Spine

Many of us have gone through back pain and realize how disruptive it can be. We have watch friends and relatives struggle with back problems sometimes for years. For those of us who have never had back pain we should be grateful.

Back pain is a result of a number of things going wrong with our body. The muscles controlling the multiple joints of the spine and pelvis become either too weak to control movement of the joints or too tight to allow normal excursions of joints that are designed to move.

This results in the loads going through the spine increasing to the point where ligaments get inflamed, discs herniate, spurs develop and nerves get impinged upon. What can you do about it?

First cut back your activity. Back pain means you are asking your back to do something it can’t. So spend less time upright and weight bearing. Try to cut back to a level where your back doesn’t hurt.

Now that you have found an activity that your back can handle, the next step is to increase the back’s capability so it can handle more. You do this with an appropriate exercise program involving strengthening and endurance.

The strengthening should focus on the muscles of the back and abdomen They should be done in a supine position. The endurance exercises should be done semi or non-weight bearing either on a bicycle or in a pool.

Sitting tends to worsen back problems. Try a towel roll in the small of your back. Get up every 10 minute and stretch your back. Consider a kneeling chair.

Remember. Pain means your back can’t do what you’re asking it to do.

If you try to take pain medication and keep doing what you are doing, then your pain is going to get worse. The remedy for your pain then becomes more prolonged and involved.

Back pain means you can’t do it. Back off.

Start an exercise program. Pain medication doesn’t cure your back. So don’t act like it does.

ANATOMY OF THE SPINE

Spine is a complex structure which is made of multiple bones called vertebrae along with their associated ligaments, capsules, muscles, and nerve structures.  It extends from the base of the skull to the pelvis.  Spine is essentially made up of 33 vertebrae.  The lower four vertebrae are joined together to form the coccyx or the tailbone.

The five vertebrae above the tailbone are joined together to form the sacrum.  Rest of the other vertebrae are mobile units.  The spine is divided essentially into 3 parts.  The neck or the cervical spine, the mid back or the thoracic spine, and the lower back or the lumbosacral spine.

The cervical spine is made up of upper seven vertebrae. It allows movement of head. The thoracic spine is made up of twelve vertebrae and hinges the ribs in the front to make the chest.  The lumbosacral spine is made up of five lumbar, five sacral, and four coccyx vertebrae and it helps in distributing the weight of the upper body to the pelvis and the lower limbs.

ANATOMY OF THE SPINE VERTEBRAE

Vertebra is the basic unit of the spine.  Each vertebra is made up of two parts, the front solid portion called the body, which is strong and stable and stacked over each other to provide stability to the spine.  The back portion of the vertebrae is made of a V shaped flat bone called the lamina and is joined to the body by two pedicles.

The lamina forms the arch over the back of the body make a canal through which the spinal cord and nerve roots pass and are protected.  There are vertebral foramina below each pedicle through which the nerve root from the specific level passes out of the spinal canal to supply the structures in their respective areas.

The portion of the junction of the lamina with the pedicle is called pars interarticularis.  This may be involved or fractured in some patients (especially young patients) causing instability of the spine.  There are articular processes above and below from the back of lamina called facets which articulate with the facets above and below on each side to form the facet joints.  The two vertebral bodies articulate with each other also through an intervening intervertebral disk.

INTERVERTEBRAL DISC

Intervertebral Disc is present in between bodies of vertebrae above and below. It helps providing stability as well as mobility to the spine.  It also acts as shock absorber preventing injury to the vertebral body.  A disk is made up of outer fibrous rings called annulus fibrosus and the inner jelly called the nucleus pulposus.

The disk can be damaged due to injury or wear and tear or aging.  This may lead to herniation of the nucleus through the annulus fibrosus causing herniated disk.  This herniated disk may cause compression over the spinal cord or nerve roots, which may lead to radicular pain down the leg or the arm called radiculopathy.  Degeneration of the disk itself may cause back pain.

FUNCTION OF SPINE

The spine functions to keep our body erect and straight as well as protect all the nerves in the form of spinal cord and the nerve roots that come from the brain within the spina canal and are distributed all over the body.

