Diffuse Idiopathic Skeletal Hyperostosis

A Patient’s Guide to Diffuse Idiopathic Skeletal Hyperostosis

Introduction

Diffuse Idiopathic Skeletal Hyperostosis

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a phenomenon that more commonly affects older males. It is associated with stiffness and back pain, but often it causes no signs or symptoms.

The most common finding of Diffuse Idiopathic Skeletal Hyperostosis (DISH) is ligaments that turn into bone. It is also known as Forestier’s disease, after the name of the physician who recognized it. It is most often confirmed by x-ray.

This guide will help you understand

  • what parts of the spine are affected
  • what causes this condition
  • what does this condition feel like
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

What parts of the spine are involved?

Diffuse Idiopathic Skeletal Hyperostosis

The spine, or vertebral column, is made up of bones that stack on top of one another. These bones are called vertebrae. There are five sections of the spine. At the top is the neck, or cervical spine, which connects with the skull. Below the neck is the thoracic spine or mid-back, which has the ribs attached. The ribs form your chest. Below the thoracic spine is your lumbar spine or low back. The lumbar spine attaches to the sacrum which is part of the pelvis. The last section of the spine is the coccyx, also know as the tail bone.

There are ligaments that help stabilized the spine. The ligament along the front of the spine is called the anterior longitudinal ligament. There is another ligament that attaches to the back of the spine called the posterior longitudinal ligament. These are the spinal ligaments that can turn into bone in Diffuse Idiopathic Skeletal Hyperostosis (DISH).

Causes

What causes this problem?

Diffuse Idiopathic Skeletal Hyperostosis generally occurs in people between the ages of 50 and 60. It appears more often in men than women. While the cause is unknown, there seems to be a connection with having diabetes, high blood pressure, coronary artery disease, and being over weight.

Some researchers feel that the extra bone is made because of extra blood supply near the spine. Growth factors that effect the formation of calcium likely play a role.

DISH generally affects the ligament in front of the spine called the anterior longitudinal ligament. This is the most common ligament that turns into bone with DISH, but it can affect other ligaments as well. Another common feature of DISH is that it can cause syndesmophytes (a bony outgrowth attached to a ligament) and tendonitis at sites other than the spine. These calcification sites can lead to bone spurs in the heels, elbows, ankles, knees, and shoulders. Bone spurs and inflammation develop where the tendon attaches to the bones.

Diffuse Idiopathic Skeletal Hyperostosis

Although DISH is considered a form of osteoarthritis, it is not considered degenerative, from wear or tear. The disc heights and facet joints do not show wear and tear as with other forms of osteoarthritis.

Medications that are used to treat acne may increase your risk of having DISH. These medications are called retinoids. They are similar to vitamin A.

Symptoms

What does the condition feel like?

Stiffness and decreased range of motion are the most common symptoms of DISH. The stiffness usually happens in the morning upon waking. It also happens after a long period of rest. Often the decrease in motion in the spine is with side-bending. DISH most commonly affects the mid back, but can also affect the neck and low back. It also seems to affect the right side of the thoracic spine more often than the left side. Pain may be a symptom of DISH, but not always.

Diffuse Idiopathic Skeletal Hyperostosis

In addition to changes in the spine, DISH can also cause stiffness, pain, and inflammation in tendons throughout the body. When DISH affects areas other than the spine, it feels like tendonitis. Ligaments and tendons where they attach to the bone near the joints develop extra bone growth.

Difficulty swallowing (dysphagia), or a hoarse voice, can happen when people have DISH in the neck. The bone spurs can put pressure on your esophagus (tube connecting the throat with the stomach), making it difficult to swallow. The pressure can also cause a hoarse voice or difficulty in breathing. In rare cases, this can become serious. This may require surgery to remove the bone spurs.

Neurological problems are rare in DISH. In severe cases, the extra bone growth around the spine can cause problems with the spinal cord or nerves. Squeezing of the spinal cord can cause loss of feeling and paralysis.

Diagnosis

How do doctors diagnose the problem?

Your doctor will complete a history and physical examination. Your doctor will ask you questions about things such as activity, urination, bowel movements, weakness, and stiffness. Range of motion of the spine is usually evaluated, as well as tenderness of the spine or muscles next to the spine.

Neurological examination usually includes checking reflexes at the knees and ankles (elbows and wrists if your neck is involved), sensation, and muscle strength. Your doctor may ask you to walk on your heels and toes.

Your doctor may ask that you have x-rays of your spine, usually the mid-back. If you have signs of nerve problems, a magnetic resonance imaging (MRI) scan, or a computed tomography (CT) scan may be ordered.

The MRI allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not x-rays. It shows the soft tissues of the body. This includes the spinal cord, nerves, and discs. It can also show spinal bones.

Computed tomography (CT) is best for evaluating problems with the vertebral bones. It is usually tolerated well but exposes you to radiation.

Extra bone growth along the vertebral column can be identified with any of these imaging tests. The extra bone growth must involve three or more adjacent vertebrae to meet the criteria for DISH. The calcification along the spine has a very unique appearance. Some doctors call it cascading or flowing. It is also sometimes described as appearing like candle wax dripping and oozing down the spine.

Treatment

What treatment options are available?

Nonsurgical Treatment

While there is no cure for DISH, there are treatments that can help the symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help manage pain or tendonitis-like inflammation. Tylenol® which is also called acetaminophen may also help relieve pain. More severe pain may be treated with corticosteroid injections.

Surgery

Rarely is surgery necessary. However, if the extra bone growth compresses the spinal cord or nerve roots, surgery may be needed. Surgery is done to relieve pressure on the spinal cord or nerve roots. Surgery to take out the extra bone growth (spurs) in the neck may help with symptoms of difficulty swallowing. You should expect to be hospitalized for a brief stay. Initially you may be asked to wear a corset or brace for support.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Physical therapy may help delay the loss of motion in affected joints. Regular exercise such as walking or stretching is recommended. This helps with the stiffness and pain. Exercises help increase your range of motion in your joints. Heat may also be helpful to areas of your body affected by DISH.

After Surgery

Physical and/or occupational therapy can help you with getting in and out of bed properly, moving, walking, dressing, etc. Initially, you will not be allowed to lift more than 10 pounds. At first, using a walker may be more comfortable and safe. Gradually you will be able to return to your normal activities.

Regular exercise such as walking or stretching is recommended. This helps with the stiffness and pain. Exercises help increase your range of motion in your joints. Heat may also be helpful to areas of your body affected by DISH.

Your surgeon will want you to follow up on a regular basis. Repeat examination will include testing of the nerves and spinal cord. Imaging studies will also be repeated.

Adult Degenerative Scoliosis

A Patient’s Guide to Adult Degenerative Scoliosis

Introduction

Adult Degenerative Scoliosis

A normal healthy spine will be straight when seen from the front or the back. When seen from the side, the normal spine forms a gentle “S” curve, which is known as adult degenerative scoliosis.

Scoliosis is an abnormal or exaggerated curve of the spine from the side or from the front or back. Adult degenerative scoliosis is different from the type of scoliosis that occurs in teenagers. Adult degenerative scoliosis occurs after the spine has stopped growing and results from wear and tear of the spine. The condition most often affects the lumbar spine.

This guide will help you understand

  • what parts make up the spine
  • what causes adult degenerative scoliosis
  • how your doctor will diagnose this condition
  • what treatment options are available

Anatomy

What parts make up the spine?

The spine is made up of 24 moveable bone segments called vertebrae. The spine is divided into three distinct portions. There are seven cervical or neck vertebrae, 12 thoracic or mid-back vertebrae and five lumbar or low back vertebrae.

The spine is made up of three general parts.  The top portion is the cervical spine and connects with the skull or cranium.  The middle portion is the thoracic spine and is identified by the ribs that attach to each of the vertebrae.  The lower portion is the lumbar spine. It connects with the pelvis at the sacrum.

Adult Degenerative Scoliosis

The vertebra stack on top of one another and are separated by discs. The spine has normal curves. When looking at the spine from the side, the spinal column is not straight up and down, but forms an “S” curve. The cervical spine has an inward curve called a lordosis. The thoracic spine curves outward. This curve is called a kyphosis.  The lumbar spine usually has an inward curve or a lordosis. The “S” curve seen in the side view allows for shock-absorption and acts as a spring when the spine is loaded with weight.  This “S” curve maintains balance of the spine in a forward and backward plane.

