Spondylolysis and spondylolisthesis

Spondylolysis is a condition in which the there is a defect in a portion of the spine called the pars interarticularis (a small segment of bone joining the facet joints in the back of the spine). With spondylolysis, the pars interarticularis defect can be on one side of the spine only (unilateral) or both sides (bilateral). The most common level it is found is at L5-S1, although spondylolisthesis can occur at L4-5 and rarely at a higher level. Spondylolysis is the most common cause of isthmic spondylolisthesis, in which one vertebral body is slipped forward over another. Isthmic spondylolisthesis is the most common cause of back pain in adolescents; however, most adolescents with spondylolisthesis do not actually experience any symptoms or pain. Cases of either neurological deficits or paralysis are exceedingly rare, and for the most part it is not a dangerous condition. The most common symptom is back and/or leg pain that limits a patient's activity level. Since spondylolysis is the most common cause of spondylolisthesis, it may be referred to as an isthmic spondylolisthesis and sometimes these terms are used interchangeably, although this is not correct. There are at least 6 recognized causes of slippage as seen in spondylolisthesis in the literature. According to Dr. Leon Wiltse, these causes are listed as: * Dysplastic spondylolisthesis (which includes congenital) * Isthmic spondylolisthesis (which includes lytic or stress fracture, an elongated but intact pars or an acute fracture of the pars) * Degenerative spondylolisthesis (Pseudospondylolisthesis) — secondary to long-standing degenerative arthrosis (degenerative disc disease and degeneration of the facet joints) * Traumatic spondylolisthesis (secondary to a fracture of the neural arch) * Pathologic spondylolisthesis (from bone disease such as metastatic disease, tumor, osteoporosis, etc.) Importantly, spondylolysis only refers to the separation of the pars interarticularis (a small bony arch in the back of the spine between the facet joints), whereas spondylolisthesis refers to anterior slippage of one vertebra over another (in the front of the spine). Therefore, although the terms are sometimes used interchangeably, this is incorrect and the two are technically not interchangeable. The underlying cause of spondylolysis has not been firmly established. According to major researchers in spine medicine (including Wiltse, Yochum and Rowe) there have been no recorded cases of spondylolisthesis in a new born and therefore the condition is not believed to be genetic. Some physicians believe that repetitive trauma (such as from certain sports) may either cause or contribute to the development of spondylolysis. Spondylolysis or isthmic spondylolisthesis activity restrictions In the past, patients have often been advised to limit their activities (especially participation in sports and active exercise) to avoid causing advancement of the spondylolysis. However, new information developed from modern imaging tests and recent research indicates that reduced activity and/or rest to protect the spondylolysis from slipping may not always be necessary. Rest is only necessary if the patient becomes symptomatic. Rest can help eliminate the pain, and when the pain resolves the patient can resume his or her normal activities. Often adolescents are pulled from their sports participation because of fears that their spondylolysis will lead to spondylolisthesis (slippage of the affected vertebra) and that the slippage will become so severe as to cause permanent damage or paralysis. Adults with spondylolysis are also often counseled to avoid rigorous exercise and/or physically demanding jobs. However, in published medical literature, there are no instances of a patient in a work, industrial, or sports-related environment that has experienced trauma causing spondylolisthesis to slip further and produce neurological deficit or paralysis. Sophisticated imaging modalities such as single-photon emission computed tomography (SPECT) bone scans and magnetic resonance imaging (MRI) scans of the spine now provide the ability to evaluate the physiological changes that are associated with spondylolysis. This information allows for the important distinction between active and inactive spondylolysis. * Active spondylolysis. On the SPECT scan an active spondylolysis shows uptake, and an MRI scan shows bone marrow edema adjacent to the pars defect. These findings indicate that there is activity/movement associated with the pars defect, which is likely to produce symptoms of low back pain. * Inactive spondylolysis. If there are no indications of activity with the pars defect, then the spondylolysis is considered inactive and any low back pain the patient is experiencing is probably incidental (meaning that there is probably another cause of the patient’s lower back pain, such as a muscle strain). Even though activity restriction is not always necessary, careful management of spondylolysis is always advisable. Acute (active) spondylolysis requires more intensive management, while symptoms from spondylolysis that has moved into a chronic (inactive) phase can be managed conservatively. Source: Spinehealth

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Sciatica first aid

The term sciatica (sometimes misspelled "ciatica" or "siatica") is used to describe pain that radiates down the course of the sciatic nerve, which starts from each side of the lower back, extends down the back of the thigh, and into the foot. This type of pain is caused by compression of nerve roots in the lower part of the spine, which merge together to form the sciatic nerve in the pelvis. Pain may result from a variety of conditions, including disc problems. The good news, however, is that most cases of sciatica are not serious and will get better within a few days or weeks. When the sciatica pain flares up, it is helpful to know several options that can be used to help alleviate the pain and discomfort and help you to quickly return to your normal activity. Cold and heat treatment for sciatica Ice and heat sources are easily available, inexpensive, and usually quite effective in treating sciatica. * A cold pack or ice application can reduce inflammation and numb sore tissue, alleviating some of the pain in the sciatic nerve. This should be used initially when pain is sharp and intense, usually for 2 to 7 days, depending on the severity of the pain. * Heat dilates blood vessels, increasing the flow of oxygen and nutrients to the area, which assists in healing. Applying heat also stimulates sensory receptors in the skin, so the brain focuses less on the pain of sciatica. This is best used after the acute, sharp pain has subsided, typically 3 to 7 days after the start of the condition. For some people, alternating between ice and heat is the most effective sciatica treatment. One option for applying cold is to utilize an ice massage. This is most easily accomplished by freezing water in a paper cup and after its frozen, cut the top half of the cup away exposing the ice (like a Popsicle). The ice cup is then applied directly to the skin, usually in a circular motion over the course of the painful area. There are 4 stages of cooling, of which the second to last is a burning sensation, similar to eating ice cream too quickly. The last stage is numbness after which time frostbite can occur so stop when the burning turns into numbness. This process usually takes between 3 to 6 minutes, depending on the thickness of the area being treated. The ice massage can be given by someone else with the patient lying on his or her stomach or side. The ice should be gently applied to the six-inch area where the pain is felt, and massaged using a circular motion, using care to avoid the bony portion of the spine. The goal is to numb the area of discomfort, at which time gentle, minimal movements can be made to stretch out the sciatic nerve and relieve the compression that is causing the pain. When the numbness wears off, the ice can be re-applied and the procedure repeated. This treatment can be done two or three times a day. An ice pack is another approach where the ice is wrapped it in a towel or, a commercial ice pack can be used. This is usually kept in one spot, such as the low back, for 15 to 20 minutes per application, and repeated for three times (15 minutes on-off-on-off-on, which takes 1 hour, 15 minutes = 1 session). For sciatica, the pack is placed over the lower back as that is where the sciatic nerve is usually pinched. Several sessions can be performed throughout the day. Heat should also be applied carefully to avoid burning. The temperature of the heating pad, hot water bottle, (or water for a bath), should be warm, not hot, and is frequently buffered with a towel so the skin does not get too moist. In addition to the benefits stated above, heat relaxes the muscles, which again, allows for some pain relief, allowing the patient to stretch out the sciatic nerve and diminish the compression that is causing the sciatica. Medications to treat sciatic pain The pain associated with sciatica may also be reduced and sometimes relieved with the use of over-the-counter or prescription medications. Because some of the pain is coming from inflammation of the sciatic nerve, treatment using non-steroidal anti-inflammatory drugs (NSAID's) can be very effective. Aspirin can also help reduce the inflammation, but NSAID's have fewer gastrointestinal side effects (such as gastritis or ulcers). There are many options to consider when choosing NSAID's. Each is somewhat different and it is always advisable to discuss the benefits and drawbacks of each with a physician or pharmacist. NSAID options include: * Ibuprofen—such as Advil, Nuprin, Motrin * Naproxen—such as Naprosyn, Aleve * COX-2 inhibitors—such as Celebrex or Bextra (which require a prescription) Acetaminophen (such as Tylenol) can also be used for relief of sciatic pain. Because NSAID's and acetaminophen work differently, the two medications may be taken at the same time or staggered (i.e., NSAID's followed by acetaminophen, etc.). Other, stronger pain medications are also available through a prescription from a physician and may be necessary to help alleviate the pain from irritation to the sciatic nerve. Exercise for long-term pain relief Once pain control has been achieved, gentle stretching of the affected area, and low-impact exercise, (such as walking two to three miles) will help bring healing nutrients to the affected area and help to restore function. As with any back treatment, care should be taken to not further aggravate the situation. It is always advisable to consult with a doctor with any questions or concerns that may arise during the course of care. For long-term relief of sciatica pain, most experts agree that a regular routine of stretching and exercise is crucial. * Stretching. Patients may find it takes several weeks or months to develop flexibility in the spine and soft tissues, but may also find that the stretching helps bring sustained pain relief. The spinal column and its contiguous muscles, ligaments and tendons are all designed to move, and limitations in this motion can accentuate pain and make one more susceptible to re-injury. Stretching exercise should focus on increasing flexibility in the disc, muscles, ligaments, and tendons. Additionally, it is important to stretch muscles not directly involved with the injured area, such as the arms and legs. For example, the hamstring muscles play a major role in lower back pain, as it is clear that hamstring tightness limits motion in the hip, which increases stress across the low back, especially during forward bending. * Strengthening. Building strength is also important to help prevent and/or lessen future recurrences of sciatic pain. Specific exercises designed to strengthen the “core” or trunk muscles are most important in the management of low back pain. Depending on the underlying cause of sciatica (such as a herniated disc vs. a degenerated disc), different exercises may be prescribed. Two common forms of strengthening exercises to treat sciatica are McKenzie exercises and Dynamic Lumbar Stabilization exercises. Learning which exercises to do, as well as how to do them correctly, is typically best learned with the help of a qualified spine specialist. Manipulation and physical therapy Another treatment option that can be helpful for many causes of for sciatica is manipulation by a qualified health care provider (most commonly a chiropractor or an osteopath). The type of manipulation, amount of force, the direction of the manipulation and the frequency of application are taken into consideration when managing patients complaining of sciatica. Combining this with various forms of physical therapy such as exercise therapies can be very effective. Other considerations with sciatic pain Though uncommon, when the sciatic condition worsens, it is most important to obtain a prompt evaluation. This is especially true if progressive muscle weakness, foot drop, or loss of bowel or bladder control occur, as these symptoms require immediate emergency attention and permanent problems can result if not managed promptly. In general, whenever questions arise about the course of care and associated signs and symptoms, health care provision should be obtained and the questions answered. The good news is that most cases of sciatica will resolve naturally within a few weeks. The treatments described here can help alleviate pain until things return to normal, and help speed recovery, as well as avoid recurrence. Every patient is different of course, and not all sciatica treatments will work for all cases of sciatica. Sciatic pain can be mild and intermittent, but this type of pain along the large sciatic nerve can also be searing and unbearable. For severe cases of sciatic pain, it makes sense to get a firm or definitive diagnosis regarding the underlying cause of the sciatica (e.g. a herniated disc, degenerative disc disease, spondylolisthesis) and discuss additional treatment options with a spine specialist. In addition to the remedies discussed above, there are a wide variety of additional treatment options, including injections, surgery, and more. Source: Spine-health

