Your Back: Don't take Your Best Friend for Granted

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

Director, Memphis Spine Center, PLC

Part Two

As we discussed in part one of ”Your Back, Don’t Take Your Best Friend for Granted” the back has a lifecycle from the crib to the crypt that permits it to fulfill its role as a support structure for the body, and a protective conduit for the spinal cord. The spine begins life as a largely cartilaginous, flexible array of bones separated by plump discs and held together with strong flexible ligaments. As it ages, the discs thin and dry out, and the ligaments become weaker and less flexible, yet still the spine fulfills its two primary functions of support and spinal cord protection. During the young adult and working years the spine is typically abused like no other time in its lifecycle. Motor vehicle accidents, sports injuries, on the job injuries, smoking and other poor lifestyle habits, challenge spinal health and cumulatively lead to the first signs of degeneration, during this period.

So you and your friend, your back, have made it through childhood and adolescence, still friends. The risk of acquiring disorders associated with growth, development, and primary malignancies now drop off, and degenerative disorders have not yet had the opportunity to take hold. Young and working adults however, have their very own series of challenges. Most people, especially males, as they move into adulthood, take on an air of invulnerability, and risk taking is much more common. With the increased independence of adulthood comes increased power to abuse your best friend, your back. Accidental injuries and specifically motor vehicle accidents peak in the fifteen to twenty four year old age group, and unfortunately too often the victims do not wear seatbelts. It is during this time that adults reach there physical peak. Competitive sports such as football and gymnastics have been shown to cause injuries to the spine with significant long term negative effects. Deleterious habits such as obesity, alcohol and tobacco abuse usually begin during early adulthood and continue to overstress the spine for the remainder of life. These habits have been correlated with advanced degenerative changes to the back. It is during this stage that discs are most susceptible to herniation or rupture. Lastly, it is during the middle adult years that back injuries most commonly affect the workplace. Back and neck injuries cause more lost days from work, and greater worker’s compensation expense than all other on the job injuries combined. Through proper warm up and ergonomic job site analysis, much of these injuries could be prevented.

By the time you reach retirement, your back has changed significantly. Just as you have developed some grey hair and a few wrinkles, so your spine has developed some disc collapse, arthritis, and rigidity…but that is a discussion for part three.

Accidents/Alcohol Abuse

Motor vehicle accidents are the number one cause of death in young adults. According to the CDC more than one in three accidents are associated with alcohol consumption. In addition, the use of seatbelts has been shown to dramatically diminish the rate of injury and death associated with motor vehicle accidents. The NHTSA (National Highway Traffic Safety Administration) has documented a 45% drop in MVA fatalities in autos, and 60% drop in MVA fatalities in light trucks. Despite this only approximately 75% of front seat occupants typically wear seatbelts in states where it is not mandated by law. In 2002 over 42,000 people were killed on the nation’s highways and 3 million suffered serious injuries making this the most common cause of death in the 2 – 33 year age group. By far and away the most common demographic to leave their seatbelt unbuckled is the young adult male. In 2002, 6,000 young men died on the nation’s highways that would have survived had they been wearing seatbelts. As of 2004, there are still only 21 states and the District of Columbia that have mandatory seatbelt laws, making seatbelts still largely a matter of choice. Tennessee has a seatbelt law, making it unlawful to drive and not buckle up.

Prior to the current lap belt/shoulder belt combination, head on and rollover accidents caused a severe forward bend across the lap belt, rupturing the abdominal organs, and ripping the mid/low back apart. The use of shoulder belts decreased this injury, but did not improve the incidence of neck injuries. In 2002, there were 50,000 major spinal injuries, and the data suggests that many of these were also not wearing seatbelts. 38% of those patients that survived a traumatic injury in the mid/low back suffered permanent neurologic injury, while 40% of those surviving a neck injury suffered permanent spinal cord injury. For those that have never met such a victim, the longevity and quality of life of an otherwise healthy individual is profoundly impacted. This fact was brought home for many of us through the heroic story of Christopher Reeves. For those young readers that remain in denial that seatbelts are too much trouble, or don’t matter, I would refer them to the Christopher Reeves website and foundation for spinal cord injuries. The bottom line? Wear them…if not for you, then for all those you care about that will suffer from your poor choices, gradual painful decline and inevitable, demise.