The spinal cord travels within a canal made by the vertebra.  Branching off of the spinal cord are nerve roots. These nerves then supply arm, trunk, and leg muscles for movement. They also supply muscles of organs such as the bladder.

Adult Degenerative Scoliosis

Discs are fluid-filled cushions between the vertebrae. Facet joints are small joints in the back that allow movement.  Facet joints are lined with cartilage. The cartilage is a covering of the joint surface that gives some cushion and protects the bone. It is also slippery which helps with motion.

Related Document: A Patient’s Guide to Cervical Spine Anatomy

Related Document: A Patient’s Guide to Thoracic Spine Anatomy

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Causes

What causes adult degenerative scoliosis?

Adult degenerative scoliosis can be a result of scoliosis from childhood. The curvature may increase during adulthood and become painful. Scoliosis that happens in childhood is usually idiopathic, meaning there is no known reason for it.

Any part of the spine can be affected by scoliosis including the cervical, thoracic, or lumbar vertebrae. Most often the lumbar spine is affected. The vertebrae curve to one side and may rotate, which makes the waist, hips, or shoulders appear uneven.

Adult Degenerative Scoliosis

The most common cause of adult degenerative scoliosis is from degeneration, known as wear and tear. It usually occurs after the age of 40. In older women, it is often related to osteoporosis. Osteoporosis is the loss of calcium in the supporting bone. This makes the vertebrae weak.

In adult degenerative scoliosis, the spine loses its structural stability and  becomes unbalanced. This imbalance of the spine causes changes in the way the forces of the spine are directed. The larger the scoliotic curve becomes, the faster these changes cause degeneration of the spine. This creates a vicious cycle where increasing deformity causes more imbalance, that in turn causes more deformity. While this process occurs very slowly, it usually continues to slowly progress until something is done to restore the balance in the spine.

When there is an “S” curve when viewing the spine from the front, the condition is called scoliosis. The scoliotic deformity may also affect the normal “S” curve that the spine has when vised from the side. These curves are normal and required to maintain the proper balance of the spine. Many patients with scoliosis actually lose the normal curves of the spine.

Our body has a natural tendency to try to maintain a balance where the head is straight above the middle of the pelvis. If one leg is longer that the other, and the pelvis tilts, the spine will curve in the opposite direction to place the head above the center of the pelvis. If there is a curve in a portion of the spine, then the remainder of the spine will bend in the opposite direction to try and keep the head above the middle of the pelvis.

The scoliotic curve has a convex and concave side. The convex side is simply the outside of the curve where concave is the inside of the curve. The spine above and below the curve will tend to bend in the opposite direction in an attempt to balance the spine. Remember, the body will always try to place the head immediately above the middle of the pelvis. The concave side will tend to have more compression of the facet joints and possibly the nerve roots. This can lead to more pain from arthritis on the concave side of the curve and may lead to pain, weakness and numbness into the legs from the compressed nerve roots. These nerve changes are called radiculopathy.

Adult Degenerative Scoliosis

In adult degenerative scoliosis, there is gradual narrowing of the discs that cushion between the vertebrae.  The cartilage and joint surfaces of the facet joints in the spine can wear out, causing arthritis. This can cause back pain.

Adult Degenerative Scoliosis

Stenosis is a term meaning narrowing. There are times when the canal for the spinal cord is narrowed. The openings for the nerve roots may also be narrowed.  This will usually cause compression of the nerve structures.  When the spinal cord or spinal nerves are compressed, pain, changes in feeling and/or motor function of the muscles can happen.

Adult Degenerative Scoliosis

Sometimes spondylolisthesis occurs. This is slippage of one vertebra on the other. This can happen in adult degenerative scoliosis when the vertebrae do not stack on top of one another like they are supposed to.  One vertebra may be shifted sideways, not lining up as it should. The slippage is graded from I to IV, one being mild, IV often causing neurological symptoms.

In rare and severe cases, the chest may become deformed because of scoliosis. This may affect the lungs and heart. This can lead to breathing problems, fatigue, and even heart failure.

Degenerative scoliosis is more common the older we get. As our population ages, adult scoliosis will be even more common. It will be an increasing source of deformity, pain, and disability.

Related Document: A Patient’s Guide to Scoliosis

Symptoms

What does adult degenerative scoliosis feel like?

Most people who have scoliosis will notice the deformity it can cause. There is usually a hump (rib hump) in the back. One shoulder and/or side of the pelvis may be lower than the other. You may have noticed that you have shrunk in height. You may not be able to stand up straight. For many, there is no significant pain caused by the scoliosis. Other symptoms may include:

  • Decreased range of motion or stiffness in the back
  • Pain involving the spine
  • Stiffness and pain after prolonged sitting or standing
  • Pain when lifting and carrying
  • Pain may travel to areas away from the spine itself.  It may cause pain in the buttocks or legs
  • Spasm of the nearby muscles
  • Difficulty walking
  • Difficulty breathing

Diagnosis

How will my doctor know if I have adult degenerative scoliosis?

Your doctor will ask you several questions about your pain, function, what makes your pain better and worse, when it started, bowel or bladder function, motor function, and whether you have had previous surgery.

Your doctor will perform a physical examination that will include observation of your posture in standing position both sideways and from the front and back to assess for scoliosis. Mobility of your spine and hips, as well as walking ability will be evaluated.

A neurological exam that includes testing reflexes with a small rubber hammer, and testing of sensation will likely be included.

Adult Degenerative Scoliosis

Your doctor will want to start with x-rays to measure the degree of the scoliosis. X-rays provide pictures of the alignment of the vertebra. Using a device to measure angles held up to the x-ray image, the degree of curvature of the spine can be measured. These measurements are referred to as the Cobb angles. Diagnosis of scoliosis is made when a curve measures greater than 10 degrees. X-rays can also give your doctor information about how much degeneration has occurred in the spine. They show the amount of space between the vertebrae. They can also show the degree of fusion of the spine following surgery.

If you are having pain into your leg(s), or difficulty with bowel or bladder function, your doctor will likely order a magnetic resonance imaging (MRI) scan. The MRI scan provides a better image of the soft tissues such as discs, nerves, and the spinal cord. The MRI machine uses magnetic waves rather than x-rays to show the soft tissues of the spine. The pictures show slices of the area imaged. The test does not require a needle or dye.

A computed tomography (CT) scan may be ordered. It is best for evaluating problems with the vertebral bones.  It is a form of x-ray.  Sometimes, it may require dye into the spinal canal fluid so that the spinal cord and nerve root anatomy is identified better. When dye is injected for this purpose, the technique is called a myelogram.

SPECT stands for Single Photon Emission Computed Tomography. It is a nuclear scan because it uses a radioactive tracer, Technetium. Technetium is injected into your vein. Where there is increase in metabolic activity, such as in the case with inflammation (arthritis), fracture, infection, or tumor the Technetium will be more concentrated.

Electromyogram (EMG) and/or or nerve conduction velocity (NCV) tests are performed by the placement of small needles in extremities where there is concern about change in motor function, or sensation.  By using low-level electrical current, the device measures whether or not a motor nerve is being compressed. It can also help determine the source of changes in sensation. The EMG tests the muscles to see whether they are working properly. If they aren’t, it may be because the nerve is not working well. The NCV test measures the speed of the impulses traveling along the nerve. Impulses are slowed when the nerve is compressed or constricted.

Treatment

What treatment options are available?

Most of the time treatment of adult degenerative scoliosis is conservative care, meaning non-surgical. Rarely is surgery necessary. Treatment decisions for adult degenerative scoliosis are based on how much pain you are experiencing, how much the condition is affecting your ability to function and whether or not you are having symptoms of nerve compression.

Nonsurgical Treatment

Whenever possible, doctors prefer treatment other than surgery. The first goal of nonsurgical treatment is to ease pain and other symptoms so the patient can resume and maintain normal activities as soon as possible.

Your doctor may prescribe treatment from a physical therapist. Much of the pain from adult degenerative scoliosis is the result of muscle spasm. This spams occurs when the normal muscles must work harder than normal try to restore the balance to the spine. The muscles become fatigued and begin to spasm. This causes pain.

