Common Conditions of the Spine

• low back pain
• fracture
• scoliosis

LOW BACK PAIN

Low Back pain is one of the top five reasons patients visit their doctors.  About 80% of people will experience low back pain at some point in their life.  The most common causes of acute low back pain are trauma, falls, motor vehicle accidents, injury during lifting or bending, or poor posture.  Low back injuries are the most common injury in the workplace, especially in the fields of construction, mining, transportation, and manufacturing, and has become a significant problem over the last 30 years in terms of lost work and disability claims. 

Your back is made up of many bony parts that protect the spinal cord and nerve roots.  In between these bony parts are discs that act like “jelly donuts” between each bony body.  A nerve root exits the long vertical spinal canal at each bony body or “level” in the back and supplies sensation, movement, and reflex function to specific areas.  Your back has many muscles and ligaments that work with the abdominal muscles in voluntary and involuntary contractions to help stabilize the spine and decrease its load. 

There are many factors that put a patient at risk for low back pain, including poor flexibility and/ or posture, being overweight, engaging in high demand activities or activities that cause vibration in the whole body (e.g. – truck drivers, construction workers), smoking, and previous low back pain.  Low back pain can occur with a variety of related symptoms in variable combinations.

Other symptioms that can be related to a low back condition are such things like pain in the buttocks or radiating pain down one or both legs, cramping in the legs when walking one or more blocks, numbness or  tingling or pain that is affected by certain positions such as sitting, standing, bending forward or backwards, or lying the fetal position.

 The most common clinical conditions that cause low back pain are:

      Lumbar Strain or Sprain:  Lumbar strain or sprain, or a “pulled low back” is the most common diagnosis given to patients with low back pain.  It refers to a strain or sprain of the muscles and/or ligaments that surround and stabilize the spine.  Even though an isolated sprain or strain of the lumbar area does not cause nerve damage, it can be quite painful even into the buttocks.  A low back strain/spasm might cause a person to sonstantly shift to get comfortable  because prolonged sitting, standing, or repeated heavy lifting or twisting all can cause discomfort.  Bed-rest, anti-inflammatory medications and/ or muscle relaxants, and activity modifications are the mainstay treatment options.  Physical therapy and stretching exercises are also common methods of treatment.

      Bulging Disc or Disc Herniation:  The discs between the bony bodies in the spine are like jelly donuts with an outer fibrous ring and a soft jelly-like inside.  When a disc protrudes out of place, it can be referred to as a “bulging disc” or a “herniated (ruptured) disc.”  Bulging discs are usually caused by a degenerative process where the soft jelly-like portion becomes hardened over time, causing the entire disc to loose elasticity and not allowing it to bounce back into place.  Herniated (or ruptured) discs are often caused by pressure, usually from an acute event, which causes the inside jelly part of the fibrous disc to leak or protrude out.  Disc conditions become problematic only when there is compression on the nerve roots.  If this occurs, pain can occur in a pattern of radiation down the legs that can help your physician localize the level of the problem in the back.  This leg pain may or may not be accompanied by numbness, tingling, weakness, and/or decreased reflexes in the lower extremities.  Patients may even state their leg pain bothers them more than their actual back pain.  It is often aggravated by bending forward and/ or prolonged sitting.  About 80% of patients with a disc condition will gradually improve over four to six weeks time because herniated portions of discs often shrink over a period of time.  However, it may take up to six months to heal completely.  Bed rest for up to two days followed by early activity, physical therapy, or one or more medications (anti-inflammatory, muscle relaxant, pain medication) and/or activity restrictions may be recommended in any combination to help the recovery process.  Steroid injections into the back and surgery are two secondary options to be considered if first line conservative management has not been effective.  

      Spinal Stenosis: Stenosis refers to narrowing of the bony portions of the spine in the area of the spinal canal or the foramen where the nerve roots exit the spine.  Stenosis results from progressive degenerative changes or “wear-and-tear” in the lumbar spine.  Stenosis can irritate the nerve root and cause radicular symptoms.  Patients might experience relief of symptoms when leaning forward, such as leaning on a cart when shopping or lying in the fetal position, because bending forward increases the space between the narrowed areas.  Stenosis  can also cause cramping in the lower extremities after walking a short distance.  This cramping from neurological reasons is different and should be differentiated from cramping that is related to a vascular or muscular problem.  Stenosis is a fairly common problem and is one of the most common reasons for back surgery in older patients if conservative treatment has been unsuccessful.       