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Spondylolysis profile and diagnosis

Spondylolysis develops most commonly in adolescents, most typically in 10 to 15 year olds. The majority of adolescents with spondylolysis do not have symptoms, or their symptoms are mild and are often overlooked. There is a chance that the deformity with continued stress can lead to the slippage of spondylolisthesis and recurrent low back pain. Spondylolysis is seen more often in athletes than in people who do not actively participate in sports, although studies differ as to just how much more. Approximately 3% to 7% of the general population is thought to have spondylolysis. It is suspected that spondylolysis occurs most frequently in young athletes who are involved in sports that require repeated hyperextension of the lower back. * One study found that spondylolysis occurred most frequently in young athletes involved in throwing, bobsledding, gymnastics, rowing, and boxing; * Another study found the highest incidence of the condition in diving, wrestling, weightlifting, modern pentathlon and triathlon, and track and field (e.g. from javelin throwing, high jump, and other activities involving hyperextension of the spine). Of course, most athletes involved in the above and other sports do not develop spondylolysis, and at this time it is not known what causes the condition to develop in some people and not in others. Older adults can also develop spondylolisthesis because of degeneration in the disc and the facet joints, which can allow slippage even without a fracture. While it is not known exactly what causes this condition, it is theorized that it probably involves overloading the back part of the facet joints, which can eventually lead to stress fractures. Spondylolysis diagnosis Whenever an athlete (especially a young athlete in the 10 to 15 year old age group) experiences lower back pain with or withouta traumatic event, spondylolysis must be considered as a potential cause of the pain. Typically, symptomatic spondylolysis involves a complaint of focal low back pain, although the pain can also extend into the buttock or legs. One orthopedic test that is useful (although not totally conclusive) in diagnosing spondylolysis is the one-legged hyperextension maneuver (also known as the unilateral extension test or Michelis' test). The patient stands on one leg in a position that hyperextends the lumbar spine; he or she then repeats the move on the opposite side. If the test produces pain, this can indicate spondylolysis. For any young individual with low back pain, organic disease must also be considered as a possible cause of back pain. For example, diabetes, and primary or metastatic cancer can cause lower back pain and must be ruled out prior to a definitive diagnosis of spondylolysis. If spondylolysis is suspected, an anterior (front), posterior (back), and lateral (side) x-ray can confirm the diagnosis. An oblique view x-ray can help determine if the spondylolysis is unilateral (on one side) or bilateral (on both sides of the spine). Finally, to determine if the spondylolysis is active or inactive, a SPECT bone scan or MRI is needed. * Active spondylolysis. On the SPECT scan if a fracture is recent and active spondylolysis shows uptake, and an MRI scan shows bone marrow edema adjacent to the pars defect. These findings indicate that there is activity/movement associated with the pars defect, which is likely to produce symptoms of low back pain. * Inactive spondylolysis. If there are no indications of activity with the pars defect, then the spondylolysis is considered inactive and any low back pain the patient is experiencing is probably incidental (meaning that there is probably another cause of the patient’s lower back pain, such as a muscle strain). Even though activity restriction is not always necessary, careful management of spondylolysis is always advisable. Acute (active) spondylolysis requires more intensive management and more supervision, while symptoms from spondylolysis that has moved into a chronic (inactive) phase can usually be monitored only periodically when necessary. -Spine-health

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Diagnosis of depression and chronic back pain

Depression is a commonly missed diagnosis One of the biggest problems in treating major depression for the patient with chronic back pain is missing the diagnosis. This occurs for two reasons: the chronic back pain patients often do not realize they are also suffering from a major depression, and the doctor is not looking for depression. Chronic back pain patients will often define their problem as strictly medical and related to the pain. This is supported by a recent study which found that individuals with chronic pain and depression went to their physicians 20% more often than a comparison group of non-depressed medical patients. In addition, depressed chronic back pain patients were 20% less likely to see a mental health specialist than medical patients without a pain problem (Bao, Sturm, & Croghan, 2003). The depressive symptoms may be downplayed by the chronic back pain patient who believes that, “just get rid of this pain and I won’t feel depressed” or that acknowledging depression is a sign of weakness in dealing with the pain. When the diagnosis of major depression in the chronic back pain patient is missed or ignored, treatments strictly directed at the pain are much more likely to fail. As concluded by Ohayon and Schatzberg (2003), the presence of a chronic pain physical condition increases the duration of depressive mood, and chronic pain patients seeking medical consultation should be routinely screened for a major depression. Simultaneous treatment for depression and chronic back pain Treatment of depression associated with chronic back pain requires a specialized approach. It is generally accepted that the pain and the depression should be treated simultaneously in a multidisciplinary fashion. The treatment of clinical depression most often includes psychological interventions (e.g. counseling, relaxation training, etc) and anti-depressant medication. In a recent review of the research from 1980 though 2000 that looks at treatment of depression, it was found that the combined treatment approach of medication and psychotherapy yielded better outcomes than either of the interventions alone (Pampallona et al., 2004). Simultaneous treatment directed at the chronic back pain is critical. It has been found that chronic pain may interfere with depression improvement. Treatment for the chronic pain might include such things as physical rehabilitation aimed at restoration of function, trying to “normalize” one’s life as much as possible even with the pain, appropriate medication management, among other things. Multidisciplinary treatment of the chronic back pain and major depression will ultimately give the patient more of a sense of control over the pain and start a “positive spiral” toward physical and mental re-conditioning. Assessing depression The Depression Questionnaire is a self-administered test that patients can take to gauge the severity of their depression. If the score is in the moderate to severe range, the patient should discuss the results with his or her doctor or back specialist. It may find be helpful to print up this page to take the depression questionnaire and record the answers and final score.

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Depression and chronic back pain