The physical therapist can help you with positions and exercises to ease these symptoms. The therapist can design an exercise program to improve flexibility of tight muscles, to strengthen the back and abdominal muscles, and to help you move safely and with less pain.

You may also be prescribed medication to help you gain better control of your symptoms so you can resume normal activity swiftly. Over-the-counter anti-inflammatory medications such as Ibuprofen or Aleve may be helpful. There are also many prescription anti-inflammatories available. Narcotic medication may be considered to make you more comfortable.

Bracing may provide some help especially when the scoliosis is painful or unstable. Braces that are made to fit may be more comfortable and effective but they are more expensive than off-the-shelf braces or supports. There are also unloading braces to help relieve pressure on the discs, nerves and joints of the spine.

If symptoms continue to limit your ability to function normally, your doctor may suggest an injection into the spine to help with pain. Your doctor may recommend facet injections into the joints of the spine. A procedure called radiofrequency ablation may provide more lasting benefit. Epidural or transforaminal injections into the spine can also be helpful. A series of injections may be more helpful to provide temporary decrease in pain.

If you have osteoporosis, discuss with your doctor how you can optimize your treatment for this condition to slow the progression of osteoporosis. Adequately treating the osteoporosis can help reduce the progression of the scoliosis.

Related Document: A Patient’s Guide to Epidural Steroid Injections

Related Document: A Patient’s Guide to Facet Joint Injections

Related Document: A Patient’s Guide to Radiofrequency Ablation

Surgery

Surgery is usually considered when non-surgical treatments have not provided enough relief from pain – or when the nerves of the spine are being damaged. Surgery is more common when the curvature is continuing to increase and the imbalance of the spine is clearly getting worse. Surgery to correct adult degenerative scoliosis is both complex and difficult. Most surgeons would not suggest surgical intervention except as a last resort when all conservative measures have failed and the pain is intolerable.

Adult degenerative scoliosis is a disease of older people. As a result, the overall health of the individual is important when making decisions about whether or not to consider surgery. Other illnesses, such as heart disease, lung disease or diabetes, may increase the risk of medical complications either during or after the operation and make surgery too risky.

Surgeons must consider the quality of the bone of the spine as well. Older individuals are more likely to have some degree of osteoporosis. This makes the bone weaker. Weaker bone may not be able to hold the instrumentation, the rods and screws necessary to correct the spine. If the bone weakened by osteoporosis cannot hold the screws necessary to hold the spine aligned as it fuses, this can lead to failure of the entire operation.

The goal of surgery is to improve the balance of the spine and remove pressure on any of the nerves of the spine. Surgery to relieve pressure on the nerves is called a decompression. Surgery to reinforce the area that is unstable is called a fusion. To accomplish the goals of the surgery requires several steps.

First, the surgeon must be able to adequately see the area of spine to be corrected. This is called the exposure. The surgery usually requires an incision in the back. In some cases, surgery will also need to be performed on the front of the spine. This may require an incision in the abdomen or from the side of the body to allow the surgeon to reach the front of the spine. Sometimes a combination of both is necessary.

Next, the surgeon must perform a decompression so that all nerves are free of any pressure. This is accomplished by removing any bone spurs or disc material that is causing pressure on the spinal nerves.

The surgeon must then mobilize the spine. Usually after the  decompression is finished, the spine is mobilized a great deal. Removing bone spurs and disc material also loosens the contracted scar tissue around the spine and allows the surgeon to straighten the spine back toward normal.

Finally, the surgeon must insert the screws and rods that will hold the spine in the new position while the fusion occurs. Two special screws called pedicle screws are inserted into each vertebra. These special screws are then attached to metal rods that hold the vertebrae in alignment.

Bone graft is placed between each vertebra. This bone graft will form a solid bone bridge between each vertebra and allow the spine to grow together – or fuse. The combination of the pedicle screws and the metal rods is called the instrumentation. This instrumentation forms the strut that will hold the spine in the correct alignment until the spine fuses.

Once the spine has fused, it will remain in the balanced position. The instrumentation is no longer really necessary, as the fused bone of the spine is now what is keeping the spine from collapsing again. The instrumentation is rarely removed and only removed when it is causing a problem. Restoring balance to the spine should decrease pain and reduce the risk of future problems.

Related Document: A Patient’s Guide to Posterior Lumbar Fusion

Rehabilitation

What can I expect during recovery and treatment?

Nonsurgical Rehabilitation

Physical therapy is important for strengthening muscles of the spine, abdomen, hip girdle, and legs.  Stretching of certain muscles may also be recommended. Stretching or traction applied to the sides of the curve is sometimes used by physical therapists and chiropractors. Exercises must be done on a regular, ongoing basis. It may be possible to improve posture and motion.

Your physical therapist may be instructed by your physician to place a battery operated electrical device (TENS unit) over the area of pain. This reduces painful input to the brain from your back.

Traction devices may be tried by your physical therapist or chiropractor. These are often available for home use.

Muscle stimulators are battery-powered electrical devices that cause muscle contraction.  The electrodes or patches are placed over a muscle such as along the spine. There are wires that then attach the electrodes to the device. The current is given for a limited period of time, controlled by a timer. This can help train the muscles to contract on their own.

Activity modification such as limited lifting or avoidance of prolonged sitting or standing may be helpful. Occasional use of a cane or walker to improve walking tolerance may be recommended.

Use of ice or heat may prove beneficial.  Your doctor or physical therapist can provide you with guidelines.

Your physical therapist may advise you to participate in weight bearing exercises to help strengthen your bones and muscles. These may include activities such as walking, toning with the use of weights or other resistance, and tai chi.

After Surgery

If surgery was necessary for your adult scoliosis you will likely be hospitalized for several days following surgery.  Some patients prefer to extend their stay in a transitional care unit in the hospital, or even a skilled nursing facility (nursing home).

Your surgeon may suggest a brace following surgery, to ensure that you do not bend too far and to support your spine.

You will be allowed to get in and out of bed and walk shortly after surgery.  Lifting is usually limited during the initial recovery period. You will gradually be allowed to resume your usual activities after several weeks or months.

It may be recommended that you have physical and occupational therapy after your surgery to help you regain strength and independence with daily activity. They also will help you with activity modification. They can recommend  equipment for use in your home that may be helpful.

Your surgeon will want to see you periodically to monitor your progress.  Repeat imaging with X-ray, MRI or CT scan is usually done to follow the progress of your spine as it heals.

Spinal Tumors

A Patient’s Guide to Spinal Tumors

Introduction

Spinal Tumors

A tumor is an abnormal growth of tissue. There are several types of tumors that can develop in or near the spine. There are many types of spinal tumors. They can involve the spinal cord, nerve roots, and/or the vertebrae (bones of the spine) and pelvis.

There are two classifications of spine tumors. A spinal tumor can be primary, meaning it comes from cells within or near the spine. Primary tumors of the spine are rare. More commonly a spinal tumor that is found is a secondary spinal tumor. This means that the tumor traveled there from somewhere else in the body.

Tumors can be benign (non-cancerous) or malignant (cancerous).

This guide will give you a general overview of spinal tumors and help you understand

  • what parts of the spine are involved
  • what causes spinal tumors
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

What parts of the spine are involved?

Spinal Tumors

The cervical spine is formed by the first seven vertebrae. The cervical spine starts at the bottom edge of the skull. It ends where it joins the top of the thoracic spine. The thoracic spine is where the chest begins and is made up of twelve vertebrae. This region is different than the other areas of the spine because it has ribs attached to the vertebrae. It ends where it joins with the lumbar spine. The lumbar spine is made up of five vertebrae in the lower back. It joins with the sacrum or pelvis at the bottom.

Spinal Tumors

Each vertebra is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body. When they are stacked on top of one another, the rings form a hollow tube called a neural arch. This forms a canal where the spinal cord is located. The spinal cord is protected by the bone. The spinal cord begins at the base of the brain, just below the medulla or brain stem. It ends in the lumbar spine at about the first or second lumbar vertebrae where it is called the conus medullaris. Here it splits into many fibers.

Spinal Tumors

This is called the cauda equina because it looks like a horse’s tail.

The spinal cord is a tube of nerve cells that is hollow in the middle. It carries sensory and motor messages to and from the body and the brain. It is surrounded by layers of tissue and fluid called the cerebral spinal fluid. It is housed in the vertebral or spinal column which is made up of 24 bones, called vertebrae. Vertebrae are stacked on top on one another to form the spinal column. The spinal column is the body’s main upright support.