      Sacroiliac Joint (S.I.) Dysfunction:  The sacro-iliac joint is the joint in the low back connecting the sacrum from the spine to the ileum from the pelvis.  This joint can become mal-aligned during motions that combine bending forward with twisting of the trunk and tilting of the pelvis (e.g. – golf swing or snow shoveling).  SI dysfunction is the most common cause of low back pain, and often the malignment causes other compensatory problems such as unequal leg-lengths, spasms or myofascial pain in muscles, disc herniation, or nerve root impingement.  Patients with SI dysfunction often have stiffness when initiating movement (especially after sitting) that is relieved after some period of walking.  Pain is often felt in the low back on one or both sides of the midline and there may be radiation of pain in the buttocks, back, or front of the thighs.  Patients may sense any unequal leg-lengths present as a feeling of being “crooked”.  SI dysfunction may correct itself over time or remain out of position for years.  Injections into the joint may temporarily relieve pain, but will not alter the mal-alignment.  Your physician might recommend a specialist to treat these problems with correction techniques. 

 

      Myofascial Pain:  A local or regional pain condition caused by a taut or tensed area of muscle.  Often felt as a deep, dull ache which is difficult to localize, but palpation of the muscles is necessary to uncover the “trigger points” (pinpoint areas of irritability in the muscle).  When these “trigger points” are compressed, they cause pain and possibly other similar symptoms as other back conditions.  This, as well as the fact that a myofascial condition can occur alongside other back conditions, make it a difficult condition to diagnose.  Myofacial pain may persist for years if not treated.  Stretching, cold packs, and correction of underlying causes such as posture and general medical conditions are approaches to this problem.  Also, trigger point release might be attempted to release the taut band of muscle/ fascia.  The goal is to retrain the muscles to work properly and to gradually increase strengthening exercises.

Diagnosis of low back pain involves a careful history and physical examination.  Often during this time, your physician will attempt to rule out that your problem is not from something potentially more serious in nature such as an infection, tumor, or other serious problem.  There are several imaging studies that can be used to evaluate your back condition including regular x-rays, MRI/ CT/ or Bone Scans, Discogram, or EMG studies.  Each imaging technique has its own best uses, and the appropriate test or combination of tests will be determined by your physician.  Your physician will explain what parts, if any, of the results of your tests are concerning and require management.  Laboratory testing may also be ordered to confirm your back condition is not related to a systemic condition.

Treatment for low back pain should start with prevention.  Engaging regularly in a good exercise program of strength conditioning and flexibility exercises decreases the likelihood of low back pains and helps maintain weight.  Proper lifting and handling techniques include assessing a load before lifting, establishing a firm base of support by placing feet flat, straight forward, shoulder width apart, and bending at the knees rather than bending forward, twisting at the trunk, or reaching.  Pushing to manipulate items rather than pulling is ideal, as well as using mechanical assists when they are available.  There is no clear evidence at this time that the use of supportive back braces is helpful in preventing back pain.

About half of the people who experience acute low back pain will recover in one week, and almost all patients recover within four to six weeks regardless of treatment.  Specific treatment options will be discussed with your physician, but almost always start with a conservative regimen of any combination of medications, physical therapy, back exercises, activity modifications, or injections. Lumbar spine surgery is always the last resort for treatment of back problems, but routinely performed for a variety of low back problems.

SPINAL FRACTURES

The spine is divided into four regions from the head down to the tailbone.  The spine in each of these regions, the cervical, thoracic, lumbar, and sacral regions, each have different surrounding muscle and ligaments to support them as well as having different bony and curvature characteristics.  The bony spine functions to protect the spinal cord and the nerves that exit this cord to provide the ability for our entire body to function in a variety of ways.   

Accidents are the number four cause of death in the United States, and 3% of deaths by accidents are due from trauma to the spinal cord.  Fractures to the spine usually result from high energy trauma, such as motor vehicle accidents, falls, sports, or acts of violence.  The spine and associated soft tissues can experience a variety of forces during such trauma, including compression, distraction, flexion, shearing, rotation, and/ or dislocation.  Most fractures in the spine occur in the thoracolumbar or lumbar spine regions, because of the inherent differences between the two regions (the thoracic spine is very rigid compared to the more mobile lumbar spine) and the fact that the spine at these levels has no real protection from the ribs. 