Clinical depression and back pain Depression is by far the most common emotion associated with chronic back pain. The type of depression that often accompanies chronic pain is referred to as major depression or clinical depression. This type of depression goes beyond what would be considered normal sadness or feeling "down for a few days". The symptoms of a major depression occur daily for at least two weeks and include at least 5 of the following (DSM-IV, 1994): * A predominant mood that is depressed, sad, blue, hopeless, low, or irritable, which may include periodic crying spells * Poor appetite or significant weight loss or increased appetite or weight gain * Sleep problem of either too much (hypersomnia) or too little (hyposomnia) sleep * Feeling agitated (restless) or sluggish (low energy or fatigue) * Loss of interest or pleasure in usual activities * Decreased sex drive * Feeling of worthlessness and/or guilt * Problems with concentration or memory * Thoughts of death, suicide, or wishing to be dead Chronic pain and depression are two of the most common health problems that health professionals encounter, yet only a handful of studies have investigated the relationship between these conditions in the general population (Currie and Wang, 2004). Major depression is thought to be four times greater in people with chronic back pain than in the general population (Sullivan, Reesor, Mikail & Fisher, 1992). In research studies on depression in chronic low back pain patients seeking treatment at pain clinics, prevalence rates are even higher. 32 to 82 percent of patients show some type of depression or depressive problem, with an average of 62 percent (Sinel, Deardorff & Goldstein, 1996). In a recent study it was found that the rate of major depression increased in a linear fashion with greater pain severity (Currie and Wang, 2004). It was also found that the combination of chronic back pain and depression was associated with greater disability than either depression or chronic back pain alone. Depression is common for those with chronic back pain Depression is more commonly seen in patients with chronic back pain problems than in patients with pain that is of an acute, short-term nature. How does depression develop in these cases? This can be understood by looking at the host of symptoms often experienced by the person with chronic back pain or other spine-related pain. * The pain often makes it difficult to sleep, leading to fatigue and irritability during the day. * Then, during the day, because patients with back pain have difficulty with most movement they often move slowly and carefully, spending most of their time at home away from others. This leads to social isolation and a lack of enjoyable activities. * Due to the inability to work, there may also be financial difficulties that begin to impact the entire family. * Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications. * The pain is distracting, leading to memory and concentration difficulties. * Sexual activity is often the last thing on the person’s mind and this causes more stress in the patient’s relationships. Understandably, these symptoms accompanying chronic back pain or neck pain may lead to feelings of despair, hopelessness and other symptoms of a major depression or clinical depression. A recent study by Strunin and Boden (2004) investigated the family consequences of chronic back pain. Patients reported a wide range of limitations on family and social roles including: physical limitation that hampered patients’ ability to do household chores, take care of the children, and engage in leisure activities with their spouses. Spouses and children often took over family responsibilities once carried out by the individual with back pain. These changes in the family often led to depression and anger among the back pain patients and to stress and strain in family relationships. Psychological theories about depression Several psychological theories about the development of depression in chronic back pain patients focus on the issue of control. As discussed previously, chronic back pain can lead to a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends. This situation leads to a downward physical and emotional spiral that has been termed "physical and mental deconditioning" (See Gatchel and Turk, 1999). As the spiral continues, the person with chronic back pain feels more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to major depression. Once in this depressed state, the person is generally unable to change the situation even if possible solutions to the situation exist. Depression can lead to chronic back pain For quite some time, clinical researchers have known that chronic back pain can lead to major depression, as discussed previously (See Worz, 2003 for a review). Newer studies are now looking at how psychological variables such as depression and anxiety may be linked to the onset of a back pain problem. For example: * Atkinson, Slater, Patterson, Grant, and Garfin (1991), in a systematic study of depressed male Veterans Administration chronic pain patients, found that 42% of patients experienced the onset of depression prior to the onset of pain, whereas 58% experienced depression after the pain began. * Polatin et al. (1993) reported that 39% of the chronic low back pain patients they evaluated displayed symptoms of pre-existing depression. * More recently, in a review of research studies in this area, Linton (2000) found that in 14 of the 16 reviewed studies, depression was found to have increased the risk for developing back pain problems. Depression impacts spine surgery outcome Research has clearly demonstrated that non-physical variables such as depression, anxiety, thought patterns, and personality style can impact a spine surgery outcome (See Block, Gatchel, Deardorff & Guyer, 2003 for a review). Unfortunately, it appears that in many cases, having a major depression may not bode well for the outcome of a spine surgery. For instance, as discussed by Block et al. (2003), spine surgery patients who are clinically depressed pre-operatively may continue to display depressive symptoms post-operatively and these can negatively impact the surgery outcome. Particular symptoms that may impede post-operative recovery include such things as low motivation, sleep disturbance, slower healing time, difficulty with physical rehabilitation and inability to perceive improvements (Block et al, 2003; Deardorff and Reeves, 1997). Pre-surgery considerations for patients with depression Block et al. (2003) discuss that, in looking at the issue of depression and spine surgery outcome, it is important to consider whether the individual is experiencing a "reactive depression" or shows a pre-injury history of more chronic depression. A reactive depression is defined as depressive symptoms in response to the chronic back pain and associated problems (loss of work, friends, etc). Reactive depression occurs in back pain patients who have no previous history of depression. However, many chronic back pain patients have a history of problems with depression even before the onset of the back pain. As reviewed previously, individuals with chronic depression may be at greater risk for developing a low back pain condition. It is also likely that this same group is at greater risk for a poorer outcome to spine surgery (Block et al., 2003). If a patient is facing a spine surgery and has a chronic back pain problem with significant depression, he or she may want to consider postponing the surgery until the depression can be treated. Treatment for depression is often part of a preparation for spine surgery program (See Block et al., 2003; Deardorff and Reeves, 1997).

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Weight loss for back relief

The effects of obesity Patients who are overweight or obese and suffer from back pain may not be aware that their excess weight is actually contributing to their back pain. While it has not been thoroughly studied exactly how excess weight can cause or contribute to back pain, it is known that people who are overweight often are at greater risk for back pain, joint pain and muscle strain than those who are not obese (1). In addition to back pain, symptoms exhibited by persons who are obese or severely overweight may include fatigue, as well as difficulty breathing and shortness of breath during short periods of exercise (2). If the fatigue and shortness of breath causes one to avoid activity and exercise, then this can indirectly lead to back pain as lack of exercise contributes to many common forms of back pain. This article examines the heightened risk and severity for certain back problems that obese or overweight patients may experience as a result of their weight. The article also provides practical tips and guidelines for how patients can use exercise, diet and weight loss to reduce their back pain. Problems caused by obesity According to the American Obesity Association, episodes of musculoskeletal pain, and specifically back pain, are prevalent among the nearly one-third of Americans who are classified as obese (2). The American Obesity Association also reports that more obese persons say they are disabled and less able to complete everyday activities than persons with other chronic conditions (1). Some of the most common obesity-related problems include musculoskeletal and joint related pain (1). For people who are overweight, attention to overall weight loss is important as every pound adds strain to the muscles and ligaments in the back. In order to compensate for extra weight, the spine can become tilted and stressed unevenly. As a result, over time, the back may lose its proper support and an unnatural curvature of the spine may develop. In particular, pain and problems in the low back may be aggravated by obesity. This occurs for people with extra weight in their stomachs because the excess weight pulls the pelvis forward and strains the lower back, creating lower back pain. According to the American Obesity Association, women who are obese or who have a large waist size are particularly at risk for lower back pain (1). Obese or overweight patients may experience sciatica and low back pain from a herniated disc. This occurs when discs and other spinal structures are damaged from having to compensate for the pressure of extra weight on the back. In addition, pinched nerves and piriformis syndrome may result when extra weight is pushed into spaces between bones in the low back area (3). Arthritis of the spine that causes back pain may be aggravated when extra body weight strains joints. Those patients with a Body Mass Index (BMI) of greater than 25 are more likely to develop osteoarthritis than those with a lower BMI. The American Obesity Association recommends modest weight loss as a treatment for some types of osteoarthritis (2). The effectiveness of back surgery may also be affected by a patient’s weight. Obese patients are at higher risk for complications and infections after surgery compared to patients who are not obese (2). For seriously overweight patients, paying attention to weight loss before undergoing back surgery may improve the healing process after surgery. Identifying the need for weight loss Body Mass Index (BMI) is a measure commonly used by medical practitioners. BMI is a mathematical formula (BMI=kg/m2) that takes into account a person’s weight in kilograms and height in meters and calculates a number. The higher a person’s BMI falls on a pre-determined range of values, the higher the likelihood for obesity. Although there is some debate over the specific meaning of BMI measurements, a BMI of 30 or higher is typically considered to be obese, while a measure of 25 to 29.9 is typically considered to be overweight (4). It is also important to evaluate where excess fat is carried on the patient’s body. Patients who carry more weight around their midsection are at greater risk for obesity-related health problems, such as low back pain. Weight loss for health considerations is often advisable for women with a waist measurement of more than 35 inches or men with a waist measurement of more than 40 inches (4). Spine-health

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Review of adjustable beds

Choosing a comfortable bed and mattress People with back pain should be especially choosy about the type of bed and mattress they sleep on. While there is very little research in general about what types of mattresses and beds are best for the back—and no real medical research about adjustable beds—we do get a lot of questions about whether or not an adjustable bed is a better option than a flat mattress for people with back pain. This article provides a brief review of how an adjustable bed works and some theoretical advantages that some patients might find beneficial. How an adjustable bed works As the name suggests, an adjustable bed (also called a Semi-Fowler bed, as it places the patient in a semi-Fowler position) can be adjusted to a number of different positions. For individuals with certain types of back problems, sleeping on an adjustable bed that is at a slight incline (e.g. 30 to 45 degrees) may be comfortable, with the upper body positioned higher up than the lower body (as when sitting in a recliner) and some support under the knees to bend the knees at a slight angle. The combination of upper body incline and the knee support can help take some of the stress off the lower back. Provided that the patient is comfortable sleeping in this manner through the night, this position can support the curves osf the spine and relieve pressure on the entire body. Potential benefits of an adjustable bed Basically, an adjustable bed has the potential to help anyone who feels more comfortable in an inclined position (such as sitting on a recliner with the feet up) rather than when lying on a regular flat mattress. The following provides a few examples of certain back conditions and how an inclined position in an adjustable bed can sometimes help the patient feel more comfortable. * Degenerative spondylolisthesis. For some people with degenerative spondylolisthesis, sleeping in a reclining position with support under the knees can reduce some of the pain discomfort in the lower back, making it easier to sleep through the night. * Osteoarthritis. Individuals with osteoarthritis in the spine, or facet joint arthritis, often wake up feeling quite stiff and sore in the morning. Sleeping on an adjustable bed may possibly provide better support and therefore decrease the irritation by minimizing joint compression. * Spinal stenosis. People with spinal stenosis most often feel more comfortable when bending forward instead of standing up straight. Likewise, sleeping on a flat mattress can sometimes be less comfortable for people with this condition than sleeping in the reclining position, such as that afforded by an adjustable bed. In addition, after having low back surgery, some patients feel that an adjustable bed is more comfortable than a flat mattress. Like most choices when it comes to mattresses, this is largely a matter of personal preference. In general, it is reasonable for a patient to consider the option of an adjustable bed if he or she feels better sitting in a reclining chair with the knees supported or slightly elevated and if he or she is having trouble getting a good night’s rest on a conventional flat mattress. If a patient is not sure if they would benefit from an adjustable bed, or is not sure about buying a new bed, then it is also possible to use pillows to prop up the upper body (being careful to provide support for the lower back) and placing a pillow beneath the knees. Patient’s preference should determine the choice of bed and mattress It is important to remember that the patient’s personal preference for sleep comfort and back support should ultimately determine which type of bed or mattress is best. There is no single type of bed or mattress that works for all patients, and there is no real medical evidence that supports that an adjustable bed is a preferable option. The bottom line is that whichever bed or mattress allows a patient to sleep comfortably and without additional pain or stiffness is the best choice for that individual. Spine-health

