Understand Spine and spinal disorders. What are the common causes of spinal disorders?

The Spine

Spine is the central axis of our body that runs from the head to the pelvis and it is made up of a chain of bones (vertebrae) connected to each other by discs and joints. This strong structure acts as an anchor to the trunk and limbs and provides stability to our upright posture while allowing normal movements at the same time.

Apart from providing structural support to out trunk, the spine acts as a strong protective covering for the main nerve (Spinal cord) that carries the signals (stimuli) to and from the brain to the rest of our body. The nerve roots are like cables arising from the spinal cord that exit the spine, one at each level, and run into the arms, around the trunk and the legs, on both sides, supplying all the structures of the body, carrying signals – to and from the brain.

So the functions of the Spine are:

  • Structural support to the trunk and limbs
  • Allows normal range of movements
  • Houses and protects the Spinal cord and nerve roots.

As humans evolved to walk on two legs, the orientation of the spine changed from horizontal to vertical position and that makes the human spine unique, with its own unique problems.

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What are the common spinal problems?

The structures in the spine can be affected by various disorders and lead to the various symptoms related to spine. The common symptoms include back or neck pain, pain radiating down the arms or legs, numbness or weakness in the limbs, limitation of ability to walk and result in inability to do other daily routine activities of life. Less commonly, there can be paralysis of the limbs, severe numbness and loss of bowel and bladder control in situations where there is a significant compression of neural structures in the spine.

The spine can get affected by disorders at all ages from the time of development of fetus in the womb to the old age. The most common disorder affecting the spine is the age related wear and tear changes, known as “degeneration” or “spondylosis“. These wear and tear changes start in the discs of the spine and gradually affect the joints and the bones and can lead to various symptoms like back or neck pain, sciatica, weakness of limb muscles, numbness and deformity in the spine.

 

The spine can get affected by formation defects during development in the womb leading to spinal deformity. Such deformity in the spine may manifest as an abnormal swelling at birth or as a progressive hump back as the child grows. “Scoliosis” or “kyphosis” are the usual terms used to describe these deformities. Scoliosis may also develop in the growing children, that may go unnoticed till it becomes significantly large. “Spondylolisthesis” is a disorder that affects the lower spine and starts in the growing children, where there is a forward slipping of one vertebra over the other, causing back pain and deformity as well as radiating pain into the legs due to compression of the nerve roots at that level.

Traumatic injury to the spine can cause fractures or dislocation in the spine and injure the neural structures in the spine that can lead to devastating consequences like paraplegia (paralysis of both lower limbs) or quadriplegia (paralysis of all four limbs) including loss of bladder and bowel control. Minor injuries can lead to chronic pain, neurological symptoms and disability.

The spine can get affected by bacterial infections at any age, most commonly tuberculosis in India. Other bacterial infections are often encountered though not as common as tuberculosis. Infection destroys the bones and discs in the spine and can make it unstable leading to pain and nerve compression. It may also result in spinal deformity.

Spine is a common location for tumours/cancers that spread from other organs like lungs, breast, gut, liver, thyroid, prostrate gland etc. especially in the older age group. Less commonly, tumours can primarily arise in the spine itself, at any age. Spinal tumours cause pain and disability and neurological symptoms due to compression on the nerves. It is imperative that these are detected at the earliest, to prevent serious consequences and to be able to deal with them in a better way.

Osteoporosis is a disease that occurs in old age, especially in ladies after the menopause. The bones become more porous and weak and can crumble easily leading to fractures. The spine is the most common site for osteoporosis related fractures and deformity, leading to significant disability and limitation of quality of life. Osteoporosis can progress silently, without any symptoms until it results in a fracture. It can be detected early by simple screening tests like DEXA scan.

Posture related spinal problems are very common nowadays due the modern lifestyle. Sitting in bad posture on desk jobs or overuse of mobile phones with a forward bent neck puts undue strain on the spinal muscles and leads to significant pain and disability. Lack of exercise and reduced sleeping hours makes the situation worse.