Spinal Tumors

There are three layers of tissue that surround the spinal cord. The thin, delicate lining of the spinal cord is the pia mater. The next layer is the arachnoid membrane. It was named that because it looks like a spider web. The outermost layer that is thicker and tougher is called the dura mater. These layers are continuous with the layers covering the brain. These layers may give rise to tumors that can spread to the spinal cord.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Causes

What causes this problem?

A primary spinal tumor means it comes from cells within or near the spine. They can involve the spinal cord, nerve roots, and/or the vertebrae (bones of the spine) and pelvis.They can be benign (non-cancerous) or malignant (cancerous). In general, benign tumors do not invade other tissues. Malignant tumors may invade other tissues and organs in the body. Although primary spinal tumors often contain a number of abnormal genes their cause remains unknown. In some cases the tumors run in families.

Tumors in the spine become a problem when they compress the spinal cord or nerves. This can lead to serious complications such as paralysis and loss of bladder and bowel control. Others can destroy the vertebral bone that supports the spinal cord making it unstable.

Nerve roots on either side of each spinal segment are made up of bundles of motor and sensory nerves that come from the spinal cord. Nerves are covered by protective cells called Scwhann cells. A form of spinal tumor involving the Schwann cells is called a Schwannoma.

A secondary spinal tumor is more common. This means that the tumor traveled there from cancer somewhere else in the body. These secondary or metastasized tumors are always cancerous. These cancer cells travel and cause tumors that usually involve the vertebrae or bony portion of the spine. They may come from melanoma (skin cancer), cancer in the lung, breast, prostate, kidney, or thyroid gland for example.

Symptoms

What does a spinal tumor feel like?

Sometimes the tumors are found before they cause any symptoms. The symptoms will vary depending on where the tumor is located and what tissues are involved.

At times, pain, bowel or bladder problems, sexual dysfunction, change in sensation, or muscle weakness of the arms or legs may alert you to the problem. This often means that the tumor is compressing the spinal cord or nerve root. Tumors that originate in the spinal cord itself may not cause pain. Pain that awakens you in the night or development of scoliosis (abnormal spine curve) may be a sign that the bone of the vertebra is being destroyed by a spinal tumor.

Symptoms may have a gradual or rapid onset. Symptoms usually worsen without treatment.

Diagnosis

How will my doctor diagnose the problem?

Diagnosis begins with a thorough history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about pain, feelings of numbness or weakness, change in bowel or bladder function, and whether you have noticed any changes in the way you walk. Your doctor will want to know if have been diagnosed with any type of cancer in the past.

During the physical exam, sensation of the skin, muscle strength, and reflexes are tested. Your doctor may ask you to walk to see if there are any changes in your walking pattern.

In addition to having lab work done, there are several procedures that can help your doctor diagnose a spinal tumor.

Magnetic resonance imaging (MRI) allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not X-rays to show the soft tissues of the body. This includes the spinal cord and nerves. The test may require the use of dye that is given intravenously.

Computed tomography (CT) scan may be ordered when an MRI is unavailable. Dye will be introduced into the spinal canal fluid so that the spinal cord and nerve root anatomy are identified better. When dye is injected for this purpose, the technique is called a myelogram.

X-rays of the spine may be ordered when there is the likelihood of metastasized tumor from cancer elsewhere. It can show only changes in the bones. Many primary spinal tumors do not affect the bone when they are in the early stage.

Bone scans can be used to detect fracture, bone infection, or cancer. A radioactive tracer, technetium (Tc), is injected into your vein. Where there is an increase in metabolic activity, such as is the case with cancer, the Tc will be more concentrated. Spinal tumors may be malignant, or metastasized from cancer somewhere else in the body. It is helpful to use a scan to see if there are other areas in the body where the cancer may be.

A biopsy helps determine the type of the tumor. A biopsy may require surgery. Sometimes it can be performed using a needle while using CT for guidance. A piece of the tumor is removed and looked at under a microscope.

Types of Spinal Tumors

Malignant Spinal Tumors

Osteosarcoma occurs most often in children, adolescents, and young adults. Males are more likely to be affected than females. Treatment usually consists of removal of the tumor when possible as well as chemotherapy. Radiation therapy is not effective. Older persons with Paget’s disease or who have had radiation therapy may develop this type of tumor.

Spinal Tumors

Ewing’s Sarcoma occurs in the bone of the spine or surrounding tissues. It usually affects adolescents and those in early adulthood. When it involves the spine, it may cause paralysis and loss of bladder or bowel function (incontinence), numbness or tingling. Removing the tumor is preferred if possible, in combination with chemotherapy and sometimes radiation. If the tumor has traveled to the bone marrow, stem cell transplant is a more aggressive form of treatment.

Chondrosarcoma usually occurs in adults and is most common in flat bones such as the pelvis. They usually are noticed because they cause pain and swelling. Surgery is performed to remove the tumor and any tumors that have spread, usually to the lung. In most cases, chemotherapy is not effective.

Astrocytomas are tumors that involve nerve cells within the spinal cord and brain. They most commonly occur in children and adolescents. Neurological symptoms such as weakness and/or sensory changes may be the cause for seeking treatment. They tend to spread throughout the spinal cord and brain. Astrocytomas in the spine can usually be removed surgically. However, they are difficult to completely remove. Radiation therapy may be necessary following surgery to slow the spread of the tumor.

Spinal Tumors

Cancer in the bone marrow is called multiple myeloma. Bone tissue is destroyed by excessive growth of plasma cells in the bone marrow. When X-rayed it appears that holes have been taken out of the bone. These are called osteolytic lesions. Plasma cells are part of the immune system and in multiple myeloma they grow uncontrolled forming tumors in the bone marrow. Any part of the skeletal system (bones) can be affected including the spine. For multiple myeloma, treatment may include chemotherapy and other medications, radiation, and stem cell transplantation.

Benign Spinal Tumors

Spinal Tumors

Osteoid osteoma is the most common of the benign tumors involving the bone of the spine. It is usually found during adolescence. It may be discovered because of scoliosis or curvature of the spine. It may cause pain that does not ease up, and is worse at night. Anti-inflammatory medications are used for treatment. Sometimes removal of the tumor by surgery is necessary. A newer, less invasive treatment is called radio-frequency ablation. These tumors rarely recur (come back).

Related Document: A Patient’s Guide to Radiofrequency Ablation

Spinal Tumors

Osteoblastomas are larger versions of osteoid osteomas. They tend to be found in people under the age of 30. They may cause scoliosis or curvature of the spine. Osteoblastomas tend to be more aggressive and require surgery to remove the tumor. There is a 10% chance that the tumor may recur.

Giant cell tumors are very rare and tend to affect the vertebral body of a spinal segment. They can be aggressive and sometimes spread to other parts of the body, usually the lung. Treatment involves surgery to remove the tumor. Also, radiation therapy may be used.

Enchondromas are tumors involving cartilage. They may grow into the spinal canal or press on the spinal nerve roots. When they cause paralysis, bowel or bladder incontinence, or other neurological symptoms they are surgically removed. They rarely can become chondrosarcomas, which are malignant tumors that can spread to other parts of the body.

Hemangiomas are tumors involving blood vessels that affect the vertebral body of a spinal segment. They are most commonly found in the thoracic or lumbar portion of the spine. They occur more frequently during mid-life. They are found more often in women than men. They can be a source of pain but often do not cause pain. They may be large enough to cause collapse of the vertebral body which could affect the spinal cord or nerve roots.

Meningioma is the most common spinal cord tumor. They tend to occur in older adults and are more common in women. They are usually treated with surgical removal. Rarely, meningiomas recur or spread to other parts of the body.

Ependymoma is a tumor involving the cells lining the canal in the center of the spinal cord. These tumors have the greatest chance for surgical cure.

Schwannoma is a tumor that involves the covering or sheath of peripheral nerve fibers. It may cause weakness, paralysis or sensory changes such as numbness. It can be removed surgically.

Chordomas are tumors that are typically found at the lower end of the spine. Because they can aggressively grow, they can cause compression of the spinal cord or nerve roots causing neurological problems. Treatment involves surgery to remove the tumor. Unfortunately they come back, but do not spread to other areas of the body.