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A healthy weight for a healthy back

Experts agree that the best way to achieve and maintain a healthy weight level is through a balanced diet and exercise. For people with many types of back problems, regular exercise and, when necessary, weight loss, can help ease existing back problems and prevent future ones. Obesity and extra weight can cause low back pain Along with other health issues that arise from having an unhealthy weight level, obese and overweight patients have an increased risk for back pain, joint pain and muscle strain (1). In particular, overweight patients are more likely to experience problems in their low back than patients at a healthy weight level. This is especially true for people with extra weight around their midsection as the extra weight pulls the pelvis forward, strains the low back and creates low back pain. In addition to muscle strain, spinal structures such as the discs can be negatively impacted by obesity. Patients with significant excess weight also may experience sciatica and low back pain from a herniated disc or from a pinched nerve if the discs have been damaged from compensating for the extra weight (2). Weight loss can lower risk for other back problems Managing weight through nutrition, diet and exercise not only reduces existing back pain, but can also help prevent certain types of back problems in the future. For example, overweight and obese patients have an increased risk for osteoarthritis. The additional strain on the joints from the excess weight can cause arthritis in patients whose Body Mass Index (BMI) is too high. For patients who already have osteoarthritis, weight loss is one of the recommended treatments (3). In addition, successful recovery from back surgery may also be affected by a patient’s weight because obese patients run a higher risk of complications and infections from surgery (3). As a result, overweight or obese patients may consider weight loss before major surgery in order to improve their outcome as well as to avoid contributing to further back problems. For more information about how obesity affects back health and tips for weight loss, please see Weight loss for back pain relief. Exercise helps with weight loss and back pain Maintaining a healthy weight usually helps patients to be more consistent with exercise. This is because overweight patients often have fatigue, difficulty breathing or shortness of breath as they exercise, which may cause them to avoid regular physical activity (3). As a general rule, many patients with back problems believe that they should avoid all exercise in an effort to protect their back from further injury or back pain. However, in reality, inactivity and lack of exercise can actually contribute to future pain and worsen existing problems. Patients are often unaware that movement through gentle exercise stimulates healing and a flow of nutrients within the spine. This is especially important for the discs in the spine. Physical activity causes the discs to swell with water and then squeeze it out, which exchanges nutrients between the discs and other spinal structures. When the patient does not engage in enough physical activity, the spinal discs are deprived of the nutrients they need to stay healthy and functional. The importance of physical activity is explained further in Exercise and fitness to help your back. Developing a safe weight loss, diet and exercise program The key to a healthy diet and good nutrition is balance. Patients should consume adequate amounts of vitamins and nutrients but should avoid exceeding the daily intake recommendations for some. Consuming a balanced amount of recommended vitamins and nutrients is also important because certain nutrients and vitamins work in concert while others work against each other. A balanced diet should include a range of healthy foods and, if appropriate, nutritional supplements. Because of the complexities of developing a healthy diet, exercise and weight loss program, patients should always consult a health professional before starting an exercise routine, changing their diet or taking nutritional supplements. The health professional should help the patient determine any potential limitations and guidelines to follow specific to his or her back problem. With attention to the nutritional content and quantities of food consumed, combined with gentle exercise to control weight, patients will enjoy better back health as well as improved overall health. Spine-health

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The truth about sciatica

Understanding the true nature of sciatica The term sciatica is oftentimes used incorrectly to explain leg pain, low back pain and other sciatica symptoms. It’s a condition so widespread that many people think they can self-treat it or just follow another person’s advice for how to relieve the pain. However, as this article will explain, there are many myths and misconceptions about sciatica, and patients are well-served to fully understand what can cause sciatica, warning signs that it may be a dangerous condition and the full range of treatment options. Sciatica (often misspelled as ciatica or siatica) is a relatively common form of leg pain that is often misunderstood by patients. There are frequent misconceptions about what the term sciatica means, why sciatica occurs and how to find relief from the low back pain and leg pain. Contrary to what many patients believe, sciatica is actually a set of symptoms rather than a diagnosis for what is causing the pain. Especially for more severe cases, the cause of the low back pain and leg pain needs to be correctly addressed in order to relieve discomfort. Common myths and misperceptions about sciatica Myth: Sciatica is a diagnosis for the cause of the pain Truth: Sciatica is a symptom, not a diagnosis Sciatica means that a patient’s sciatic nerve is being compressed by another spinal structure, usually causing pain in the low back, on one side of the rear and/or down the back of the leg. Sciatic nerve irritation usually occurs at the L5 or S1 level of the spine. The clinical diagnosis (and the focus for treatment) would be whatever problem is actually causing the nerve compression and the sciatic pain. The most common low back problems that cause sciatica are: * Lumbar disc herniation - where the inner core of a spinal disc in the low back extrudes and places pressure on a nerve root; also called a pinched nerve, slipped disc, bulging disc or protruding disc * Lumbar degenerative disc disease - when weakened discs in the low back allow excess motion in the spine and cause irritation of the nerve roots * Isthmic spondylolisthesis - where one vertebral body slips over another and pinches a nerve root * Lumbar spinal stenosis - in which a narrowing of the spinal canal in the low back pinches nerve roots, sometimes as the result of a bone spur * Lumbar subluxation – a term describing an altered position of the vertebra in the low back and the functional loss that results * Others causes – Although less common than those listed above, there are several other conditions that can cause sciatica and require medical attention. For example, patients who have a spinal tumor or infection should seek help immediately. Myth: The symptoms of sciatica are the same for all patients Truth: The sciatica experience can be different for each patient Sciatica pain can run from the low back, down the back of each leg and sometimes into the feet and toes. Other sensations associated with sciatica may include tingling and/or a burning or prickly feeling, usually only on one side of the body. Patients typically feel different types of sciatic pain depending on the location of the nerve compression. See Sciatica symptoms and sciatic nerve anatomy for more information. The severity and duration of pain from sciatica also vary among patients. Some find sciatica pain severe and debilitating, while others experience it as irritating and intermittent. Many patients recover from an episode of sciatica within a few weeks, but there is no hard and fast rule. Depending on the particular cause of the patient’s sciatica, the leg pain or low back pain could worsen over time and/or take much longer to be relieved. Myth: Sciatica doesn’t lead to permanent damage Truth: Serious problems or damage can occur (though rare) Pain from sciatica results from damage to the patient’s nerve tissue. In the vast majority of cases, the nerve damage is not permanent. However, the following signs indicate that there may be a more serious problem that requires immediate medical attention: * Patients who feel weakness or numbness may require surgery, and any patient experiencing these symptoms should seek professional attention. * Patients who experience bowel or bladder incontinence (inability to control the bowel or bladder) and/or increasing weakness or loss of sensation in the legs should see a doctor immediately. Myth: The sciatic nerve is only in the rear and the leg Truth: The sciatic nerve runs from the low back down to the toes The sciatic nerve is located in front of the piriformis muscle (deep in the rear), including the lowest two nerves that exit from the lower spine (L4 and L5) and the first three sacral nerves (S1, S2 and S3). Each of the nerves has two branches, one on each side of the spine. The root of each nerve exits the spine between two vertebra in the low back, travels down the back of each leg, and branches out to the leg and into each foot. The sciatic nerve is the largest single nerve in the human body. Sciatic pain that radiates along this nerve can be excruciating and debilitating for many patients. Myth: Sciatica leg pain is caused by a problem in the leg Truth: Sciatica leg pain is caused by a problem in the low back Patients often feel leg pain from sciatica, which leads them to believe that there is something wrong with their legs. However, because the sciatic nerve extends through the low back, legs and feet, a problem causing nerve compression in the low back can cause low back pain and feelings of pain through the legs, feet and sometimes the toes. Myth: Sciatica is hereditary Truth: The causes of sciatica are not genetic As explained above, sciatica is the result of a problem in the low back that can develop from aging or from a spinal injury. These conditions are not passed on genetically, as patients may mistakenly believe. There is no truth to the idea that sciatica is handed down from generation to generation. Myth: Piriformis problems can lead to sciatica Truth: Piriformis syndrome feels like sciatica but it isn’t the same Piriformis syndrome is a condition that is often confused with sciatica. When the piriformis muscle becomes tight, it can irritate the sciatic nerve. This causes sciatica-like pain, tingling and numbness that often run from the low back to the rear, down the leg and into the foot. Although the discomfort from piriformis syndrome feels similar to sciatica, the two have different causes. With piriformis problems, the pain is not caused by a compressed nerve root where it exits the spine as occurs with true sciatica. Correctly identifying the cause of the pain is important because the treatments for each type of pain tend to be very different. Myth: Arthritis or joint problems can cause sciatica Truth: Pain from arthritis or joint problems is not true sciatica The pain from arthritis or other joint problems is actually more common than sciatica, and they are often confused. In reality, sciatica and arthritis or joint pain are classified as different types of pain. Radicular pain like sciatica is caused by a pinched nerve. In contrast, referred leg pain from arthritis is dull, achy and often moves around and varies in intensity. Although the leg pain from arthritis may feel similar, it is not truly sciatica. Distinguishing the correct problem is important because the treatments for each type of pain often differ. Patients who have sciatica are best served by a treatment plan that is individualized based on the patient’s symptoms, diagnosis and response to various treatments. The process of finding relief from low back pain and leg pain associated with sciatica can often require some trial and error. Some patients may find certain treatments more effective than others. Common myths and misperceptions about sciatica relief options Myth: There is one best treatment for the causes of sciatica Truth: The causes of sciatica must be treated on an individualized basis Because of the many conditions that can compress nerve roots and cause sciatica, one patient’s treatment options may be very different than those of another. A combination of treatment options is often the most effective course, and many patients will try some combination of the following treatment options: * Physical therapy and chiropractic treatments can help relieve pressure on the sciatic nerve. * Alternating heat therapy and ice massage therapy can help to relieve acute pain from sciatica. * Anti-inflammatory medications like non-steroidal anti-inflammatory drugs (NSAIDs, i.e. ibuprofen, naproxen or cox-2 inhibitors) or oral steroids may be used to help relieve inflammation. * Epidural steroid injections can reduce inflammation around the nerve root and the associated low back pain. * To help control the low back pain and leg pain while undergoing other conservative treatments, patients may take pain medications. * Surgery may also be considered as a treatment option, usually (but not always) following a course of conservative treatments. It is important to note that what works for one patient may not work for another, even if they have the same back problems. For example, a patient who has sciatica from a herniated disc may not find relief from conservative treatments and then will choose to undergo lumbar surgery. Another patient with sciatica from a similar type of herniated disc may find sufficient low back pain and leg pain relief through conservative treatments, including physical therapy, chiropractic, heat and ice therapy, injections and/or medications. Myth: Sciatica only lasts for a few weeks Truth: Sciatica can last for much longer, depending on the cause Many cases of sciatica go away within a few weeks using conservative treatment methods. However, this is not the case for all patients. For some, sciatica can last much longer, even for several months. After back problems are diagnosed, the duration and intensity of treatment will need to be adjusted on a patient by patient basis. Myth: Surgery should be the last resort for treatment Truth: Surgery may be the best treatment option for some patients Patients should avoid having surgery too soon or too late. Although many patients hope to avoid surgery, for some, surgery might be the best (and quickest) option for pain relief. If the conservative (non-surgical) treatments (such as exercise and physical therapy, chiropractic, injections, etc.) have not helped, the patient’s pain is severe, or if the patient has lost a significant amount of function, surgery may be considered as the most effective treatment. The appropriate surgical procedure depends on the condition causing the sciatica. For example, microdiscectomy (microdecompression) may be useful for a herniated disc, while lumbar laminectomy (open decompression) is a common surgical treatment for spinal stenosis. These two procedures have high success rates for relieving patients’ pain. Myth: Exercise will make sciatica worse, so patients should avoid exercising Truth: Exercise is usually critical to help heal the problem causing sciatica Some patients believe that staying in bed and avoiding physical activity is the best idea when sciatica occurs. For the initial flare-up of sciatica, bed rest is usually fine for a day or two. However, avoiding activity any longer can typically lead to a downward spiral where episodes of pain lead to inactivity, leading to more pain, and so on. Without proper exercise, low back muscles become weak and deconditioned, leaving them less able to support the back and the spine. Keeping the hamstrings flexible by stretching is particularly important for sciatica patients, because tight hamstrings add stress to the low back, which can aggravate low back problems. Exercise also helps exchange nutrients within the spinal discs, keeping them healthy and preventing injury that can cause sciatica. Patients should develop a gentle exercise program that includes stretching, strengthening and low-impact aerobic exercise. Even after sciatica is relieved and other back problems have been treated, the exercise routine should be maintained to keep the back healthy and to help avoid future problems. See Sciatica exercises for more specific information. Before beginning an exercise program, patients should always consult a health professional. Once the cause of sciatica is diagnosed, the professional can advise the patient about which exercises will be most appropriate and which should be avoided. Working with a professional before self-treating sciatica Patients with sciatica should not attempt to self-treat their condition without consulting a health professional. Establishing a correct diagnosis is the first step towards sciatica relief, as the treatment options and precautions are different for each diagnosis. A professional can also detect any serious problems early on and take action to prevent permanent damage or injury. As described above, there are many myths about sciatica that patients often believe to be true. However, by gaining a clear understanding of their condition, patients will be better equipped to work with a spine specialist to determine the causes and the best course of treatment for sciatica. Combining his or her own knowledge with the expertise of a spine specialist is usually a patients’ best strategy for obtaining long term relief from sciatica. Spine-health.com