Understanding the Spine and common spinal disorders can help you to take better care of your spine and prevent serious spine related disability. There are a lot of misconceptions  regarding the spinal disorders that add to the problem and appropriate education and awareness can prevent significant amount of distress.!

 

 

 

 

 

 

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Work from home – is it good or bad for your spine?

Work related back pain is a common reason for sick leave all over the world. With a number of people working long hours in sitting posture on desks and in front of computers, there is a rise in prevalence of significant back or neck pain, even among the youngsters in the prime of their health.

I come across many professionals who have opted to work from home due to the back pain, thinking that resting at home and avoiding travelling to the office, while continuing to work, can relieve their pain.

But as we all know that bad posture related strain is the most common reason for spinal pain, it all depends on the posture weather at office or at home!

In fact working from home, one may actually find themselves in a much worse position that working sitting in the office chair, if you think about it!.

Most of them working form home work on a laptop, sitting on a sofa or in the bed or sitting on the floor. While it may be okay to be in those position for few minutes at a time, long hours in such postures can overstrain the spinal muscles and lead to back or neck pain.

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Lying prone and working on the laptop is another common position. The spinal muscles, discs and joints are over exerted to maintain the head and neck in extension for a long duration and can result in neck or upper back pain.

So, if you are working form home, especially to avoid posture related pain, you may not get better if you are not mindful of your posture at home!.

Here are some tips to avoid overstraining of your spinal muscles while working from home.

Make a sitting arrangement on an ergonomic chair and a comfortable desk or table.

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If you want to work on the bed, sit upright leaning your back up against the wall or the headboard of the bed. Use pillows to support your lower back and under the knees. Avoid sliding down or sidewards. (which eventually happens if you don’t correct yourself frequently).  Take a break and walk around every half an hour and stretch your muscles. Avoid slouching or hunching your back. The head and shoulders should be in line with the back.

Keeping a pillow or another form of support under the laptop is essential to bring it up to the eye level. Make sure your arms are not lifted away from your body and wrists are well supported.

It is better to avoid lying prone and working on the bed.

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Use additional supporting tables or stands to hold the weight of the laptop that trying to hold it in place yourself.

Exercise regularly to keep your spinal muscles strong.

Have a great “Work from home” time! .

5 Most important habits to keep your spine strong and healthy.

Back and neck pain is a very common symptom experienced by almost 80 percent of adult population at some point in their lifetime. In some, it can be severe and chronic or recurrent leading to frequent sick leaves from work and may be the reason behind change or loss of jobs.

Follow these most important tips to minimise the chances of back or neck pain becoming a significant problem in your life.

Habit no 1.

Good posture. Maintain good spinal posture during all the daily routine activities including household chores, sitting at work, bending and lifting weights, travelling etc. Adequate back support and maintaining head and neck  in alignment with the back are important points to remember and practice. Read and practice the guidelines regarding office ergonomics. Learn the right way of bending and lifting weights without hurting your back.

Make good posture a habit !. Be aware of your posture and keep correcting yourself until it becomes a habit !.

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Habit No 2.

Exercise. Regular exercises to strengthen the spinal muscles, abdominal muscles and improving the core muscle strength is an extremely important factor for preventing frequent spinal pain. Those with long duration sitting jobs, women after child birth, old women and men are likely to have weaker core strength that leads to more stresses on the structures in the spine and the back muscles, resulting in spinal pain.

Make exercise a habit !. Exercise regularly to improve the core strength and strengthen the muscles of the back as well as the neck and shoulders.

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Habit No 3.

Sleep. It is during the sleep that the spine recovers from the entire days stresses. The spinal muscles are continuously working the entire day when we are in an upright posture. They need adequate duration of rest to recover overnight to be ready for the next day. The discs in the spine loose some water during the day when they are loaded. It is when we sleep and rest that the discs recover the lost water pressure in them. If the sleep duration is inadequate, over a period of time, the repetitive stresses lead to muscle fatigue and also may accelerate disc degeneration.