Plasmacytoma is a single tumor involving the bone of a spinal segment. It can have characteristic punched out holes in the bone on X-ray. It can cause a compression fracture of the vertebral body. This can cause neurological symptoms. Spinal surgery to decrease pain and improve function may be necessary. Plasmacytoma is felt to be an isolated form of multiple myeloma, which will then develop lesions in other bones in the body. Multiple myeloma is a malignant process and is the most common primary bone cancer.

Treatment

What treatment options are available?

The type of treatment will depend on symptoms, general health, the results of imaging studies, and a biopsy if done. Many times a combination of surgical and non-surgical treatments are required. If your treatment involves radiation or chemotherapy, you will be asked to see an oncologist (a doctor that specializes in cancer).

Early diagnosis and treatment of a spinal tumor is important. If undiagnosed, the damage caused by the tumor can become permanent.

Nonsurgical Treatment

Sometimes watching the tumor for growth is all that is necessary if significant symptoms are not present. The tumor is monitored with repeat imaging such as MRI. Not all spinal tumors can be removed by surgery due to their location.

A back brace or corset may help to stabilize the spine. This should also reduce pain. It may need to be custom made to fit you.

Medications such as corticosteroids may be prescribed. They are used to decrease the swelling in the spinal cord that can cause compression. They may be taken temporarily or long-term to relieve symptoms. Analgesics such as narcotics may also be used. Medications that diminish the blood supply to the tumor have shown some success. Bisphosphonates are medications more commonly used for osteoporosis. They may be used to treat tumors that can destroy bone in the spine.

Embolization is a term used when the blood supply to a tumor is interrupted. This is done by burning the blood vessel(s). Several types of spinal tumors are treated using this method.

Spinal Tumors

Chemotherapy is used if the primary tumor is a malignant or cancerous tumor. Chemotherapy is also recommended when the tumor is a secondary tumor that has traveled from another area in the body and invaded spinal tissue.

Radiation therapy may also be used to treat tumors that cannot be removed by surgery.

Stem cell transplant may be used for aggressive cancers such as Ewing’s sarcoma.

Surgery

Spinal Tumors

Surgery may be the only treatment for a primary spinal tumor that is non-cancerous. As much of the tumor is removed as possible without causing neurological problems. A decompression refers to removing bone around the spinal cord or spinal nerves in order to take pressure off these structures. Neurological damage during surgery has been improved with the use of newer techniques. These techniques include ultrasonic aspirators, and microsurgery. Ultrasonic aspirators use sound waves to destroy the tumor. It also sucks up the pieces of tumor. Microsurgery uses a microscope for a better view of the operation site. This helps to minimize any damage to surrounding healthy tissue.

If the spine needs to be stabilized or fused as a result of removing a tumor in bone, metal hardware may be required. Metal plates, cages, rods, or screws may be used. The bone may be additionally supported by bone graft or bone cement.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Your doctor will require you to have periodic follow-up. New lab tests and imaging studies may be required. You may need pain management on a regular basis.

Physical therapy can help with balance, strength, walking, and coordination. Occupational therapy helps with activities of daily living such as dressing, bathing and assistance with mobility. You may need instruction in the use of a brace. Instruction in proper ways to lift and move may be necessary.

After Surgery

The amount of time you will be hospitalized depends on the type of surgery required.

After surgery, activity such as sitting and walking will be allowed as well as activities that do not require stretching of the spine or straining. Lifting is limited during the initial recovery period. You may be required to use a brace or corset after surgery to help with stability.

Radiation is often used following surgery to kill remaining tumor cells. It usually begins one to two weeks following surgery. Radiation lasts only 15-20 minutes per day for two to six weeks.

You can expect recovery and improvement in symptoms between two weeks and several months following surgery. You may need pain management during your recovery, or possibly on a more long-term basis.

Physical and occupational therapy may be beneficial to help restore any lost strength, coordination, or other skills.

Your surgeon will require you to have periodic follow-up. New lab tests and imaging studies may be required. Sometimes the tumor will grow back and need to be removed again.

Nutrition and Your Spine

A Patient’s Guide to Nutrition and Your Spine

Introduction

Nutrition and Your Spine

You are what you eat. Is that simply a funny saying or is there some truth to that old adage? The spine is not something that usually comes to mind when one thinks about nutrition – but it should. Nutrition is important in having a healthy spine. Good nutrition also helps control pain and disability when we are suffering from many different types of spine conditions.

This guide will help you understand

  • what is nutrition
  • how nutrition affects the spine
  • how nutrition affects injury, inflammation, and pain
  • how to use good nutrition to get ready for and recover from spine surgery

How you eat and exercise (or don’t exercise) will make you more or less likely to have problems with your bones, joints, and connective tissue. This guide will help you learn how to use nutrition for healing after an injury. We will describe how you can make simple changes to your diet and other lifestyle habits. These changes can be helpful if you have a painful spine condition. You will learn how to tell if you have given the changes enough time to work for you. You’ll learn to know if it’s time to move on to other health care solutions for your problem.

Nutrition

What is nutrition?

Nutrients are the chemical elements that make up a food. Nutrients are the basics of what you eat that give your body what you need for “running the show”, that is, for metabolism. Certain nutrients such as carbohydrates, fats, and proteins provide energy. Other substances such as water, electrolytes, minerals, and vitamins are needed for metabolic processes.

Nutrition is all of the internal chemical changes that happen as a result of what we eat (or do not eat) each day. Good nutrition means that what we are swallowing is something that adds to our health. Once we have digested it, food has an important job to do in our body.

Good nutrition is needed for tissue growth and repair. We get good nutrition by eating foods and taking supplements that contain all the proper and necessary ingredients. We also get good nutrition by being able to completely digest the things we swallow. Then we must be able to absorb the nutrients into the blood and other body fluids. With the right nutrients given to the cells, metabolism, or the work of the body, can occur in the most efficient and healthy way.

By the definition above, we know that a lot of what we eat is not nutritional. When we eat a purple pill or swallow a blue-colored sports drink, what we are taking in has no job to do in our body. That purple or green coloring is not a chemical your body has any use for.
The same is true for things like the preservatives added to your cereal. These chemicals are put in so that the cereal doesn’t get moldy in the box. The same thing is true for traces of hormones and antibiotics left in our meat and dairy foods. When you eat French fries from a fast-food restaurant, the oil they have been cooked in has changed into a type of fat that can’t be used by your body. In fact, it has become something called a trans-fat. Trans-fats damage the walls of your body’s cells. This will make more work for your body.

Metabolism

What is metabolism?

Metabolism refers to all of the physical and chemical changes that are taking place in your body every moment. Making energy in the body is part of metabolism. All the physical work that occurs inside your cells is part of this process, too. It includes all the work and chemical changes that happen every day in your bones, connective tissues, body fluids, and organs.

Metabolism refers to the work of changing the chemical energy in nutrients into mechanical energy or heat in your cells.

Metabolism involves two basic processes. There is anabolism (building up) and catabolism (disintegration or breaking down). During anabolism the body works to change simple chemicals from what you have eaten into complex parts, like blood, bone, or connective tissue. During catabolism, complex parts are broken into simpler pieces. One catabolic process is the breaking down of an apple you have chewed and swallowed. It is broken down into water, fiber, vitamins, and minerals. The end of catabolism is usually something being passed out of the body. We are healthy when both anabolism and catabolism are in proper balance.

Our bodies have very good ways to know when food we eat is not useful and to get rid of it. But it takes up a lot of good nutrients to sort out what’s good and what’s not. Getting rid of damaging things you eat uses up energy in the cells, too.

Nutraceuticals

If you have aches and pains, if your joints are inflamed, or if you are overweight, your diet may not have enough good nutrition to get all the necessary work done. That is why nutraceuticals have become so important.

Nutraceutical is a new word, invented by Dr. Stephen DeFelice in 1989. It is a combination of the words nutritional and pharmaceutical. Nutraceuticals are dietary supplements that are sometimes also called functional foods. Many people take nutraceuticals to offset an inadequate or unhealthy diet.