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Treatment options for a herniated disc

Individualized treatment for a herniated disc The primary goal of treatment for each patient is to help relieve pain and other symptoms resulting from the herniated disc. To achieve this goal, each patient’s treatment plan should be individualized based on the source of the pain, the severity of pain and the specific symptoms that the patient exhibits. In general, patients usually are advised to start with a course of conservative care (non-surgical) prior to considering spine surgery for a herniated disc. Whereas this is true in general, for some patients early surgical intervention is beneficial. For example, when a patient has progressive major weakness in the arms or legs due to nerve root pinching from a herniated disc, having surgery sooner can stop any neurological progression and create an optimal healing environment for the nerve to recover. In such cases, without surgical intervention, nerve loss can occur and the damage may be permanent. There are also a few relatively rare conditions that require immediate surgical intervention. For example, cauda equina syndrome, which is usually marked by progressive weakness in the legs and/or sudden bowel or bladder dysfunction, requires prompt medical care and surgery. Conservative and surgical treatments For lumbar and cervical herniated discs, conservative (non-surgical) treatments can usually be applied for around four to six weeks to help reduce pain and discomfort. A process of trial and error is often necessary to find the right combination of treatments. Patients may try one treatment at a time or may find it helpful to use a combination of treatment options at once. For example, treatments focused on pain relief (such as medications) may help patients better tolerate other treatments (such as manipulation or physical therapy). In addition to helping with recovery, physical therapy is often used to educate patients on good body mechanics (such as proper lifting technique) which helps to prevent excessive wear and tear on the discs. If conservative treatments are successful in reducing pain and discomfort, the patient may choose to continue with them. For those patients who experience severe pain and a high loss of function and don’t find relief from conservative treatments, surgery may be considered as an option. The different conservative and surgical treatment options for a lumbar herniated disc and a cervical herniated disc are described below. Lumbar herniated disc treatments Conservative treatments for a lumbar herniated disc A combination of the following conservative treatment options can be used through at least the first six weeks of discomfort and pain: * Physical therapy, exercise and gentle stretching to help relieve pressure on the nerve root * Ice and heat therapy for pain relief * Manipulation (such as chiropractic manipulation) * Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or COX-2 inhibitors for pain relief * Narcotic pain medications for pain relief * Oral steroids to decrease inflammation for pain relief * Epidural injections to decrease inflammation for pain relief Surgical treatments for a lumbar herniated disc If a course of conservative treatments (generally four to six weeks) is not effective for relieving pain from a herniated disc, lumbar decompression surgery may be considered as an option. Often a microdiscectomy (or microdecompression) - a type of lumbar decompression surgery - is used to treat nerve compression from a herniated disc. During a minimally-invasive microdiscectomy procedure, the herniated portion of the disc under the nerve root is removed. By giving the nerve root more space, pressure is relieved and the nerve root can begin to heal. The microdiscectomy procedure is usually highly successful for relieving the leg pain (sciatica) caused by a herniated disc. Although the nerve root takes several weeks or months to fully heal, patients often feel immediate relief of their leg pain and usually have a minimal amount of discomfort following the surgery. For some patients with severe pain and loss of function, having a microdiscectomy surgery early on will be the best treatment for their pain. A more in-depth description of surgery for a lumbar herniated disc can be found in the article Microdiscectomy (microdecompression) spine surgery. Cervical herniated disc treatments Conservative treatments for a cervical herniated disc The first step in conservative treatment is usually rest and the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or COX-2 inhibitors. If the pain from a cervical herniated disc is severe and/or continues for more than a couple of weeks, physicians may prescribe additional medications including: * Oral steroids to decrease inflammation and relieve pain * Oral narcotic agents for severe pain If the pain lasts for more than two to four weeks, the following conservative treatments are often recommended: * Physical therapy and exercise to help relieve the pressure on the nerve root * Low-velocity chiropractic manipulation may be helpful; however, caution should be used with manipulation if the patient is experiencing any neurological deficits * Manual traction to help open up the cervical foramen where the nerve root exits the spinal canal * Epidural injections to reduce inflammation and relieve pain Surgical treatments for a cervical herniated disc In general, if about six weeks of conservative treatment fails to relieve the arm pain or if the patient and the spine specialist determine that surgical removal of the disc is the best course of treatment, patients may consider anterior cervical decompression (discectomy). During this surgical procedure, the disc material is removed through the front of the neck and then the disc space is usually fused to keep the disc space open. Another surgical option to treat a herniated disc is a posterior cervical laminectomy, where the disc material is removed through the back of the neck. For a more detailed explanation, please see Anterior cervical decompression (discectomy). Cervical decompression can also be performed through the back of the neck as a posterior cervical decompression (discectomy). For more information, please read Posterior cervical decompression (discectomy). Conclusion to successful treatment of a herniated disc Treatment of a herniated disc is complicated because of the individualized nature of each patient’s pain and symptoms. A treatment option that relieves pain and discomfort for one patient may not work for another. However, by working with one or several types of spine specialists, patients can find the best combination of treatment options for their pain and can avoid having surgery too soon or too late.