Sleep adequately !. At least 7 hours of sleep is necessary for the spine to stay healthy.

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Habit No 4.

Diet and Sunlight. Adequate water intake is essential to prevent dehydration.  The function of the discs in the spine depends on its ability to retain enough water in its matrix. Loss of this ability is the first step towards disc degeneration and related problems.

A balanced diet rich in calcium and vitamin D is essential for muscle and bone strength. Vitamin D deficiency is very common in our population due to lack of adequate sunlight exposure and poor diet habits.

Low vitamin D is associated with increased risk of falls in the elderly, as it affects the muscle co-ordination. Loss of calcium from bones leads to osteoporosis which in turn leads fractures and also results in acceleration of disc degeneration.

Get some sunlight, eat healthy and hydrate yourself well.!

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Habit No 5.

Quit Smoking. The only factor that is proven to lead to early disc degeneration, apart from genetic composition, is tobacco smoking !. The discs in the spine do not have their own blood supply and they depend on the adjacent vertebral body for  oxygen, glucose  and other essential nutrients.

Smoking results in reduced blood supply to the vertebral bodies and this affects the permeation of nutrients into the discs, setting off an acceleration of disc degeneration and related problems.

Smokers are also at a significantly higher risk of osteoporosis.

So if you are a smoker, quit now!!.

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QUIT SMOKING !

These 5 habits can help minimise the chances of significant back or neck pain troubling you by taking care of the most common causes. There could be other causes of spinal pain and if symptoms persist or keep recurring, see your doctor for further evaluation.

 

Osteoporosis: Early detection is the key to prevent fractures.

“Osteo” means bone and “porosis” means porous. Osteoporotic bone has less bone mass per unit volume.

Post-menopausal women are most commonly affected although men beyond 70 years of age are also affected less commonly. People with severe liver or kidney function impairment or those with endocrine problems are at risk of developing osteoporosis. Smoking can accelerate osteoporosis also.

Bone looses calcium at an accelerated pace after menopause in women due to less oestrogen levels in the body.  The bone gradually becomes more and more porous and eventually can fracture even under routine normal loads.

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Most commonly, fractures due to osteoporosis occur in the spine, hips or near the wrists. Vertebral or hip fractures can make them bed ridden for a while and tilt the balance towards worsening of general health of the person. After one osteoporotic fracture, the risk of another fracture increases by at least 5 times. Recurrent multiple vertebral compression fractures lead to a forward bend / curve in the spine, reducing the overall height. The spinal muscles are at a disadvantage due the deformity in the spine and can lead to significant back pain.

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The forward stoop can lead to a significant restriction of lung capacity and restrict the capacity of the stomach as the sternum digs into the upper abdomen. These factors lead to reduced oral intake as well as reduced endurance of the person to physical activity.  Both these, in turn can lead to worsening of general condition and depression. This is the beginning of the downward spiral of health that can eventually result in mortality.   It is an established fact that those with osteoporotic fractures have higher mortality than those without fractures. So, prevention of an osteoporotic fracture is of utmost importance in old age. Prevention starts with early detection of the condition.

Early detection of osteoporosis needs screening tests to assess the bone density. DEXA scan or quantitative CT scans are used to diagnose osteoporosis and estimate the severity. Women who are over 5 years after menopause should undergo a DEXA scan to assess the bone density. There are tools to assess the future risk of fracture in any individual based on certain clinical parameters.

Post-menopausal women need additional calcium and vitamin D supplements to meet the daily recommended allowances. Diet rich in calcium and vitamin D, including milk products, eggs, fish, nuts and fruits like oranges are recommended. Those with a low density score need additional medication to improve the bone density and reduce the risk of fracture. Bisphosphonates are the usual first line medications used to increase the bone density. Other options like teriparatide or denosumab injections are chosen based on individual clinical scenario.

 

 

 

Cervical disc prolapse in a surgeon, causing hand muscle weakness: A treatment dilemma!

