (the
corticosteroid preparation, perhaps mixed with a
local anesthetic). Their rationale is that one needle
is less painful than two; however, the cortisone
injection involves a thicker material and, therefore,
they use a larger gauge needle.” With a two-needle
technique, the physician uses a smaller needle to
anesthetize the area, waits three to five minutes
for an optimal numbing effect, then switches to a
larger needle for the actual injection.
Risks and Complications
A corticosteroid injection should not be given to
a person with a
SPINAL INFECTION or other fever-
producing illness. In an article for Quest Diagnos-
tics, Kerry Cooke said, “Corticosteroids should be
used with caution. Although they may provide
relief from pain and inflammation, corticosteroids
can also slow healing and new bone formation.
You may experience an increase in pain during the
first 2 to 4 days after an injection.” Some people
also encounter side effects, such as easy bruising or
edema. In addition, long-term use can thin bones
and even cause
OSTEOPOROSIS. However, Cooke sug-
gested, “To prevent osteoporosis while taking long-
term or high-dose corticosteroids, also take 1000
mg to 1500 mg of calcium daily, 800 IU of vitamin
D daily, and a preventive medication, such as alen-
dronate or risedronate. Weight-bearing exercise
also helps reduce the risk of osteoporosis.”
Outlook and Lifestyle Modifi cations
An article on the Spine-dr.com Web site reported
the success of corticosteroid injections in treating
pain in the
CERVICAL SPINE. With 80 percent of the
injections at the C7 to T1 level and the other 20
at C6 to C7, “The study results show marked ini-
tial relief in 63% (19/30), with relief lasting an
average of eight months in 50% (15/30) of all
70 corticosteroid injection
injected patients. Seventy-six percent of injected
patients who had relief initially sustained their
improved state or improved further during follow
up.” Although the procedure does not cure a prob-
lem such as
DEGENERATIVE DISC DISEASE or SPINAL
STENOSIS, a corticosteroid injection may enable a
patient to delay
SURGERY, resume regular ACTIVITY,
or begin therapeutic
EXERCISE to strengthen the
back and decrease vertebral pain.
Cooke, Kerry V. “Corticosteroid Injections for Spinal Ste-
nosis,” Quest Diagnostics ® Patient Health Library.
Available online. URL: http://www.questdiagnostics.
com/kbase/topic/detail/drug/uh1944/detail.htm.
Downloaded December 20, 2005.
Rosenberg, Jerrold N., M.D. “Corticosteroid Injections
of Joints and Soft Tissues,” eMedicine.com. Avail-
able online. URL: http://www.emedicine.com/pmr/
topic211.htm. Downloaded December 20, 2005.
Spine-dr.com. “Cervical Epidural Corticosteroid Injec-
tion In Degenerative Disease.” Available online. URL:
http://www.spine-dr.com/site/surgery/block_article3.
html. Downloaded December 20, 2005.
costotransverse and costovertebral joint injec-
tions In small joints where the ribs meet the SPINE,
pain invites poor company. Upper back pain or pain
between the ribs may signal the arrival of rib dys-
function syndromes. Since this party of problems
can masquerade as other conditions, joint injec-
tions can identify the syndrome and also relieve the
unwanted pain.
Procedure
For this 15- to 30-minute procedure, the patient lies
facedown as a medical specialist uses
FLUOROSCOPY
to locate the rib joint where an injection will occur.
The needle brings a quick prick, but any
ACUTE PAIN
or
CHRONIC PAIN emanating from that joint should
soon subside, and mobility should proportionately
increase.
In an article for Spine-health.com, Dr. Ray
Baker discussed what happens next: “Twenty to
thirty minutes after the procedure, the patient will
be asked to try to provoke the usual pain. Patients
may or may not obtain pain relief in the first few
hours after the injection, depending upon whether
or not the area injected is the main source of the
patient’s upper back pain. On occasion, patients
may feel numb or a slightly weak/odd feeling for
a few hours after the injection. This may last sev-
eral hours, but the patient should be able to func-
tion safely, if proper precautions are taken.” For
example, the person should not drive a vehicle or
resume daily
ACTIVITY for about 24 hours.
Risks and Complications
Patients who take blood thinners or who expe-
rience allergic reactions to medications should
not have a joint injection. In general, side effects
include edema and changes in weight, mood, blood
pressure, or blood sugar. Discomfort may occur in
the first few days after a treatment, but an ice pack
or other form of
COLD THERAPY will usually bring
relief. Although rare, long-term use of the injec-
tions can produce
ARTHRITIS.