Even with a good diet of fruits and vegetables, whole grains, and the right amount and kind of protein, the standard American diet usually does not have enough nutrition for all the work your body needs to get done. We grow our fruits and vegetables with lots of fertilizers. Chemicals from the fertilizers remain on it when it’s part of your meal. The same is true for pesticides and herbicides sprayed on the plants before harvest.

We harvest fruits and vegetables when they are not quite ripe. Then they are trucked thousands of miles to our stores. Food that is not quite ripe when picked means it doesn’t have its full nutritional value. Food harvested too early will not bruise as easily when it is loaded on and off trucks. It will look good when you buy it, but it won’t have all the nutrition you need to get from eating it.

Proper Balance

We face challenges our grandparents never knew. There are extra chemicals in our food and water. Our food supply just is not as nutrient-rich as we need it to be. A proper balance between protein and high fiber, starchy foods is important for good nutritional health.

It is important to understand that nutrients always work together. Nutraceuticals can help when you aren’t able to eat a perfectly balanced diet. The same is true when you can’t eat everything organic. Supplemental vitamins, minerals, amino acids, and fatty acids are the way to help yourself meet all the needs of your body. This includes growth and repair after injury. It’s also true for the metabolic work needed to feel good, be strong, and live well.

Healthy fats are needed to grow and repair normal connective tissue, bones, and body fluids. The fiber and carbohydrates in whole grains and fresh produce are what your body is designed to thrive on. The fats found in olive oil, deep ocean fish (like salmon and sardines), and nuts and seeds are all part of good nutrition.

Organically raised beef, poultry, and wild ocean fish give the best protein. When you can’t eat organically raised meats, you can decrease your exposure to damaging chemical residues. You can do this by removing all visible fat from the meat before you cook it.

Specific problems can be related to not enough (or too much) of a single vitamin or mineral. But the proper function of the human body requires the right amounts of ALL the nutrients. You can think of it like a recipe. Your soup will taste good when all the ingredients are there in the right balance. Having too much of some of the spices, or not enough salt, will make a pot of otherwise really good food taste terrible. The same is true for the nutrient “soup” in your body. You need to have the right amounts in the correct proportions to have all your body systems work at their best. Every vitamin, mineral, amino acid, and fatty acid has hundreds of jobs to do. None of these nutrients can work well if it is not in the right relationship with all of the other nutrients.

Nutrition and the Spine

How does nutrition affect the spine?

Nutrition will determine how strong your teeth, bones, and connective tissue are. We begin to build our skeleton and connective tissue before we are born. Our diet in childhood has a major effect on how strong we are as adults. What you eat during your whole life will decide how able you are to repair bones, cartilage, ligaments, tendons, and muscles.

Everyone has to replace body tissues due to normal every day wear and tear. Some of us also have repair work to do after injuries or surgery. The raw material for repair comes from our diet. Vitamin C, all of the B vitamins, vitamin D, vitamin K and the minerals calcium, magnesium, copper, zinc, boron and manganese are especially important for bone and connective tissue health. Drinking enough water is also essential.

Your spine is your backbone. The bony pieces of the spine are called vertebrae. There are 33 of these bones. Between each vertebra is a disc made of tough cartilage with a fluid center. These discs provide the cushion that allows your backbone to bend and twist. Discs also act like shock absorbers as we walk, run, and jump. Each vertebral segment consists of bone next to bone with a cartilage cushion between. They are tied together with connective tissue, ligaments, and tendons.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Degenerative disc disease is an example of damage to connective tissue that is affected by nutrition. Everyone is going to have a certain amount of damage to the spine. This occurs throughout a lifetime. The discs can flatten, and protrude from between the bones. In time, most people will have small tears in the outer layers of these discs. You are more likely to have injuries if you have poor nutrition. And you’re less likely to have good healing.

Poor nutrition means not getting enough vitamins C, A, B6 and E, as well as the minerals zinc and copper. Daily wear and tear plus injuries from work, sports, or accidents can damage your spinal discs. Good nutrition and adequate hydration (getting enough fluids) play a vital role in your body’s ability to repair the damage and recover from the inflammation that causes the pain of back injury.

Connective tissue, like the cartilage between your joints and the ligaments and tendons that hold them together is made mostly of collagen. Collagen is a type of protein and water. Strong collagen fibers require a steady supply of dietary protein. They also need vitamin C along with vitamins A, B6, and E, and the minerals zinc and copper.

Building Bone with Good Nutrition

Joints are made and maintained, repaired, and protected with proper nutrition. Bone is made of minerals like calcium, phosphorus, magnesium, and boron. Bones also contain water and collagen. The upkeep and repair of bone and connective tissue requires the right amounts of vitamins and other nutrients working together.

Another diet and nutrition-related bone disease is called osteoporosis. Osteoporosis means the bones are weakened, brittle, and can break easily. Lifestyle and nutritional factors can lead to the bone loss of osteoporosis. This includes what you eat during bone-building stages in childhood and adolescence. Nutrition throughout the adult years is also important to maintain good bone density. Calcium intake is a major factor for building bone density. You will find yourself with weakened bones if you do not get enough calcium. The same is true if you do not absorb or properly metabolize the calcium you do eat. You can also lose too much calcium through the urine because of dietary choices. Other conditions like chronic mental or emotional stress that cause inflammation of the digestive tract can prevent calcium absorption. A lack of proper acidity in the digestive tract can also make calcium pass through unabsorbed.

Vitamin D is essential for maintaining and regulating the health of bones and teeth along with many other functions in the body. It is a compound that is more of a hormone than a nutrient or vitamin and thus has an important role in regulating immune function and cell growth.

Vitamin D is needed to absorb calcium from the gut. It prevents bone loss and helps rebuild new bone. Vitamin D is needed for the enzymes that strengthen collagen. Collagen is a major component of bone and connective tissue. Vitamin D has also been shown to aid in nerve and muscle (neuromuscular) function.

How can you get enough vitamin D to ensure good body and bone health? Sunlight will produce vitamin D in your skin. Exposure of the skin to sunlight for five to 30 minutes between 10 am and 3 pm (in most geographical locations) twice a week is usually enough to make your own Vitamin D. As you get older, your capacity to produce vitamin D from sunshine slows down.

Diet may aid you but not with natural foods. Except for cod liver oil and some types of fish (salmon, tuna, mackerel, sardines), vitamin D is not found in what we eat. Only foods that have been fortified with vitamin D (e.g., milk, cereal, yogurt, orange juice) have any significant amounts of this vitamin.

A very low fat diet will make it harder for you to absorb vitamin D from your food. Lack of sunshine and limited consumption of foods fortified with Vitamin D may mean you need to take a nutritional Vitamin D supplement. Your physician will help you decide what kind and how much to take for your age, health, and risk factors. Vitamin D supplementation may be based on current levels of vitamin D in your blood.

You may be someone who does not rebuild bone as quickly as you lose it. Nutritional deficiencies can make this problem worse. Caffeine-containing drinks like coffee and colas will cause increased loss of calcium through the urine. Cola drinks with high levels of phosphorus also disrupt calcium metabolism and healthy bones.

Magnesium is as essential as calcium for strong bones. As much as 50 per cent of your magnesium is found in your bones. Magnesium is required to move calcium into bone. Magnesium is also needed to make vitamin D active. A typical American diet contains much less than the recommended daily requirement for magnesium.

Magnesium is lost through the urine. This happens when people are stressed. Studies have shown something as common as loud noise levels will increase the loss of magnesium. Alcohol and many drugs used for heart disease and high blood pressure also cause magnesium loss. Bone repair calls for amounts of magnesium usually much higher than the recommended daily allowance.

L-lysine is an amino acid that you need to activate intestinal absorption of calcium. You will lose too much calcium through your kidneys if you do not have enough lysine. Lysine is an essential element for building the collagen framework. Minerals like calcium and magnesium weave into collagen to create bone.

You may need supplementation with these minerals, vitamins, and amino acids. This applies to you if you work indoors or don’t get out in the sun much. You are also at risk if you are elderly, or are a sedentary person who drinks a lot of coffee or cola drinks. If you do not digest well, or if you eat a very low fat diet, it may be important to use a good quality supplement to protect your bones.