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Understanding the clinical diagnosis of a herniated disc

Integrated findings form the clinical diagnosis A physician’s clinical diagnosis focuses on determining the source of a patient’s pain. For this reason, the clinical diagnosis of pain from a herniated disc is based on more than just the findings from a diagnostic test, such as an MRI scan or CT scan. Instead, the spine care professional arrives at a clinical diagnosis of the cause of the patient’s pain through a combination of findings from a thorough medical history, conducting a complete physical exam, and, if appropriate, conducting one or more diagnostic tests. * Medical history. The physician will take the patient’s medical history, such as a description of when the low back pain, sciatica or other symptoms occur, a description of how the pain feels, what activities, positions or treatments make the pain feel better and more. * Physical exam. The physicians will conduct a thorough physical exam of the patient, such as testing nerve function and muscle strength in certain parts of the leg or arm, testing for pain in certain positions and more. Usually, this series of physical tests will give the spine professional a good idea of the type of back problem the patient has. * Diagnostic tests. After the physician has a good idea of the source of the patient’s pain, a diagnostic test, such as a CT scan or an MRI scan, is often ordered to confirm the presence of an anatomical lesion in the spine. The tests can give a detailed picture of the location of the herniated disc and impinged nerve roots. It is important to emphasize that MRI scans and other diagnostic tests are not used to diagnose the patient’s pain; rather, they are only used to confirm the presence of an anatomical problem that was identified or suspected through the medical history and physical exam. For this reason, while the radiographic findings on an MRI scan or other tests are important, they are not as significant in diagnosing the cause of the patient’s pain (the clinical diagnosis) as are the findings from the medical history and physical exam. Often, an MRI scan or other type of test will be used mainly for the purpose of surgical planning—for example, so the surgeon can see exactly where the herniated disc is and how it is impinging on the nerve root. What happens when a disc herniates While the spinal discs are designed to withstand significant amounts of force, injury and other problems with the disc can occur. When the disc ages or is injured, the outer portion (annulus fibrosus) of a disc may be torn and the disc’s inner material (nucleus pulposus) can herniate or extrude out of the disc. Each spinal disc is surrounded by highly sensitive nerves, and the inner portion of the disc that leaks out contains inflammatory proteins, so when this material comes in contact with a nerve it can cause pain that can travel down the length of the nerve. Even a small disc herniation that allows a small amount of the inner disc material to just touch the nerve can cause significant pain. Pain from a herniated disc vs. degenerative disc disease A herniated disc will typically produce a different type of pain than degenerative disc disease (another common disc problem). * When a patient has a symptomatic degenerated disc (one that causes pain or other symptoms), it is the disc space itself that is painful and is the source of pain. This type of pain is typically called axial pain. * When a patient has a symptomatic herniated disc, it is not the disc space itself that hurts, but rather the disc problem is causing pain in a nerve in the spine. This type of pain is typically called radicular pain (nerve root pain, or sciatica from a lumbar herniated disc). Typical symptoms of a herniated disc A herniated disc most often occurs in the lumbar spine (lower back) or the cervical spine (neck), but it can also occur in the thoracic spine (upper back). Each location for a herniated disc produces different symptoms of pain. Lumbar herniated disc Leg pain (also known as sciatica) is the most common symptom associated with a herniated disc in the lumbar spine. Approximately 90% of herniated discs occur at L4-L5 and L5-S1, causing pain in the L5 or S1 nerve that radiates down the sciatic nerve. Symptoms of a herniated disc at these locations are described below: * A herniated disc at lumbar segment 4 and 5 (L4-L5) usually causes L5 nerve impingement. In addition to sciatica pain, this type of herniated disc can lead to weakness when raising the big toe and possibly in the ankle, also known as foot drop. Numbness and pain can also be felt on top of the foot. * A herniated disc at lumbar segment 5 and sacral segment 1 (L5-S1) usually causes S1 nerve impingement. In addition to sciatica, this type of herniated disc can lead to weakness when standing on the toes. Numbness and pain can radiate down into the sole of the foot and the outside of the foot. Cervical herniated disc A cervical herniated disc is less common than a lumbar herniated disc because there is less disc material and substantially less force across the cervical spine. The pain and other symptoms from a cervical herniated disc differ by level: * A herniated disc at cervical segment 4 and 5 (C4-C5) causes C5 nerve root impingement. Patients may feel weakness in the deltoid muscle in the upper arm but do not usually feel numbness or tingling sensations. A cervical herniated disc at this level can also cause shoulder pain. * A herniated disc at cervical segment 5 and 6 (C5-C6) causes C6 nerve root impingement. This level is one of the most common areas for a cervical herniated disc to occur. It can cause weakness in the biceps (the muscles in the front of the upper arms) and in the wrist extensor muscles. Pain, numbness and tingling can radiate to the thumb side of the hand. * A herniated disc at cervical segment 6 and 7 (C6-C7) causes C7 nerve root impingement and is another common type of cervical herniated disc. It can cause weakness in the triceps (the muscles in the back of the upper arm and extending to the forearm) and in the extensor muscles of the fingers. Numbness and tingling along with pain can radiate down the triceps and into the middle finger. * A herniated disc at cervical segment 7 and thoracic segment 1 (C7-T1) causes C8 nerve root impingement. This may lead to weakness when gripping with the hand, along with numbness, pain, and tingling that radiates down the arm and to the little finger side of the hand. Thoracic herniated disc Herniated discs in the upper back are rarely symptomatic and rarely produce pain, but if they are symptomatic, the pain is usually felt in the upper back and/or chest area.

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Insights and advice about herniated discs

Pain from a herniated disc Pain and other symptoms generated from a cervical or lumbar herniated disc can be misunderstood by medical and health professionals and patients alike. This confusion occurs partly because health professionals commonly do not agree on spinal disc pathology, and partly because disc problems such as a herniated disc are not always well explained to (or understood by) patients. Some of the factors that make the identification and treatment of a herniated disc challenging include the following: * Terminology about a herniated disc can be confusing. There are many different terms to describe a herniated disc, such as a pinched nerve, bulging disc, ruptured disc or slipped disc. These terms tend to be used somewhat differently among health professionals because there are no generally agreed upon definitions for many disc problems. Interchangeable terminology can be confusing and frustrating for patients who hear their condition referred to in different terms by different practitioners, causing the patients to remain unclear as to the real diagnosis. * The extent of disc problem or disc herniation does not necessarily correlate to the patient’s level of pain. Although it may seem contrary to common sense, the severity of pain from a herniated disc does not always correlate to the amount of physical damage to the disc. Additionally, less serious back problems may cause more pain than a herniated disc. For example, a large herniated disc can be completely painless, while a muscle spasm from a simple back strain may cause excruciating pain. This means that the severity of pain is not a determining factor for identifying a herniated disc. * Many herniated discs do not cause any pain. Radiographic findings of a disc herniation are common (such as from an MRI), but oftentimes the herniated disc is not associated with any pain or symptoms. While there may be an association between trauma to the disc and the onset of the patient’s symptoms, a herniated disc also may occur without a specific, recalled event. * It is difficult to distinguish a herniated disc from other spinal problems. The nerves and anatomical structures—such as discs, muscles and ligaments in the spine—have a great deal of overlap. This makes it difficult for the brain to distinguish between problems with one structure in the back versus problems with another. For example, a herniated disc can feel similar to a bruised muscle or ligament damage. Please see What’s a herniated disc, pinched nerve, bulging disc, etc...? for explanation of the differences between a herniated disc and other common disc problems. * Pain from a herniated disc is a complex personal experience. Physical and psychological factors are constantly changing and can contribute to a patient’s experience of pain. A herniated disc may not be painful at all times, or it may become even more painful because of psychological and other factors in the patient’s life. For example, many studies have established a correlation between back pain and depression. While it is often not know which problem comes first—the pain or the depression—it is known that it’s important to treat both for the patient’s overall health. The pain from a disc herniation also may become more severe when compounded with other physical problems in the spine, or situational factors (such as poor posture, sitting for a long period, etc). * There is no single treatment that works best for all patients. Different treatment options are available for either a cervical or a lumbar herniated disc, as described later in this article. Some patients may find that a combination of conservative treatment options work best (such as medications, injections, and/or physical therapy), while other patients may find that early surgical intervention is necessary to find adequate relief from the pain and symptoms caused by a herniated disc. Working with a spine care professional, patients will need to develop an individualized treatment plan to relieve their pain and provide for long term rehabilitation. Importance of a clinical diagnosis for a herniated disc Because of the complexities of understanding pain from a herniated disc, patients should not attempt to make their own diagnosis. An inaccurate self-diagnosis may lead to further damage to spinal structures or to more severe episodes of back pain or leg pain if the condition is left untreated or treated incorrectly. Working with a spine specialist helps ensure that the correct location of a herniated disc, extent of the problem and source of pain are identified early on. The next section outlines the process of obtaining an accurate clinical diagnosis and explains in more detail how a herniated disc causes pain. Spine-health.com

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When is back pain a fracture?