A few months ago, a well accomplished busy surgeon walked into my clinic with severe radicular pain in her left arm associated with numbness in the thumb and index finger. The symptoms were troubling her for a couple of weeks and symptoms had made it difficult for her to operate. She is an ardent runner and was obsessive about her fitness activities. She had to stop all the fitness activities due to this pain.

On examination, it was clear that she had a cervical nerve root compression, most likely due to a cervical disc prolapse. There was sensory loss in the index finger and thumb and  weakness in triceps muscle. An MRI of the cervical spine was done and it revealed a C5-C6 disc extrusion causing significant C6 root compression on the left side.

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Cervical disc prolapse causing nerve root compression.

She recieved pain medications and physiotherapy and advised on some activity limitations and asked her to stop operating for a while. We hoped that it would start improving in a few weeks as it usually does in most cases. Though the pain was getting better with medication, the dense numbness in the index finger and thumb persisted even after four weeks, with no sign of improvement. It was time to decide whether to wait further or to consider surgical treatment to give her the best chance of full recovery of nerve function.

A persistent numbness in the index finger and thumb and triceps weakness could affect her work as a surgeon. Waiting for too long could lead to a some persistent neurological deficit that may affect her function as a surgeon.

After a discussion with her about the pros and cons of non-surgical and surgical options, we decided to wait for a couple of weeks. In the mean time, I allowed her to scrub in a couple of cases and assist other surgeons, to see if the numbness and triceps weakness affected her function. She came back saying that she was able to do it quite well and it was not affecting her ability to operate. As the pain settled, she gradually increased her activities. Triceps strengthening and isometric neck exercises were advocated. She started running few minutes a day and gradually increased her fitness activities including swimming and jogging. Her numbness also started getting better gradually and she was back to operating over the next three weeks.

Although we know cervical disc prolapse with nerve root compression has a good chance of recovery, apprehension of permanent neurological deficit affecting hand function that can put a career at stake could push us towards an aggressive treatment approach which involved a surgical procedure. Loosing the hand function is the most dreadful thing for a surgeon and an aggressive approach to treat may be chosen in such situations to ensure full functional recovery. But a close observation and a wait and watch approach with a gradual rehabilitation program helped her to get back to normal eventually, avoiding a surgery, luckily.

But not everyone may be able to recover so well and a surgical option needs to be considered in certain situations to achieve the best functional outcome.

A young girl, her final exam and an endoscopic disc surgery.

An unexpected health problem striking at a wrong time is the last thing a 20 year old would expect. But sometimes the nature has its say on our bodies and we are forced to face such situations.

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A 20 years old girl was in the middle of her college degree final examinations when she started having severe radiating pain in her left leg. She had to sit for this exam just 2 days away and missing that was not an option she would consider. But this sudden onset severe radiating pain in her leg wouldn’t allow her to sit for even five minutes. She also had some tingling sensation and some numbness in part of the left foot and leg. She had a prior history of low back pain and was diagnosed to have an L4-L5 disc bulge one year ago but was free of symptoms after treatment till this episode.

She came to see me in this condition in our spine clinic just 48 hours before the important exam. After a clinical examination it was obvious we needed a MRI of the lumbar spine as it looked like a disc prolapse causing severe nerve root compression. An MRI of the lumbosacral spine was done immediately and she had disc prolapse at two levels causing severe nerve root compression and that was the reason for her symptoms. She was explained about the problem and given the option of bed rest and medications or a root block injection. But she wasn’t willing to give up the examination for which she had prepared putting in a lot of hard work. She insisted on a more definitive treatment for her leg pain. She was advised to undergo an endoscopic discectomy and the pros and cons were explained. She consented for the procedure and it a two level interlaminar endoscopic discectomy using Destandu endoscope was done at L4/5 and L5/S1 levels the same evening. She recovered well and was able to walk without leg pain and was able to sit comfortably for over half an hour by next morning. She was discharged from the hospital the next evening after surgery.

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Endoscopic discectomy

She took her final exam sitting for 3 hours and was able to successfully complete the exam without any leg pain. She made a great recovery since and has started spine strengthening exercises after 6 weeks post surgery.

