Your Back: Don’t Take Your Best Friend for Granted

Edward S. Pratt, M.D., M.B.A.

Director, Memphis Spine Center, PLC

In this three part series we will look into how our back changes over time, what spinal conditions pose the greatest risk at each stage of our spine’s lifecycle, and how our choices can affect our long term health and the health of our best friend…our back.

Part One

            There is nothing like the loyalty of a good friend. Someone who is never far away, supporting you in good times and in bad, whether you are nice to them, ignore them, or are down right mean to them. A good friend is usually low maintenance, forgives you your transgressions, and celebrates your victories. As the years pass, a good friend stays with you through thick and thin, as you both grow old and grey together. Many of us take for granted such a friendship, ignoring it and leaving it unnurtured until we become painfully aware that the friendship is in trouble. So it can be with our backs.

            As a population we eat too much and gain weight, putting excess loads on our backs. We smoke cigarettes, cutting off the blood supply and nutrients to our discs. We push, pull and tug on things that are too heavy for us without warming up, asking our backs to take up the slack. We adopt poor postures in front of the TV or computer, and then fail to stretch or exercise often enough to keep our muscles healthy. We become weekend warriors and in the rush to get done, lift heavy, bulky objects without help, the wrong way, not using our legs, expecting our back to just pitch in and do the rest. As youngsters we might play football, strapping on shoulder pads to hit other people with all our might. We are taught to use the power of our legs to drive people off the ball, but use our backs to deliver the blow. Or we put on cheerleader outfits and gymnastics uniforms training to do vaults and handsprings, working to increase our back’s flexibility until it can stretch no further. At that stage in our lives we believe we are invulnerable…our backs were fine!

            But…do we really know what in the world we are talking about? Do we even consider our best friend, our back? Do we really understand today the impact our actions have on our spine? Is it any wonder that our backs rebel from time to time? Or that 80% of Americans eventually must seek medical attention for a back condition? Or that back injuries are the most common, most expensive type of Worker’s Compensation claim, accounting for more days lost from work than all other injuries combined?

            Back and neck problems are epidemic in the United States. The incidence of back strains, disc herniations, stenosis, degenerative disc disease and chronic back pain are all on the rise. The incidence of back and neck related surgery is several times greater than in any other industrialized nation in the world and increasing every year.

            The spine disease epidemic is not simple. It is not caused by one lifestyle problem, or one disease. It affects children, adolescence, working adults and the elderly. The problem is aggravated by our culture, our genetics, and our lack of knowledge about how our daily decisions impact our backs. Every age has its own types of spinal problems, risk factors, and preventative steps that can help avoid spinal disease. Let’s look at the spine lifecycle then at a few of the major problems facing each age group to see what can be done to help take care of our best friend…our back.

The Spine Lifecycle

            Our spines have a lifecycle just like we do. Although the spine changes profoundly through life, its primary roles do not. Those roles are; first, to support the head, neck, upper body, upper extremities, and trunk; and second, serve as a protective conduit for the spinal cord and nerves as they pass from the brain to their final destinations in the body.

            When young, the spine is growing and very flexible. The discs are soft, fluid and thick with a very strong outer wall (annulus). The bones are often not fully developed and are still partly made of growth cartilage. At this age the spine can be deformed by trauma to an amazing degree, then recoil back into position and not break. Subsequently, athletes can sustain injuries with great temporary deformity, pinch nerves (stinger) or strain muscles without any obvious injury on X-ray. This hyper flexibility during growth can also permit progressive abnormal curves such as scoliosis and kyphosis to develop. These conditions unless very extreme, progress and change only during the adolescent growth years when the spine is flexible and growing. It is also during these early growing years that most primary tumors develop in the spine. Each of these problems cause back pain, and unlike adults with baseline arthritic changes or issues of secondary gain, young people with back pain, more often than not, have a diagnosable problem that should be addressed. The take home lesson here is, “Don’t ignore back pain in children and adolescents. In this age group, when there is smoke there is usually fire.”

            Once growth is complete and our bones are fully mature many of the childhood spinal diseases stabilize. College age young adults usually continue to be active, but often begin to develop the kind of health habits that will get them into trouble later. Late nights in front of the TV or computer, hunched over preparing a term paper, causes fatigue in those muscles that support the neck and upper body. In an effort to keep the eyes steady while reading, great effort is required by the upper trunk and neck to keep the head motionless in space. Stiffness, fatigue, and muscle soreness can develop even in a young healthy spine as the areas under pressure are excluded from natural blood supply. Poor posture habits can begin to create significant mechanical dysfunctions even at this age.

            By the time the spine is thirty years old, it is beginning to show the first signs of age. MRI (Magnetic Resonance Imaging) studies begin to show the first signs of disc arthritis at this age. People begin to become more sedentary and the confluence of poor posture, early arthritis and poor muscular conditioning begin to become evident. Activities that “were no problem” ten years before, now might cause several days or weeks of back or neck pain. These acute strains or sprains resolve in over 90% of cases, but the mechanical issues that precipitated them are still at work, making recurrence very likely. At this age, the discs also remain plump and fluid. Weaknesses or failures of the outer annular wall can allow disc material to flow out into the spinal canal impinging passing nerve roots, a condition known as a ruptured or herniated disc. As degeneration of the spine continues to progress, the peak load to failure of each tissue begins to decrease. In other words, they become weaker and easier to injure. It becomes ever more important to warm up and stretch before any major physical activity. More pliable muscles and joints will give more during activities, creating less stress and decreasing the chance of injury. Multiple small injuries some even unnoticed become additive, leading to advancing degenerative disease.