Tobacco

It has been estimated that two thirds of those who smoke will die from complications associated with cigarette smoking. Although the popularity of smoking as a habit dropped through the last decade of the twentieth century, it is again on the rise. It is risk taking young adults that are largely responsible for this rise. Besides causing profound increases in most forms of cancer, chronic obstructive pulmonary disease and heart disease, cigarette smoke also affects your friend the back.

Twenty three very unusual and specialized structures within each of our spines, extending from the base of your skull to your pelvis are the intervertebral discs. These structures are specialized joints made of cartilage and fibrous tissue. One of the ways they are unusual is that they are the largest structures in the body without a specific blood supply. Each disc is surrounded by small blood vessels, but few if any penetrate into the disc itself. For cells inside the disc to receive nourishment and oxygen, these nutrients must diffuse out of the blood vessels around the periphery of the disc and into the disc itself. This passage of nutrients is aided by a gradual squeezing of fluid out of the disc during the day with weight bearing, and a gradual rehydration at night that occurs while you are asleep. This process is inhibited by nicotine. Nicotine in cigarette smoke is a very powerful vasoconstricting agent. In other words, it makes blood vessels spasm, and the amount of blood flow drop off or stop all together. The cells within the disc then, one by one begin to starve to death, and the disc gradually looses volume, and strength, leading to premature degenerative disc disease. Once the damage is done it cannot be reversed. This may not seem like a problem to you, as a young adult, but it makes your friend the back very unhappy, and over time the arthritis that develops in each disc can become so widespread that even surgical fusion procedures cannot effectively control the disabling pain. The bottom line?  Smoke at your own risk…and that of your friend your back.

Disc Herniations

These injuries occur when the outer ring of the disc (annulus) weakens and tears, allowing the soft inner material within the disc (nucleus) to pass out of the confines of the disc and into the spinal canal. Most commonly this injury occurs in a disc which has begun to have some degree of degeneration, yet have relatively young fluid nuclear material that is still mobile. Disc herniations most commonly occur during the 30s and 40s, but can occur at any age. Although some disc herniations can probably be avoided through proper warm up and lifting technique, they occur in many patients without any manageable risk factors identified.

The nuclear material compresses nerve roots or spinal cord, and incites an inflammatory response that can further cause pain. The pain experienced most commonly is a combination of leg or arm pain, tingling and numbness with about half of patients suffering pain in the back, neck or between the shoulder blades as well. The treatment of disc herniations should always be conservative at first, unless there are clear signs of progressive weakness, numbness or loss of bowel and bladder function. Nearly 70% of these injuries will gradually subside with non surgical treatment. This treatment should include a short period of rest, anti-inflammatory medications, gentle stretching to maintain range of motion, and if possible increase the space available for the compressed nerve root. Avoiding activities that aggravate the arm or leg is also important. Nearly 50% will improve over four weeks with this treatment alone. Those that do not are usually offered a targeted epidural steroid injection, done under direct fluoroscopic vision. If pain persists outpatient microscopic discectomy in the low back, or discectomy with anterior fusion in the neck is the treatment of choice. It is important to point out that any surgical treatment is never an endpoint in and of itself. The success of any procedure depends upon the quality of the post surgical rehabilitation one receives and how closely one follows his or her surgeon’s post surgical plan.

Sprains/Strains

Cervical and lumbar sprains/strains are some of the most common injuries for which patients will see a physician. A strain is defined as a tearing of the muscles about the spine, while a sprain refers to the tearing of ligaments that hold the spine segments together. Unless associated with major traumatic injuries such as falls from great heights or motor vehicle accidents, these injuries will heal over a period of several weeks. In 1987 a very large interdisciplinary group published the “Quebec Study” in the journal SPINE which evaluated the scientific evidence supporting the various treatments used on patients with acute back pain. This study, which was very well accepted by the medical community, recommended mainly over the counter analgesics, mobilization, and no more than two days of rest as the only treatments that were well supported in the literature. Traction, narcotics, and prolonged bed rest were not effective in treating acute back pain.

50% of these injuries will resolve in four weeks. 90% will resolve by 3 months, and the remainder may continue to have non specific complaints indefinitely. Pain and disability that continues longer than two to three months should be evaluated for additional problems. Although these injuries will resolve in 95% of cases with only supportive care, they often occur due to risk factors that can be identified and minimized. If these risk factors are not addressed, recurrence is very likely. Patients in very poor physical condition have a significantly greater chance of back injury. Lifting with poor technique, using you back instead of your legs, lifting bulky items without help, or performing heavy lifting or sports without stretching and warming up, can also increase your chances of injury. Ligaments and muscles that are worked regularly and warmed up before activity are stronger more flexible, enabling them to stretch instead of tear. The bottom line? Warm up and stretch before you perform activities which stress you back. Keep fit with a combination of aerobic, stretching and strengthening activities.