Outlook and Lifestyle Modifi cations
Since a joint injection often makes a person feel
better immediately, care must be taken to increase
EXERCISE gradually. With the pain eased and the
RANGE OF MOTION expanded, STRENGTH TRAINING can
begin with greater comfort. Also, the patient may
be better able to handle
SPINAL MANIPULATION or
other appropriate therapies.
Baker, Ray, M.D. “Costotransverse and Costovertebral Joint
Injections,” Spine-health.com. Available online. URL:
http://www.spine-health.com/topics/conserv/joint/
joint01.html. Downloaded December 21, 2005.
Silveri, Christopher P., M.D. “Costovertebral Block,” Inter-
national Spine Intervention Society, Patient Infor-
mation, SpineUniverse.com. Available online. URL:
http://www.spineuniverse.com/displayarticle.php/
article656.html. Last updated November 16, 2005.
COX-2 inhibitors See CYCLOOXYGENASE INHIBITORS.
crush fracture See VERTEBRAL COMPRESSION
FRACTURE.
crush injury syndrome See RHABDOMYOLYSIS.
crush injury syndrome 71
curvature of the spine See FLAT BACK; KYPHOSIS;
LORDOSIS.
cyclooxygenase (COX-2) inhibitors This newer
class of
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
(NSAID) blocks cyclooxygenase, an enzyme com-
monly known as COX-2. As a MedicineNet.com
article explained, “Blocking this enzyme impedes
the production of the chemical messengers (prosta-
glandins) that cause the pain and swelling of arthri-
tis inflammation.”
Similarly, COX-1 inhibitors such as
ASPIRIN, IBU-
PROFEN, and NAPROXEN block inflammation. How-
ever, the COX-1 enzyme has the extra jobs of
protecting the stomach and helping blood to clot.
Therefore, if an NSAID inhibits COX-1 production,
that same medication removes the protection of
this specific enzyme. Conversely, COX-2 enzymes
do not safeguard the lining of the stomach, so
blocking their production does not alter stomach
protection.
Dosage and Potential Side Effects
The dosage of a COX-2 inhibitor depends upon the
brand as well as the condition treated. For exam-
ple, celecoxib (Celebrex) may be prescribed in 100
mg capsules twice a day or 200 mgs once a day to
ease symptoms of pain and inflammation caused
by
ARTHRITIS, OSTEOARTHRITIS, or RHEUMATOID
ARTHRITIS. Also, Drug Topics announced, “The FDA
has approved a sixth indication for Pfizer’s selec-
tive COX-2 inhibitor Celebrex (celecoxib). The
drug can now be used for the relief of the signs
and symptoms associated with ankylosing spon-
dylitis.” If all goes well with the daily dose initially
recommended for about six weeks, 400 mg daily
may be tried.
In general, the side effects for COX-2 inhibitors
range from more common episodes of headache or
queasiness to the rare but severe allergic reaction
apparent in a rash. If itching, chest pain, or respira-
tory distress occur, the product should immediately
be discontinued and medical attention sought.
Statistics and Studies
In a document updated on July 18, 2005, the U.S.
Food and Drug Administration (FDA) issued a
statement requiring manufacturers of both
OVER-
THE-COUNTER and prescription COX-2 inhibitors
to change their labels. Specifically, “all sponsors
of marketed prescription Non-Steroidal Anti-
Inflammatory Drugs (NSAIDs), including Cele-
brex (celecoxib), a COX-2 selective NSAID, have
been asked to revise the labeling (package insert)
for their products to include a boxed warning,
highlighting the potential for increased risk of car-
diovascular (CV) events and the well described,
serious, potential life-threatening gastrointestinal
(GI) bleeding associated with their use.” Besides
this directive, “FDA has also requested that the
package insert for all NSAIDs be revised to include
a contraindication for use in patients immediately
post-operative from coronary artery bypass . . .
surgery.”
Regarding COX-2 inhibitors previously with-
drawn from the market, FDA will be unlikely to
reissue approval unless benefits can be shown to
outweigh those of other NSAIDs. According to an
article in Family Practice News, the FDA requested
the manufacturer to continue post-marketing
studies of Celebrex. The article also said, “So far,
the FDA has stopped short of asking other NSAID
manufacturers to perform additional studies, but it
has asked them to review all available safety data
from both short- and long-term studies and look for
additional safety signals.”