            Once the resiliency of youth is behind us, our spines begin to take on a new character. The spine is considerably stiffer in older individuals. This stiffness allows the spine to satisfy its primary functions of body support and nerve protection despite the progressive degeneration of joints and bone. As the discs begin to age they lose the ability to attract water and begin to dehydrate. As a result they shrink and flatten, accelerating arthritic degeneration. This degeneration leads to increasing stiffness, bone spur formation and joint thickening. All of which can begin to compress passing nerves, a condition known as spinal stenosis. It can also lead to decreased body height. This progressive degenerative change can also lead to joints becoming unstable and moving in abnormal directions. Abnormal curvatures and instability develop in this age group more commonly than at any other age. Age also has a direct negative effect on the strength of the bones in our backs. Bone mass usually peaks in the mid thirties, and then gradually decreases throughout the rest of life. If extreme, this condition, known as osteoporosis, can lead to multiple fractures, pain, deformity, senescence and premature death.    

Children and Adolescents

            As young people we are very active, engaged in sports, school and play. We are also engaged in the process of growth and development. Some of the most common problems facing kids are overuse syndromes, scoliosis, spondylolysis and spondylolisthesis.

Overuse Syndromes

            Overuse syndromes tend to affect kids when they are rapidly growing. As kids grow, their muscles can occasionally mature more quickly than their bones, becoming stronger than the bones they are mounted upon. The resulting over pull and irritation at the point of muscular attachment leads to pain with activities, sports, carrying heavy book bags and so forth. These “enthesopathies” are usually self-limiting, respond to activity modification and mild over-the-counter medications such as ibuprofen. Back pain associated with overuse, many times is related to high intensity sport in a skeletally immature athlete, or recurrent heavy lifting. The classic example is that of the sixth grade girl with the 60 pound book bag. Awareness is half the battle. Getting extra copies of books to leave in class or at home and providing extra time to change out books at a locker can go a long way in limiting the stress. I have also seen children that are pushed by their parents and themselves to achieve great feats in competitive sports. Many sports such as swimming and gymnastics require kids to dedicate themselves to superhuman workout schedules in order to succeed. Extreme physical and emotional duress can develop under these conditions, in a child ill equipped to recognize or deal with it. Occasionally the only way a child has of pleading for help is to develop an injury or painful condition.  Occasionally, the workup will reveal a painful benign tumor (osteoid osteoma), stress fracture, or other even more serious problem that would have gone undiagnosed had an investigation not been performed. It is important to remember however, that just because the physical workup is negative does not mean there is no problem. It is important to remember that most kids will not continually complain unless there is something wrong. Recurrent complaints of pain should be evaluated by a physician.

Scoliosis

            The word scoliosis means curved spine. In truth, the spine has several normal curves, most of which are best seen by looking from the side. The neck has a gentle backward curve called the cervical lordosis, the upper back has a gentle forward curve between the shoulder blades called the thoracic kyphosis, and the lower back has a gentle “swayback” curve called the lumbar lordosis. When there is an obvious side to side curve (greater than 10 degrees) we call this scoliosis. It can occur in the upper (thoracic) spine, the lower (lumbar) spine or combinations of both. Usually, when the spine develops an abnormal curve it will also twist. This is what creates the characteristic rib hump or prominence of the rib cage seen with many curves on the right side of the spine with forward bending. Scoliosis can occur in newborn, (congenital form), in young children, (juvenile form), and in older children, (adolescent form). Scoliosis is much more common in girls, but does occur from time to time in boys. In general the earlier scoliosis develops, the more likely it is to get worse; and because it often progresses, the later it is diagnosed the more severe the curve and the more involved the treatment.

            Scoliosis can often be suspected from a simple “forward bending test” that every mother or father ought to do on every child yearly from the age of about eight or nine through the age of thirteen or fourteen. The forward bending test is done by sitting in a chair with your child standing in front of you turned away with his or her back toward you. Have your child gradually bend forward and touch his or her toes while you hold the pelvis stable, then gradually return to a standing position. During this maneuver look closely along the spine. The spine and ribs should be symmetrical, of equal fullness, on the left and right. The spine should be straight without any evidence of curve. A scoliotic curve will be most obvious in this forward bent position, and will usually show as a “rib” hump (actually all of the ribs where the spine is curved) that sticks up on the right side, or a fullness or enlargement of the muscles along the spine on one side or the other. If any of these abnormalities are found or even suspected, an immediate referral to your pediatrician or an orthopaedic spine specialist is in order.