Fractures of the spine are classified as stable or unstable, often by understanding which forces were involved as well as which actual parts within the spine have been affected.  Many fractures of the spine are stable injuries and do not result in severe devastation.  Some compression fractures are an example of such injuries and are common injury seen in the clinical setting.       

The most important part of the physical examination is assessing for the presence of neurological problems as a result of the injury.  However, pain, muscle spasms, pre-existing curvature deformities (kyphosis or scoliosis), and certainly the presence of other severely acute injuries or conditions might make examination at the time difficult and ambiguous.  X-rays will be performed to evaluate the location of the bony injury or fracture.  If more extensive information about the injury is required, your physician might order a CT or MRI scan. 

The scope of spinal injuries is very wide and variable, ranging from a stable, isolated compression fracture with no neurological problems to severe injury resulting in paralysis or even death.  Treatment of spinal fractures depends on the stability of the fracture as well as the general medical condition of the patient.  Non-operative treatment consists of immobilization by bracing for a period of months with restrictions on lifting and activities.  Follow-up x-ray examination and decreased pain are important factors in weaning from the brace and starting physical therapy.  There are a wide variety of operative treatments for more severe, unstable fractures which are usually referred to a spine specialist who uses instrumentation (rods, hooks, screws) to realign and stabilize the spine, and if possible effectively decompress the spinal canal.  The specific risks and pros and cons of these surgeries should be taken into account.  The recovery of any neurological deficits incurred at the time of a spinal injury is difficult to predict despite the best of interventions, both non-surgical and surgical.

SCOLIOSIS

Scoliosis is a condition that refers to an excessive abnormal curvature in the spine.  This disorder usually occurs during periods of growth when forces on the growth areas in the bones of the spine create wedge shaped structures instead of squarish, symmetrical structures.  These abnormal wedge shaped bones cause the spine to bend to one side or the other.  There are many different types of scoliosis.  The condition can occur at birth, during early or late childhood, during adolescence, or as the result of a connective tissue disorder.  Scoliosis can result from other primary conditions such as neuromuscular disorders like cerebral palsy, muscular dystrophy, or spina bifida.  Other  conditions such as poor posture or unequal leg lengths can contribute to less severe curves in the spine, and are termed postural or functional scoliosis, respectively.

The most common form of scoliosis affects adolescents going through puberty between the ages of ten to 16 and is not due from any congenital or neuromuscular disorder.  This form is more common in girls, especially daughters who have mothers also with severe spinal curves.  When there is an abnormal curve in the spine, there are often visible signs such as asymmetry in shoulder heights, shoulder blades, or in the trunk and/ or waistline.  Often the curve can be seen best when bending forward.  Scoliosis from a neuromuscular disorder might result in problems walking, foot deformities, reflex abnormalities, or muscle weakness especially prominent the lower extremities.  If scoliosis has been present since birth, there are often associated kidney, cardiac, or intra-spinal problems. 

Diagnosis of scoliosis starts with a careful history and physical examination by your physician for some of the above signs.  X-rays of the full spine are needed to evaluate the extent of any curvatures in degree measurements.  An MRI scan can be used to evaluate curves that seem to be progressing rather quickly or for determining any intra-spinal abnormalities.

Management of scoliosis is based on the magnitude of the spinal curve in degree measurements and on the extent the bones have “matured” or completed in their growth.  Successful management of scoliosis is very dependant on treatment that is started while the spine is still flexible and growing.  Curves arising during adolescence that are mild may be merely observed for progression, and most of these curves can be expected to leave no functional limitation when bony growth has stopped.  More severe curves or unusual types of scoliosis are commonly referred to a pediatric or spinal deformity orthopedic specialist for treatment.  Bracing or spinal surgery are the two primary in which scoliosis might be treated for these patient populations.  Bracing is used to stop the progression of an existing curve (not to correct the curve), and a variety of braces can be recommended based on the specific deformity.  Fusion of the spine can be recommended for more severe cases of scoliosis.  This is a procedure where graft of bone is used to fuse the vertebrae together and halt their growth and therefore progressive curvature.