Specific nutritional factors that will increase your risk of pain and inflammation are

  • not enough omega 3 fatty acids from ocean fish
  • not enough fruits and vegetables in the diet
  • not enough vitamin D from sun exposure or fortified foods
  • risk factors for vitamin D deficiency (e.g., older age, dark skin, use of sunscreen, obesity, kidney disease, liver disease, use of some medications, milk intolerant)
  • not enough of the minerals potassium and magnesium
  • not enough protein and high quality fat in the diet to control enzymes that produce inflammation
  • too many sweets and starches in the diet, leading to weight gain and to excess insulin
  • too many free radical ions from rancid and hydrogenated fats, low nutrient refined foods, chemical additives and residues

Nutrition and Inflammation

Inflammation is most often thought of as the redness, warmth, swelling, and pain that occur with an injury. The body responds this way whether it’s a surgical incision or a spider bite. Inflammation is also present in an infection like a strep throat or the achy, hot finger joints of rheumatoid arthritis.

Wound healing and fighting infection are just some of the ways inflammation is activated. Inflammation is happening all the time in more or less obvious ways in your body. Medical science has begun to understand the connection between inflammation and most of the chronic degenerative diseases. Some of these diseases – like cancer, heart disease, or diabetes – develop quietly for many years before causing problems. We aren’t even aware they are present. Pain isn’t always a part of these diseases. People can be pain free even when a lot of tissue damage has occurred. Others conditions, like osteoarthritis, gall bladder disease, or degenerative disc disease, make their presence known. Pain with these conditions can range from mild to unbearable.

These conditions all have one thing in common. The tissues of the body parts involved are inflamed. The process of inflammation depends on a number of different chemical elements. These are called inflammatory mediators. Chemical mediators are released from certain kinds of white blood cells. These white blood cells are part of our immune system. First they travel to a target area. Then they cause a series of reactions that create the tissue changes we refer to as inflammation. At first this process is actually a repair response to some sort of injury or insult to the tissue. Later, the inflammatory process can become chronic and the cause of further injury.

Inflammation and Back Pain

Healthy repair depends on good nutrition. Poor nutrition can lead to damaging inflammation in the joints of your spine. Inflammation causes the loss of the cellular framework that holds bone and connective tissues together. Studies show that some people with osteoarthritis have more rapid damage to their joints. This is because they have more inflammatory chemistry in their bodies.

Back pain may or may not be present in people with bone or cartilage changes in their spine. For instance many people have x-ray images that show they have flat and bulging discs. Or they may have brittle bones. Yet they have no pain. It is inflammation that causes the tissue changes that create the sensation of pain.

Inflammation stimulates the growth of new blood vessels in joint tissues. This growth process also causes new nerves to grow in areas around joint cartilage. Doctors think this new nerve growth may be why back pain goes along with inflammation. The increased tissue activity and the swelling that comes with inflammation can make the new nerves very sensitive. All of the steps in this inflammatory process (new blood vessel growth, new nerve growth) keep each other going in a never-ending cycle. Stopping inflammation will relieve pain and slow down joint damage.

Back Pain and Obesity

Abdominal obesity adds to spine problems in very important ways. Fat around your middle can cause strain on the muscles and ligaments that support your spine. The joints of your spine are especially vulnerable to daily wear and tear from lack of support.

Most of us get fat by eating too much of the kind of starchy, refined foods that call up more insulin. Insulin will signal enzymes in your body. These enzymes increase levels of inflammatory cells. They also increase cholesterol and constrict (close down) blood vessels. All of these actions help increase the levels of pain you feel from all over your body.

Abdominal fat is made of the type of cells most active at making the kind of chemistry that causes damaging inflammation to all of your joints. The more belly fat you have, the more inflammatory chemistry you are making. Some lean people are also at risk.

How does nutrition affect healing after injury or surgery?

Good circulation is needed to build and repair a surgical incision, injured bone, or connective tissue like cartilage and ligaments. Your blood vessels carry all the raw materials needed to maintain proper strength and function of your bone and connective tissues. Your blood vessels also carry away from these body parts all the waste material from normal wear and tear as well as from injuries. A diet that has too much starch and sweets, and not enough protein and healthy fats, will cause blood vessels to constrict. Then there is less blood flow to the areas that are injured and need repair.

All of the chemical reactions that make up the work of growth and repair require good nutrition. Herbs, fruits, and vegetables contain the dietary sources of antiinflammatory chemistry needed for tissue healing. Plant foods have antioxidants that decrease the chemistry that triggers inflammation. This type of plant is called a flavonoid. Flavonoids are plants that have biologic and metabolic properties in the body. They also strengthen the healing process. They do this by knitting collagen fibers into tightly woven connective tissue. The result is well-knitted skin and blood vessels; dense bone; and strong, elastic ligaments and tendons.

What changes can you make to your diet and supplement choices if you have a spine condition?

It can be confusing to try to sort out what supplements to take. It’s not always easy to know what foods to eat or not eat to help with a spine-related problem. Different musculoskeletal conditions will have some different nutritional requirements. The form of each supplement will also be important, in terms of how useful it is for your condition.

For example, powdered nutrients in capsules or liquid forms are much more likely to be fully digested and absorbed. Tablets are often less expensive. But they don’t break down in many people’s digestive tracts.

Osteoporosis is an example of a spine-related condition with a clear link to nutritional status. Most people with osteoporosis will be advised to take at least a calcium/magnesium supplement. The best quality mineral supplements for osteoporosis are powdered and in the citrate form (for example, calcium citrate). Vitamin D should always be included in an osteoporosis formula.

Inflammatory conditions benefit from antioxidant nutrients like vitamin E. It must be natural vitamin E, not synthetic. It should always have mixed tocopherols in order to be most effective. Any inflammatory condition can be improved with the addition of at least five fish meals a week. A good, pure fish oil supplement taken daily can also help.

Here are some changes you can make to improve your spine condition. Most people will notice results in less than two weeks by following these general rules

  • Drink at least eight large glasses of water or herbal tea daily. Avoid fruit juices or other beverages with coloring and preservatives added. This includes soda pop.
  • Eliminate simple sugars. Get rid of sweets and starchy, refined white flour foods from your diet.
  • Avoid packaged foods with added preservatives and colorings
  • Take a high quality multiple vitamin/mineral supplements three times daily with each meal
  • If you have any form of arthritis or any inflammatory condition, take a pure fish oil supplement. Most people are helped by one to three grams of combined omega 3 fatty acids daily. Look for EPA and DHA on the label.
  • Add vitamin D3 to your supplements; make sure you are get 800 IU to 1000 IU daily. You may need more if you have a history of malabsorption (e.g., celiac disease, inflammatory bowel disease, cystic fibrosis, gastric bypass surgery)

Long-term dietary changes can benefit your spine condition. If you are overweight, ask a health professional to help you lose weight, especially abdominal fat. Most people can do this safely by

  • eating fresh, raw, or steamed vegetables every day
  • eating two or three pieces of fresh fruit every day
  • eating five to seven fish meals a week
  • eating three to six ounces of clean, lean beef, poultry, lamb, or game meat daily – eggs are also an excellent source of protein for most people
  • using olive oil on salads and for cooking daily
  • eating fresh nuts and seeds. Almonds, walnuts, and pumpkin seeds give us high quality, healthy fats

If you do not have a regular habit of exercise, invest in instruction with a professional who can teach you how to strengthen your muscles and protect your joints. Certain exercises will be very good for some spine conditions, and possibly harmful for others. An exercise professional is your best choice for guidance to design a safe, effective program just for your needs.

How long does it take to see results from these changes?

Many people who change their diets see results right away. The difference in body pain levels can be noticed in a matter of days. Reducing inflammation by stopping the triggers that sweets and starches create can be felt very quickly. The effects of diet changes are even more when added to the supportive chemistry of antioxidants. Dietary supplements can encourage your healing even more dramatically.

It can take some months of steady supplementation to rebuild your tissues after illness or injury. It depends on how deficient you are in certain nutrients. It may take three to six months for to experience the benefits of a specific supplement program. This time frame may vary based on your condition. Your doctor can advise you about this.

For expert help to start a nutrition plan for your spine health, see a nutritionist or contact a licensed naturopathic physician. Specially trained nutritionists may be available in your area. Many registered dietitians and conventionally trained nutritionists are limited in their ability to give personalized attention to in-hospital patients. You may have to look for an independent practitioner with more advanced training. The ongoing support of a progressive nutritionist can help you start new, healthy habits that will become a permanent part of your daily life.