Compression fractures of the spine Spinal fractures that occur as a result of osteoporosis are actually quite common, occurring in approximately 750,000 people in the U.S. each year. The problem is that the fracture is not always diagnosed—instead, the problem is often just thought of as general back pain, such as from a muscle strain or other soft tissue injury, or as a common part of aging. Because of this, approximately two thirds—or 500,000—of the vertebral fractures that occur each year are not diagnosed and therefore not treated. Spinal fractures due to osteoporosis often occur while doing something that causes relatively minor trauma to the spine, such as opening a window, an insignificant fall, or twisting while lifting. Advanced cases of osteoporosis can even lead to a vertebral fracture with routine activities that would normally not cause any trauma, such as sneezing, coughing or turning over in bed. Vertebral fractures are usually followed by acute back pain, and may lead to chronic pain, deformity (thoracic kyphosis, commonly referred to as a dowager's hump), loss of height, crowding of internal organs, and loss of muscle and aerobic conditioning due to lack of activities and exercise. A combination of the above problems from vertebral fractures can also lead to changes in the individual’s self-image, which in turn can adversely affect self esteem and ability to carry on the activities of daily living. It’s important to note that fractures from osteoporosis don’t just occur in the elderly, they can also occur in people as young as 40 or 50 years old. Because osteoporosis is a “silent” disease, meaning that there are typically no symptoms until a fracture occurs, it is not uncommon for someone with back pain to be unaware of the fact that she has actually fractured a vertebra (or multiple vertebrae) in her spine. This article provides an overview of vertebral compression fractures caused by osteoporosis, including symptoms and diagnosis. Osteoporosis is the main cause of vertebral fractures Osteoporosis is fairly common disease, and is especially common in postmenopausal women. In fact, it is estimated that approximately 25 percent of all postmenopausal women in the United States have had a vertebral compression fracture.1 Osteoporosis also occurs in men, but is far more prevalent in women—approximately four times as many women have low bone mass, or osteoporosis, as men. Osteoporosis causes bones to thin and become more brittle and weak. When the bones in the spine weaken they can break or cave in under normal pressure. The thinning bones can collapse during normal activity, leading to a spinal fracture. These compression fractures can cause a great deal of pain and can permanently alter the shape and strength of the spine. The type of break in the spine that is typically caused by osteoporosis is called a compression fracture, usually defined as a vertebral bone in the spine that has decreased at least 15 to 20% in height due to fracture (as seen on an x-ray). These compression fractures can occur in vertebrae anywhere in the spine, but they tend to occur most commonly in the upper back (thoracic spine), particularly in the lower vertebrae of that section of the spine (e.g. T10, T11, T12). They rarely occur above the T7 level of the spine. With a compression fracture caused by osteoporosis, the fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged. This results in a wedge shaped vertebra. Because the majority of damage is limited to the front of the vertebral column, the fracture is usually stable and rarely associated with any nerve or spinal cord damage. Unlike many other conditions that can be treated before a serious complication develops, usually a fracture is the first sign that someone has osteoporosis. By the time a fracture occurs, the osteoporosis is usually advanced and the individual is then susceptible to more vertebral fractures. Reference: 1. Melton LJ 3d. Epidemiology of spinal osteoporosis. Spine. 1997;22:2S-11S.

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Osteoarthritis medical diagnosis

Any patient experiencing back pain or stiffness in a joint or joints for more than two weeks should see his or her physician for an evaluation. The evaluation usually consists of a discussion of symptoms and a detailed medical history, a physical examination and—if osteoarthritis is suspected—a series of x rays. Other tests (blood tests, MRI or CT scans) may be performed to confirm the presence of spinal arthritis or to rule out other conditions that can cause similar symptoms, such as a tumor, infection, fracture, or other types of arthritis. Diagnosing spinal osteoarthritis Typically, the physician will use a combination of findings from a patient’s medical history, physical exam and medical tests to accurately diagnose whether a patient has osteoarthritis. An accurate diagnosis is very important for guiding the selection of treatment options—and for actually helping relieve the pain and discomfort associated with the patient’s condition. Medical history. The patient will be asked to describe his or her symptoms, such as a description of the pain, stiffness and joint function, when and how the symptoms started, and how the symptoms have changed over time. The patient should also discuss how the symptoms affect his or her everyday life and work activities. The doctor also needs to know about the patient’s other medical conditions, current medications, past experience with other treatments, family history, and general lifestyle habits (such as alcohol intake, smoking, etc.). When dealing with pain problems, the doctor is likely to ask key questions related to those things that reliably cause or aggravate the pain and those that reliably bring relief or prevent the pain. Other questions may relate to certain lifestyle topics, such as exercise, nutrition and activities for diversion, sports, etc. Physical examination. The doctor will conduct a physical exam to assess the patient’s overall general health, musculoskeletal status, nerve function, reflexes and direct evaluation of the problematic joints in the back. The doctor will be looking at muscle strength, flexibility, and the patient’s ability to carry out daily living activities such as walking, bending, and reaching. The patient may also be asked to perform some exercises to test range of motion and determine whether pain worsens during any particular type of movement. X-rays. The doctor will likely order an x-ray to see if there is joint damage and how much joint damage has occurred. The x-ray can show cartilage loss, bone damage, and the presence and location of bone spurs. X-rays are also useful in helping to exclude other causes of pain and to better inform possible considerations about surgery. However, it is important to keep in mind that what shows up in an x-ray may not correlate to the presence or absence of osteoarthritis and associated pain. For example, most people over age 60 have degenerative changes in their spine consistent with osteoarthritis, but for perhaps 85% of them there is no pain or stiffness. Conversely, an x-ray conducted during the early stages of osteoarthritis may not yet show any visible damage to the joints. For all these reasons, the clinical history and physical examination are essential to arriving at an accurate clinical diagnosis and plan of treatment. Other tests may also be used to rule out conditions other than osteoarthritis that may be causing the patient’s symptoms. For example, blood tests are used to exclude diseases that can cause secondary osteoarthritis or other types of arthritis that simulate osteoarthritis. Joint aspiration, where fluid is drawn from the joints through a needle for examination, can help rule out conditions such as infections or gout. Additional tests that may be needed to rule out other causes of pain or to identify the presence of arthritis with more sophistication than an x-ray can include: * A radioactive bone scan, used to rule out inflammation, a tumor, infection or a small fracture. With a bone scan, the radioactive ‘tracer’ material is injected intravenously and then is concentrated by the body where there is high metabolism or bone turnover. If something suspicious is found on the bone scan, it is usually followed by a CT or MRI scan to distinguish what the bone lesion might represent, since the bone scan alone cannot distinguish among tumors, infections or fractures. * A CT scan may be used to better show the adequacy of the spinal canal and surrounding structures. A CT scan may also include myelography, where an x-ray contrast dye is injected into the spinal column to show structures such as a bulging disc or bone spur possibly pressing on the spinal cord or nerves. * The MRI or magnetic resonance imaging scan, is a very sophisticated imaging method that can show great anatomic details of the spinal cord, nerve roots, discs, ligaments and surrounding tissues and spaces. Most MRI studies require the patient to lie flat in a tube for about 40 minutes, although open frame and even standing MRI scanners exist and seem particularly appropriate for patients having claustrophobia (fear of tight spaces). MRI scans can be adjusted to show different tissues including their water content, important in determining disc degeneration, infections or tumors. The goal of all diagnostic studies is to discover patterns or confirmations between the various tests that point to a clear diagnosis among various possible ones. The key is to diagnose the condition causing the patient’s pain and disability and to guide appropriate treatment, including psychological, physical, medical and/or surgical. Diagnosis is a detective hunt for causes and effects with the goal of improved treatment.

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Range of osteoarthritis symptoms