Worker’s Compensation Injuries

Back injuries are the most common cause of lost work days in employees under 45 years of age. Two percent of the U.S. workforce suffers an on the job work injury each year accounting for 175 million lost work days per year, costing 23.5 billion dollars annually. It’s no wonder that employers are scratching their collective heads looking for ways to decrease these expenses. Ironically, the worker’s compensation system was designed to be a “no fault” system in which dollars were spent directly on patient care rather than in expensive court battles to determine whether employer or worker was at fault in any particular injury. In many injured employees the system has worked well, however in most studies it has been established that average outcomes for worker’s compensation patients are inferior to those for patients in a non worker’s compensation environment. The current worker’s compensation system unfortunately creates a negative incentive for patients to get back to work or to get well.

Some patients anxious about re-injury upon returning to work, may delay their treatment or recovery, yet continue to be paid two thirds of their normal wage while avoiding work return, reinforcing their undesirable behavior. A patient, who magnifies his disability successfully, stands to increase his final monetary settlement. Such behavior has lead to insurance adjusters hiring nurse case managers to move cases along. Employers and employees all too often become adversaries in the process as employers see the costs mount day after day as loss work days add up, while patients feel they are being pushed back to work with very little concern for their personal well being.  Patients sometimes focus on their disability rating and cash settlement losing focus on getting well. The final financial settlement seldom reimburses an injured worker for the loss of earning capacity, independence, and self esteem that nearly always occurs in this situation.

As a result, all parties lose. Physicians must deal with patients that are often evasive and not focused on recovery, while being forced to complete volumes of paperwork documenting treatment progress. Employers feel they pay too much for employees that may never be productive again, uncertain when and if an employee will return to work. Employees often squander their best chance to get well striving for a cash settlement that is uniformly disappointing. They come out of the system alienated from their employers, and marked as a worker with a bad back that no employer will hire, all for the sake of a cash settlement that often won’t even support the patient a single year.

The bottom line? If you are unfortunate enough to have an on the job neck or back injury, realize that resources provided for your care will not last forever. Your greatest asset is your friend, the back, and your focus should be on doing anything and everything you can to get it as healthy as possible. When all is said and done, a healthy back is worth more than any settlement you will ever receive. Bad things can happen to good people, and once you have recovered as much as possible, it is time to move on, and use whatever settlement you may receive to maximize your long term earning potential. If you are an employer realize that the best predictor of a successful worker’s compensation claim is an employee’s satisfaction with his employer. Offer limited duty to facilitate your employee’s return and welcome them back into the fold. Be supportive, honest and consistent by setting expectations with your employee right from the start of an injury. Let them know that just as it was prior to their injury, if they are responsible, keep their medical appointments, show up on time, and work hard, you will support them with your resources throughout the process.  

Tips for Young Adults and Injured Workers

1)      Drive responsibly, use seatbelts, don’t drink and drive. You are not from Krypton…really!

2)      Don’t smoke…two chances in three it will kill you. If you are lucky enough to avoid death, smoking will destroy your discs…really!

3)      Work to stay fit by exercising regularly including weight training, aerobics and stretching.

4)      Stretch and warm up before performing sport or heavy lifting.

5)      If you are injured on the job, ask questions, learn your rights and responsibilities. Your best course is to use the resources available to get better. Focus on this and you will maximize your chances for recovery.

6)      If your employee is injured, support them through the process, but keep them accountable. Set expectations and demand that they are fulfilled. When they are able, welcome them back. If they like you they will continue to try to perform for you, even while ill.

In the last installment of this three part series I will discuss the aging spine. In our later years, we must work even harder to maintain ideal body weight, bone and muscle mass. This requires more attention to exercise and spine maintenance than ever before. Problems that affect the aging spine are usually caused by arthritis in various forms. Cancer, osteoporosis, and other diseases in various forms also peak in later years. Our friend the back is getting on in years, and it may ache and complain from time to time, but it will usually serve us well as long as we take the time to nurture that friendship.

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                                                    Last modified: 04/04/06