            Scoliosis can occur in conjunction with many very serious diseases such as tumors, neurological degenerative diseases, spinal cord trauma, and various birth defects, however by far the most common for of scoliosis is called idiopathic, (not associated with any other problem). The purpose of the initial exam is largely to check for associated diseases, and to measure the severity of the curve.

            Scoliosis is treated in different ways depending on the severity of the curvature. Mild curves, those less than 20 degrees, are only observed over time for signs of progression. These kids need not change anything they do day in and day out, and receive X-rays every six months or so. We become more concerned around active growth spurts when these curves most commonly progress. Moderate curves, those between 20 degrees and 45 degrees, must be placed in a scoliosis brace. The brace type and the hours per day a child must wear it will vary based upon the curve configuration and the skeletal maturity of the child. As a rule, bracing is not intended, nor is it successful in decreasing the severity of a curve. Rather, bracing can if successful, prevent progression of a curve in growing children. The vast majority of curves that remain less than 45 degrees by the time a child reaches skeletal maturity will not progress during adulthood, while those that exceed 45 degrees usually do. The role therefore of any bracing program is to slow or stop curve progression such that no curve exceeds 45 degrees before skeletal maturity is reached and the brace is discontinued. Most if not all curves that exceed 45 degrees must be considered for surgical correction and fusion.

            Scoliosis fusion is sometimes accomplished through the back, sometimes through the side, and occasionally through both approaches. The best approach is influenced by the age of the child, curve pattern, and the curve severity. There are many additional factors your doctor will need to consider here, and the final decision of the physician is usually made with a great deal of deliberation. The surgery consists of placing two rods in the spine spanning the curve and securing them to the vertebrae with screws or hooks. This construct of rods, hooks and screws is then rotated and extended or compressed to straighten the scoliosis and recreate as closely as possible the normal curves of the spine. The area from the top to the bottom of the rod is then roughened and packed with bone graft, in an effort to convert the once mobile vertebral segments into a solid fused sheet of bone. Once fused solid, the curves usually will not progress or change over a lifetime. Occasionally, 10% of the time, a gap in the fusion can develop (pseudoarthrosis) and further surgery may be required to obtain solid fusion. Other possible complications associated with surgery include blood clots in the legs or lungs, pneumonia, infection, reaction to blood products, neurologic injury, and dislodgement of the hooks and rods. These additional risks are unusual, less than 1-3% taken in total. Youngsters rebound very fast after major surgery, but even so, expect 4 to 6 weeks before energy levels come back to normal. Lastly, although this surgery will effectively correct the majority of a scoliotic curve, it will never correct it all. In addition, the remaining movable segments above and below the fusion often undergo added stresses through life, frequently developing premature arthritis, instability or both.

 Spondylolysis/Spondylolisthesis

            Spondylolysis is thought to represent a small stress fracture that develops in the low back of children after minor trauma. The break occurs in an area of the spine called the “pars intrarticularis” or “part between the joints”. This condition occurs in less than 5% of the population, however in certain football players, cheerleaders and gymnasts the incidence can be as high as 50%. When symptomatic it causes low back pain (which is made worse with back bending), and stiffness in the hamstrings caused by walking in a habitual forward bent, knee flexed posture. Treatment consists of stabilization and stretching exercises while avoiding activities that cause pain. Occasionally, more aggressive techniques including pain blocks or surgical fusion are required, however these are seldom necessary.

            When spondylolysis occurs on both sides of the spine it can lead to a slipping of one vertebra on another, a condition known as spondylolisthesis (spine slip). The vertebrae will usually only slip a centimeter or so, but occasionally slippage can be extreme. The best prognosticator for slip progression here seems to be the angle the slipping bone has with the pelvis (slip angle). The more vertical the slip angle, the more likely the slip will get worse over time. The treatment of spondylolisthesis is similar to spondylolysis in milder forms, but can require surgical spine fusion in more severe cases. Spondylolistheses that is progressing on repeated X-ray exams or have slipped more than 50% of the way off of the vertebrae below are candidates for fusion. Spine fusion for spondylolisthesis as with scoliosis is designed to lay down bone graft between the two slipping vertebrae so that they may form a solid sheet of bone between them, thus preventing further slip. As with scoliosis this is occasionally done with rods and screws, but in children it is often done without instrumentation. As we will see later, adult cases are very different. The rates for solid fusion and pain relief are superior when rods and pedicle screws are used as part of the fusion process.

Tips for Children and Adolescents:

1)      Parents perform the forward bending test on both sons and daughters from eight to fourteen, and seek medical opinion for any suspected abnormalities.

2)      When kids complain of pain, access the situation, look for signs of overuse, and implement rest and activity modification. If the pain persists seek help. Kids usually are not chronic complainers, take them seriously.

3)      Teach good habits early including proper diet, regular exercise, good posture, and stretching.

In the second of this three part series, I will discuss the problems associated with the young and working adult spine. This is the age that demands the most from its friend the spine and gives the least in return. Fast cars, late nights, and irregular lifestyles make this time a roller coaster for most backs. Fortunately, our friend the back is usually up to the challenge. Near the end of this stage the back begins to show the first signs of age. Just like a friendship, if you take care of it, it will take care of you. Otherwise…..

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                                                    Last modified: 04/04/06