Osteoarthritis is characterized primarily by stiffness and pain in the joints, although not everyone with osteoarthritis actually experiences pain and disability. The stiffness and pain tend to be worse in the morning (particularly for about 30 minutes after waking up) and again in the evening, often called “first movement pain” with improvement during the day as the person carries on his or her daily activities. Pain that awakens one during the night is often an indicator. Other symptoms can include: * Swelling and warmth in one or more joints, particularly during weather changes (which may be related to barometric pressure changes and cooling of the air) * Localized tenderness when the joint or affected area of the spine is pressed * Steady or intermittent pain in a joint, which is often described as an aching type of pain. The pain may be aggravated by motion * Loss of flexibility of a joint, such as inability to bend and pick something off the floor * A crunching feeling or sound of bone rubbing on bone when the joint is moved (called crepitus), particularly notable in the neck * An abnormal curve in the spine which may be due to unbalanced muscle spasm * A sensation of pinching, tingling or numbness in a nerve or the spinal cord, which can occur when bone spurs form at the edge of the joints of the spine and irritate the nerves Osteoarthritis usually develops over time. Early on, a person may only experience joint aches after physical work or exercise, which fades and then returns as the affected joint is used or overused. As the cartilage between the bones gradually thins, the pain often becomes steadier, making it difficult to walk or climb stairs. Joint pain and stiffness can begin to occur after long periods of inactivity, such as while sitting for long journeys or watching a two-hour movie. With advanced osteoarthritis and increased rasping friction between bones, the pain often becomes substantial even at rest or with very little movement. With progressive osteoarthritis, a single joint may at first be affected, but with time and further activities, many joints of the body may be affected—in the base of the neck, or in the knees, hips, hands and/or feet. Although less common, some patients may experience severe deformities of certain joints over time. Osteoarthritis differs from systemic forms of arthritis because it only affects joints (although it may lead to an entrapment of a nerve at any level in the spine or the spinal cord in the neck) and does not affect organs or soft tissue areas of the body. Low back (lumbar spine) osteoarthritis pain and other symptoms As with other joint involvement in arthritis, lower back pain is typically most pronounced in the morning and worsens again later in the day. Pain is decreased during the day as the person’s normal movements stir the fluid lubricant of the joints. Lower back pain commonly may radiate (“referred pain”) to the pelvis, buttocks, or thighs and sometimes to the groin. Nerve irritation from a herniated disc or from bone spurs can cause weakness, numbness, tingling and/or pain in the legs that often radiates to one foot. Arthritis causing spinal stenosis or narrowing of the spinal canal in the lower back can cause exercise or walking-related symptoms in both legs. Neck (cervical spine) osteoarthritis pain and other symptoms Neck pain from osteoarthritis again tends to be worse in the morning and evening, with improvement during the day. This pain often radiates to the shoulder, between the shoulder blades and up the neck to cause headaches. With nerve entrapment or a disc herniation, there may also be weakness or numbness of one hand, certain fingers or sometimes even in both arms. Compression of the spinal cord in the neck can even cause problems with walking as well as in bowel and bladder control in severe cases. Osteoarthritis is sometimes confused with other conditions causing pain Because other conditions seem similar to osteoarthritis of the spine, particularly when symptoms are at their worst, it is important to receive an accurate clinical diagnosis from a doctor who specializes in spinal medicine or spinal surgery. Rheumatoid arthritis (RA) usually affects multiple joints in a symmetrical pattern (both sides of the body being affected). Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints and may involve other tissues or organs of the body. Therefore, when rheumatoid arthritis flares up, symptoms can include fatigue, poor appetite, low grade fever, muscle and joint aches, and stiffness, again usually most notable in the morning and after periods of inactivity. Joints, usually in the hands, wrists and feet, frequently become red, swollen, painful, and tender. Osteoarthritis is also sometimes confused or may be associated with degenerative disc disease (or spondylosis), a gradual deterioration of the disc(s) between the vertebrae of the spine. This is because osteoarthritis and degenerated discs are commonly found together. However, they are separate conditions and it is important to know which anatomical changes in the spine are the actual cause of the patient’s pain or disability. An x-ray will show degenerative disc disease as a narrowing of the normal disc space between adjacent vertebrae. An MRI scan may show the early changes of a loss of water content in the disc. Degeneration of the disc tissue increases its susceptibility to bulging or herniation. Disc degeneration can occur at any level of the spine and can cause local pain in the affected area with radiation of pain along the nerves emerging from the spinal canal at that level. Symptomatic lumbar disc degeneration is most common in people of working age, usually between 30 and 50. After the age of 50 or 60, the affected area of the spine actually tends to stabilize and degenerative disc disease is less likely to cause pain. In general, one cannot equate disc degeneration or bone spur formation with pain and disability, since about 85% of persons with such findings on an x-ray or scan do not have a clinically significant back problem. Osteoporosis, or low calcium content of the bones, is another condition that does not cause but can lead to chronic back pain. With osteoporosis, particularly more common in post-menopausal women, bone mineral (calcium) loss may weaken bones in several parts of the body, particularly in the hip and the spine. Spinal fractures with compression (wedging) of vertebral bodies may occur. The pain from an osteoporotic spinal fracture can last for several weeks as the bone heals, and then typically turns into more of a chronic, achy pain concentrated in the area of the back where the fracture occurred. This aching may be similar to the sensation reported by those with osteoarthritis. A bone density test, which measures bone mass, preferably taken of both a long bone and a vertebral body, is used to diagnose osteoporosis. An x-ray can usually identify a compression fracture in the spine. Since the treatments for osteoarthritis and osteoporosis are very different, it is critical to get an accurate diagnosis. Spine-health.com

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Understanding osteoarthritis of the spine

Arthritis and osteoarthritis introduction “Arthritis” is a general term that describes many different diseases causing tenderness, pain, swelling, and stiffness of joints as well as abnormalities of various soft tissues of the body. Of the combined term, “arthros” means a joint and its attachments, and “–itis” means inflammation. Various forms of arthritis affect nearly 50 million Americans and contribute to the majority of all physical disabilities. Although arthritis is ultimately associated with a wearing out of joints, nearly a half million children are also affected. Of the several varieties of arthritis, the most common, the most frequently disabling, and often the most painful is osteo- (meaning bone) arthritis, mostly affecting the weight bearing joints (hips and knees) plus the hands, feet and spine. Normal joints are hinges at the ends of bones usually covered by cartilage and lubricated inside a closed sack by synovial fluid. Normally, joints have remarkably little friction and move easily. With degeneration of the joint, the cartilage becomes rough and worn out, causing the joint halves to rub against each other, creating inflammation with pain and the formation of bone spurs. The fluid lubricant may become thin and the joint lining swollen and inflamed. Osteoarthritis is also known as degenerative joint disease and affects up to 30 million Americans, mostly women and usually those over 45 or 50 years of age. All races in the U.S. appear to be equally affected. This article focuses on osteoarthritis of the spine, particularly on facet joint arthritis. Where osteoarthritis occurs Cartilage is a form of usually slick, slightly elastic, connective tissue that covers the ends of the bone joints. In part, cartilage serves as a protective shock absorber to minimize the impact of bouncing, jumping and other types of daily activities on the joints – and is thus subjected to considerable wear and tear during life. Indeed, heavy work, sports, repeated injuries and obesity take a heavy toll on the joints of the limbs and spine. To be healthy, all joints should be exercised, but if this is excessive, joint damage may accumulate slowly. In addition to the hips, knees and lower back, arthritis commonly occurs in the neck, small finger joints, the base of the thumb, and the big toe. In the fingers, nodes (masses of bone and cartilage) can form on either side of the nail bed or the margins of joints to become reddened, tender and swollen. Cartilage breakdown in the hips and knees can be severe enough to require joint replacement. Osteoarthritis found in other joints, such as the hinge of the jaw, is often due to injury or stress. Osteoarthritis of the spine Spinal arthritis is one of the common causes of back pain. Spinal arthritis is the mechanical breakdown of the cartilage between the aligning facet joints in the back portion (posterior) of the spine that quite often leads to mechanically induced pain. The facet joints (also called vertebral joints or zygophyseal joints) become inflamed and progressive joint degeneration creates more frictional pain. Back motion and flexibility decrease in proportion to the progression of back pain induced while standing, sitting and even walking. Over time, bone spurs (small irregular growths on the bone also called osteophytes) typically form on the facet joints and even around the spinal vertebrae. These bone spurs are a response to joint instability and are nature’s attempt to help return stability to the joint. The enlargement of the normal bony structure indicates degeneration of the spine. Bone spurs are also seen as a normal part of aging and do not directly cause pain, but may become so large as to cause irritation or entrapment of nerves passing through spinal structures, and may result in diminished room for the nerves to pass (spinal stenosis). Osteoarthritis in the spine is anatomically divided into: * Lower back (lumbar spine) osteoarthritis, sometimes called lumbosacral arthritis, which produces stiffness and pain in the lower spine and sacroiliac joint (between the spine and pelvis). * Neck (cervical spine) osteoarthritis, sometimes called cervical spondylosis (spondy- implies the spine, and –osis is an abnormal condition), which can cause stiffness and pain in the upper spine, neck, shoulders, arms and head. Causes of osteoarthritis and spinal arthritis There are a number of reasons why some people are particularly disposed to osteoarthritis. However, as with nearly all abnormal conditions affecting the body, it is likely that a combination of risk factors work together to cause osteoarthritis. As indicated above, repetitive trauma to the spine from repetitive strains caused by accidents, surgery, sports injuries, poor posture, or work-related activities are common causes of spinal arthritis. Therefore, athletes and people with jobs that require repetitive, and particularly heavy, motion have been found to be at greater risk. Other known risk factors for developing spinal arthritis include: * Aging: steady and advanced aging of spinal structures, beginning in the 30’s, often work-related * Gender: osteoarthritis being more common in post-menopausal women (although below age 45, it is more common in males) * Excess weight: causing more stress on weight-bearing joints and the spine, particularly during the middle age years * Genetics: having a family history of osteoarthritis or congenital defects of joints, spine, or leg abnormalities * Associated diseases: the presence of other associated diseases, infections, diabetes, and various other forms of circulating arthritis, such as rheumatoid arthritis or gout When a specific cause of the osteoarthritis is unknown, as it is in most cases, it is referred to as primary osteoarthritis, which appears to be mostly due to aging. Aging leads to changes in cartilage and synovial fluid - the tissue water content increases as the protein content decreases. Long term repetitive joint use has been shown to lead to joint inflammation with associated joint pain and swelling, eventually leading to the loss of cartilage. When the cause of the osteoarthritis is known, it is referred to as secondary osteoarthritis, caused by a particular disease or condition, such as obesity, trauma or surgery to the joints, or abnormal joints at birth. Patients with osteoarthritis who take an active role in their own treatment can prevent additional joint damage and usually will be able to continue with most of their normal activities. The key to managing the condition is to get an accurate diagnosis and start early, proactive treatment. Most osteoarthritis treatments are focused on reducing the pain and inflammation associated with osteoarthritis and maintaining the joint mobility and flexibility needed to continue with necessary and desired activities. It is clear that a combination of proper exercise, joint mobility, weight control, nutrition and use of appropriate medication is required to control osteoarthritis. Spine-health.com

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