The mobile segments of the spine in the cervical, thoracic and lumbar spine are essentially made of three joints in between each vertebra which allow movement at well as stability.

The spine is wrapped around with muscles especially on the back and on its sides.  The major vessels of the body run along the front of the spine in the thoracic and lumbar spine while the food and wind pipe runs in front of cervical spine with other many complex and vital structures around the spine.

SPINE DISEASES

Due the complexity of itself and its surrounding structures, spine is prone to many type of diseases.  The diseases that usually affect the spine are either of the following types:

  • Congenital or developmental – These types of conditions are usually present at birth or develop in the early developing years of life.  Development of scoliosis either at birth or during adolescence is an example of this type of problem.
  • Traumatic spine injury – These injuries happen either due to motor vehicle accident or falls or other such accidents.  The patients may suffer a fracture or a dislocation or a combination of the two.  Such patients need to be treated accordingly under supervision of a spine surgeon.
  • Neoplastic – It means the patient has neoplastic lesion or tumor involving the spine.  These lesions may be either malignant or benign and usually need a diagnostic workup to rule out or confirm the diagnosis before a treatment can be planned and carried out.
  • Infective – It means that the spine is involved in an infection.  Infection of spine is an uncommon phenomenon but may happen especially in patients who are immunocompromised like patients of HIV or AIDS or patients who are on chemo or radiotherapy or on immunosuppressive medications. It is also common in IV drug users.
  • Metabolic and Inflammatory diseases of the spine – These usually include osteoporosis or osteomalacia which means weakening of the bone structure.  This usually happens due to ageing but may also happen due to medications or diseases. Most common inflammatory disease of Spine is Rheumatoid arthritis which usually involve the cervical spine or the neck.
  • Degenerative – This is the most common cause of diseases of the spine, usually involves the cervical or the lumbar spine.  It essentially involves ageing process but can be accelerated due to injuries or over use of the spine or bad posture for a long time.  Most of the patients usually present with pain in the affected area, either the neck or the lower back in most instances.

PRESENTATION OF THE PATIENT WITH SPINE PROBLEM (SYMPTOMS)

Most common presentation of a patient with spine problem is pain localized to the neck or back. The pain may be in the midline along with in paramedian location. It may be associated with muscle spasms.

The pain is usually aggravated with activity and relieved with rest.  Occasionally, the patient may have radiating pain down the extremity with or without tingling, numbness, weakness of the muscles, involvement of bowel or bladder or gait. Bowel and bladder may be in the form of retention or incontinence.

The patient may also have sexual dysfunction rarely. Rarely in cases of thoracic spine disease there may be radiating pain or tingling and numbness along the chest or abdomen.

RED FLAGS

  • The patients who have back or neck pain with any of these following conditions should seek medical attention as soon as possible.
  • Cancer, neoplasia or malignancy.
  • Unexplained weight loss of more than 10 pounds in the last 6 months.
  • Immunocompromised comorbidities like on chemo or radiotherapy or having disease like HIV or AIDs or being on prolonged corticosteroid therapy.
  • IV drug users.
  • Urinary tract infection.
  • Fever of more than 100 degrees centigrade.
  • Significant trauma from a fall or accident.
  • Bowel or bladder involvement in the form of incontinence or retention.
  • Weakness in the major joint of arm or leg.

SPINE HEALTH

Our spine is S-shaped and curved which curves to the front in the neck and lower back while curving towards the back in the thoracic spine. A healthy spine with a good posture and strong musculature is the key to prevention of spine problems.  There are multiple lifestyle changes that can be done to prevent developing spine problems as well as prevent deterioration of preexisting diseases.

Regular exercises which also include core strengthening exercises which help  strengthen muscles in the front and the back of the spine are helpful in prevention of spine disease. These exercises can be performed at home or in the gym with or without the help of a physical trainer. Yoga is one of the many good exercise routines that can help stretch and strengthen all muscles of back apart from the muscles of the extremities.

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