As
RESEARCH and debates continue, patients with
painful inflammation not helped by
SURGERY may
turn to older NSAIDs or centuries-old
HOMEOPATHIC
MEDICINE, HERBAL THERAPY, or other forms of COM-
PLEMENTARY AND ALTERNATIVE MEDICINE. For most
people, healthy habits of daily
ACTIVITY, EXERCISE,
and
NUTRITION also offer gentle but reliable long-
term help.
MedicineNet.com, Inc. “Cox-2 Inhibitors.” Available
online. URL: http://www.medicinenet.com/cox-2_
inhibitors/article.htm. Last reviewed October 2, 2005.
Staff. “Celebrex Gains New Indication; Boxed Warning
Added,” Drug Topics 149, no. 16 (August 22, 2005): 10.
Sullivan, Michelle G. “COX-2 Withdrawals Complicate
Pain Relief Decisions: Few Options Left for Patients
with Pain,” Family Practice News 35, no. 10 (May 1,
2005): 1–2.
72 curvature of the spine
U.S. Food and Drug Administration. “COX-2 Selective
(includes Bextra, Celebrex, and Vioxx) and Non-
Selective Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs),” FDA Center for Drug Evaluation and
Research, Department of Health and Human Services.
Available online. URL: http://www.fda.gov/cder/
drug/infopage/COX2/default.htm. Last updated July
18, 2005.
cyclooxygenase (COX-2) inhibitors 73
74
degenerative disc disease
A normal spine comes
naturally cushioned with sturdy gel packs. Between
the
VERTEBRAE, each DISC acts as a shock absorber to
keep one bone from rubbing another and causing
painful friction. If a
HERNIATED DISC ruptures, the
gelatinous matter seeps from the tough outer ring,
generating
ACUTE PAIN. If discs in general degener-
ate, the news comes as a spinal shock.
Symptoms and Diagnostic Path
An article posted by the Spine Institute of New York
described symptoms, saying, “The most common
early symptom of degenerative disc disease is back
pain that often spreads to the buttocks and upper
thighs. The degenerating disc(s) can also cause ‘dis-
cogenic’ pain (which just means pain that originates
in a damaged disc) and bulging discs.”
As spinal discs bulge, so may the stomach. This
occurs because the bones of the
SPINE shift and settle,
decreasing overall height. Subsequently, a person
may feel the pudgy effects of
WEIGHT even though
none has been gained. For an official diagnosis, a
physician will assess
RANGE OF MOTION in a physical
examination and inquire into a medical history. In
addition, X-
RAYS answer questions about vertebral
changes, while
MAGNETIC RESONANCE IMAGING or a
DISCOGRAM can clarify the condition of each ques-
tionable disc.
Treatment Options and Outlook
D
ISC REPLACEMENT or other type of SURGERY may
be needed to alleviate spinal nerve pressure or sta-
bilize spinal joints. Often though,
NONSTEROIDAL
ANTI-INFLAMMATORY DRUG (NSAID) THERAPY or modi-
fications in daily
ACTIVITY can arrest degenerate disc
behavior. Also, solving such problems as poor
POSTURE
or adverse
ERGONOMIC FACTORS can reform a way-
ward spine into maintaining proper disc function.
As explained in a Spine-health.com article, “The
treatment options for degenerative disc disease are
either passive [done to the patient] or active [done
by the patient]. Usually a combination of treat-
ments is used to help control the symptoms. Passive
treatments are rarely effective on their own—some
active component is almost always required.” For
example, passive therapy might include a
TRANSCU-
TANEOUS ELECTRONIC NERVE STIMULATOR (TENS) UNIT,
PAIN RELIEVERS, or an EPIDURAL INJECTION, whereas
active treatments may mean physical therapy and
STRENGTH TRAINING. As the article summarized, “Pain
from degenerative disc disease is caused by instabil-
ity at the motion segment and inflammation from
the degenerated discs. Both the instability and the
inflammation have to be addressed for the treat-
ment to be effective.”
Risk Factors and Preventive Measures
As discs fail to cushion vertebrae in the
BACK or
spine, bones often shift, which, in turn, can cause
VERTEBRAL SUBLUXATION or OSTEOPHYTE formation.
In the latter case, bone spurs sometimes grow into
the spinal column, pressing nerves or causing
SPI-
NAL STENOSIS. If neck discs degenerate, CERVICAL
SPONDYLOSIS may result.