This remarkable story is a combination of a young girl’s grit and determination and the benefits of a minimally invasive spine procedure using the spine endoscopy and is a story worth telling.!!.

Coccygodynia: The tail bone pain and treatment options.

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The tail bone – Coccyx

Coccyx is the bottom most part of the spine. It is a remnant of the tail that vanished during evolution of the humans from the apes. It consists of four or five small pieces of bone forming the lower most tip of the spine and it is attached to sacrum at the sacro-coccygeal joint.

Pain in the coccyx region is called coccygodynia. Coccygodynia can cause significant disturbance of lifestyle because it makes sitting painful. Sometimes it is very painful while getting up after sitting for a while. This pain may get aggravated while travelling, particularly in a two wheeler. Any position that causes pressure on the coccyx region will aggravate the pain. There is usually no pain while walking or bending or in lying down position.

Most common cause of coccygodynia is undue and repeated pressure on the coccyx due to bad sitting posture. The coccyx is not in a weight bearing position when the person is sitting upright but it becomes weight bering when the pelvis tilts backwards as when the person is sitting in a reclined position as seen in the picture.

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The second most common cause is a fall in sitting position that leads to a direct impact on the coccyx and may also cause a fracture or dislocation of the coccyx. Coccyx pain is common in pregnancy and after child birth. Repetitive stress during activities like cycling or rowing can strain the coccygeal ligaments and cause pain.

There are certain other conditions that may cause pain in the coccyx region. For example, a local abscess in the coccygeal region or a perianal infection needs to be ruled out by examination. More serious causes like a local tumour or a deep infection are very rare possibilities.

Treatment involves use of a doughnut pillow while sitting, local physiotherapy and medications to control pain. Sitting in good posture is the most important aspect of the treatment. Exercises that involve stretching and relaxing of pelvic floor muscles and ligaments are an important part of the treatment.

Sitz bath with warm water once or twice a day helps alleviate the pain. Most of the times it gets better with these measures.

Local anaesthetic and steroid injections are used in some patients who do not get better with conservative measures. Radio-frequency ablation of the coccygeal ganglion is another effective option in chronic coccygodynia. Very rarely a surgical excision of the coccyx may be required.

 

 

 

What is a whiplash injury?

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Whiplash injury refers to a violent backward and forward movement of the head and neck like a whip, resulting in injury to the structures of the cervical spine. It is a fairly common injury that leads to significant neck pain and associated disability.

The most common mode is sudden deceleration while travelling in a vehicle or a rear end impact that pushes the head backwards followed by a rapid forward swing of the head that injures the muscles, joints and ligaments of the cervical spine. This mechanism of injury can result in a cervical spine fracture or dislocation with spinal cord injury or even a brain injury in some.

Other modes of injury include a fall with impact on head or face, assault with direct blow to the head or upper back or violent shaking of the body. Contact sports also can result in such injuries.

Symptoms include neck and upper back pain, head aches and stiffness of the neck. Rarely, neurological symptoms like numbness or weakness in the upper or lower limbs may also be found after a whiplash injury.

The symptoms may lead to irritability and mental stress, inability to concentrate on work, sometimes leading to change of job or loss of employment in a small percentage. Although a secondary gain behaviour is blamed in some of these patients, the significant chronic pain being the cause cannot be completely ruled out.

Most of the patients with acute whiplash injury get better in a few weeks with rest, medications and physiotherapy and exercises. But the symptoms may persist beyond 12 weeks in some of them and lead to chronic neck pain and related disability (chronic whiplash syndrome). Severe initial symptoms, age more than 35 years, females are at a higher risk of developing chronic symptoms of whiplash injury.

The severity of a whiplash injury can be reduced by having a head rest in the vehicles that limitation the backward excursion of the head in the event of a rear end collision. Although there is no certain way of averting such injuries completely, exercises to keep the neck and upper back muscles stronger may help reduce the intensity of the injury.