Regardless of whether problems occur in the
CERVICAL SPINE, THORACIC SPINE, or LUMBAR SPINE,
treatments such as therapeutic
EXERCISE and SPINAL
MANIPULATION can slow or lessen deterioration. So
can healthful
NUTRITION, ample water, and adequate
SLEEP, mainly by giving the body what it needs to
hydrate, nourish, and restore cells. Other preven-
tives include low-impact dancing, swimming, row-
ing, and riding a stationary bicycle, preferably in
front of a gorgeous view to ease the mind, please
the senses, and appease boredom. Biking in front
of a television set can also keep an otherwise inert
D
body motivated into movement. This works par-
ticularly well with a program of three to four one-
hour sessions regularly scheduled each week.
Spine Institute of New York. “Degenerative Disc Disease,”
Beth Israel Medical Center. Available online. URL:
http://www.spineinstituteny.com/conditions/degen-
erative.html. Downloaded December 22, 2005.
Ullrich, Peter F., M.D. “Degenerative Disc Disease—
Non-surgical Treatment Options,” Spine-health.com.
Available online. URL: http://www.spine-health.com/
topics/conserv/degendisc/degendisc01.html. Down-
loaded December 22, 2005.
degenerative joint disease See OSTEOARTHRITIS.
diclofenac sodium See NONSTEROIDAL ANTI-
INFLAMMATORY DRUG THERAPY.
dietary needs for spinal health See NUTRITION.
diffuse idiopathic skeletal hyperostosis (DISH)
Also known as Forestier’s Disease, this form of
degenerative
ARTHRITIS occurs as soft tissue hard-
ens. What should be supple, malleable matter may
become rigid, thereby binding tendons, ligaments,
and joints from normal movement. As hardening
continues, the condition often affects the
THORACIC
SPINE, but the CERVICAL SPINE and LUMBAR SPINE may
lose flexibility too.
Symptoms and Diagnostic Path
Besides obvious signs of rigidity and decreased
RANGE OF MOTION, the disease may be asymptom-
atic. Confirmation may be accidental as a doctor
rules out similar conditions or detects DISH via such
imaging tests as X-
RAY, MRI (MAGNETIC RESONANCE
IMAGING), or CT (COMPUTED TOMOGRAPHY) SCAN.
Treatment Options and Outlook
If a bone spur (
OSTEOPHYTE) forms or bony overgrowth
hinders a joint,
SURGERY may be needed to free move-
ment. Otherwise, DISH can usually be treated with
SPINAL MANIPULATION and PAIN RELIEVERS. In addition,
NONSTEROIDAL ANTI-INFLAMMATORY (NSAID) DRUG
THERAPY can keep down the inflammation, subse-
quently reducing DISH-producing calcification.
Risk Factors and Preventive Measures
An article on the PatientPlus Web site said, “The
prevalence in European men over the age of 50
years is 5.8% and in women is 1.3%.” People under
40 very rarely have this problem, but, regardless of
the age or sex, “thoracic vertebrae are involved in
100%, lumbar in 68–90%, and cervical in 65–78%
of affected individuals.”
Until causal factors have been identified, pre-
ventive measures may be hit or miss. However, an
article in Orthopaedic Nursing gave a clue by saying,
“Environmental causes question the relationship of
fluoride in air and drinking water in the develop-
ment of Forestiers disease.” Fluoride may have a
role because, “chronic fluorine exposure looks like
DISH on radiographs.” Also, “another area of inves-
tigation into the pathogenesis of DISH is toxic prop-
erties,” such as bone changes caused by prolonged
use of high doses of
VITAMIN A supplements.
Besides those potential causes, one might say
that being sedentary almost ensures sedimentary
deposits. Therefore, regular daily
ACTIVITY, stretch-
ing
EXERCISES, and a healthy plate of NUTRITION may
put away DISH problems.
Childs, Sharon G. “Diffuse Idiopathic Skeletal Hyperosto-
sis,” Orthopaedic Nursing 23, no. 6 (November/Decem-
ber 2004): 375–382.
Shiel, William, M.D. “Diffuse Idiopathic Skeletal Hyper-
ostosis (‘DISH’ or Forestier Disease),” MedicineNet.
com. Available online. URL: http://www.medicinenet.
com/diffuse_idiopathic_skeletal_hyperostosis/article.
htm. Last reviewed May 3, 2005.
Tidy, Colin, M.D. “Forestier’s Disease,” PatientPlus. Avail-
able online. URL: http://www.patient.co.uk/showdoc/
40002443/. Last issued November 2, 2005.
diflunisal See NONSTEROIDAL ANTI-INFLAMMATORY
DRUG THERAPY.
disc, disk Like bubble wrap, vertebral discs cush-
ion bones. Instead of air though, the interior holds
disc, disk 75
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