Naturopathic doctors (NDs) are also available to help patients develop healthier nutritional habits for the spine. Naturopathic physicians practice the art and science of natural health care. They are trained at accredited medical colleges. Partnerships between medical doctors and naturopathic physicians are becoming more common all over the U.S. and Canada.

Intraoperative Monitoring

A Patient’s Guide to Intraoperative Monitoring

Introduction

Intraoperative Monitoring

Spine surgery can be unpredictable and potentially dangerous because it can involve areas near nerves and the spinal cord. During spinal surgery, there is a risk that damage to the nervous system can occur. This is especially true when hardware or instrumentation is used and inserted near nerves, or when a curvature of the spine is corrected. It is important for surgeons to be able to have someone experienced to monitor nerve tissue while doing the operation.

The nervous system can be monitored during spine surgery to make it safer. The term commonly used for monitoring the nervous system during surgery is intraoperative monitoring, or intraoperative neurophysiologic monitoring (IOM). Intraoperative monitoring is not only being used for complex spinal surgeries but is widely used for other surgeries too. Some of these include brain surgery, ear surgery, and surgery involving arteries.

This guide will help you understand

  • what is intraoperative monitoring
  • why is intraoperative monitoring important
  • when is intraoperative monitoring used
  • what happens during surgery
  • what are possible complications

Anatomy

Intraoperative Monitoring

What parts of the spine are involved?

The spine is divided into various parts. The upper portion is the cervical spine, or neck. The middle portion is the thoracic spine, or trunk. The lower portion is the lumbar spine, or low back. There are bony blocks called vertebrae that make up the spine. They are stacked on top of one another. There are discs that separate the vertebrae and provide cushion. The spinal cord is protected by the bony spine. It lies in a hollowed area, or arch made by the bony spine. This is called the spinal canal.

Intraoperative Monitoring

Projecting from the spinal cord are nerves that travel to limbs, the trunk, and internal organs. The spinal cord is similar to a tree trunk. The nerves are like branches. The portion of the nerve as it branches off of the spinal cord is called the nerve root. The spinal cord sends and receives messages to and from the body and the brain. The nerves that branch off of the spinal cord go to various body parts to provide sensation and motor function or movement.

Intraoperative Monitoring

Nerve tissue is delicate and can be damaged relatively easily. When damage is done to the spinal cord or nerve, it may cause sensory and/or motor changes in the affected body part. The damage may be permanent.

What is intraoperative monitoring?

Intraoperative neurophysiological monitoring (IOM) uses equipment to evaluate the function of the spinal cord and nerves during spine surgery. Its role is to provide the surgeon with immediate feedback and warning before permanent nerve injury has occurred. This has been shown to increase safety and improve outcomes in complex spine surgery.

Intraoperative neurophysiological monitoring (IOM) began with the use of somatosensory evoked potentials (SSEPs). This measures the conduction of sensation above and below the area of surgery. During spinal surgery, electrodes are placed on limbs that could be affected by the surgery. Electrodes are also placed on the surface of the skull over the area of the brain where the impulse from the limb is received. A machine is used to monitor the electrical activity in the brain just like an electroencephalogram (EEG). The electrical activity is recorded as waves. When the limb is stimulated with an electrical current by the surgeon or technician, there should be a response in the brain. This checks the function of the sensory portion of the nerves and spinal cord.

Somatosensory evoked potentials (SSEPs) are the most widely used intraoperative neurophysiological monitoring during surgery. However, SSEP monitoring may not detect injuries to individual nerve roots.

In the 1980’s surgeons began using electromyography (EMG) to monitor the motor portion of the nerves during spinal surgery. It is becoming more commonly used. During surgery, while the patient is asleep, needle electrodes are placed in the muscle groups that correspond to the area where the surgeon will be working. Electrical activity from the muscle can be monitored by a machine. The activity is recorded as waves, similar to the SSEP monitor. It is also similar to the waves that are recorded from the heart muscle during an electrocardiogram (ECG). Baseline recordings are taken before the surgery begins. Recordings are then repeated throughout the procedure. A significant change in the wave alerts the surgeon or technician that the nerve in the area could be damaged. The surgeon can then take action to prevent permanent damage.

EMG seems to be more accurate in identifying potential neurological damage than other methods of monitoring that have been used. However, it is not useful when muscle paralyzing agents are used for anesthesia. It is also not useful if a nerve root has been cut completely.

Studies show that the use of both SSEPs and EMG monitoring during spinal surgery is most ideal but not always available.

Other monitoring available includes rectal and urinary sphincter electromyography, motor-evoked potentials (MEPs), transcranial electrical stimulation (TES), brainstem auditory evoked potential (BAEP), dermatomal evoked potentials (DEP), facial nerve monitoring, and spinal cord mapping.

Why is intraoperative monitoring important?

Spine surgery can be unpredictable and dangerous because it can involve areas near nerves and the spinal cord. During spinal surgery there is a risk that damage to the nervous system can occur. Intraoperative neurophysiological monitoring allows the surgeon to know, during the surgery, if/when nerve tissue is being injured or is at risk for being injured. The problem can be corrected immediately. Intraoperative neurophysiological monitoring (IOM) allows assessment of nerve tissue function while the surgery is taking place. Many complications involving the nervous system can be avoided with careful monitoring during surgery. This makes spine surgery safer. It is also proven to improve the outcomes of spinal surgery. It is being used more commonly, especially during complicated spinal surgery.

Intraoperative Monitoring

Spine surgery often involves the use of instrumentation (hardware). This hardware may include screws, rods, plates, and cages. The complication rate from instrumentation with lumbar spine fusion varies from one to 33 per cent. Possible complications from placement of hardware include damage to the spinal cord and nerve roots. Up to 10 per cent of the time, pain and sensory changes in the portion of the limb affected can result. This is called radiculopathy. One per cent of the time, motor change or weakness in the portion of the limb affected at that surgical level can occur. This is called myelopathy. Neither of these outcomes is desirable after spine surgery.

Surgeons have relied on imaging, most usually X-rays and computed tomography (CT) scans to check the placement of hardware during surgery. However, there are times when these do not show improperly placed hardware, fracture of spinal bone, or damage to nerve tissue.

Intraoperative neurophysiological monitoring (IOM) is more effective in sensing neurological damage, and misplacement of hardware. In fact, some studies show that it is one-third more effective than imaging with X-ray or CT scan.

Until intraoperative neurophysiological monitoring, surgeons commonly relied on the wake up test and the clonus test to evaluate nerve function during surgery. However, these are more difficult to repeat during the surgery, can lengthen the time of surgery, and do not fully evaluate nerve function. The wake up test involves allowing the patient to wake up from the anesthesia. The patient is then asked to move body parts that may be affected by the surgery. The clonus test involves the surgeon quickly jerking the foot towards the shin to see if the stretch reflex still works. This assesses the function of the spinal cord.

Intraoperative neurophysiological monitoring (IOM) is quick, painless, easy, and inexpensive. Recordings can be taken several times during surgery or even throughout the entire procedure. It does not cause harm to the patient. It also provides real-time feedback to the surgeon. It is safe and effective for reducing nerve tissue damage during surgery.

When is intraoperative monitoring used for spinal surgery?

Some spine surgeons may prefer to use intraoperative monitoring during most (if not all) of their surgeries. Others prefer to use it during complex surgeries. It is commonly used for the following spinal surgeries:

  • All spinal cord cases
  • Spinal instrumentation with hardware
  • Scoliosis
  • Discectomy with a neurological deficit
  • Decompression with a neurological deficit
  • Total disc replacement
  • Pain stimulator placement
  • Corpectomy
  • Vertebrectomy
  • Odontoid/Dens fractures

What happens during surgery?

Intraoperative Monitoring

After you are put to sleep by the anesthesiologist, small wire electrodes are placed in the muscles of your lower leg for lumbar surgery. They may be placed in the arms for neck surgery. For EMG monitoring, the electrodes are placed in specific muscles that correspond with a specific level in the spinal cord.

Technically, EMG monitoring is relatively easy, and the setup takes practically no additional time during positioning for the surgical procedure.

Intraoperative monitoring is technically done by a technician who is in the operating room during the entire procedure. A neurophysiologist may be involved in interpreting the recordings generally at a remote location where they observe the same data as seen by the technologist. This real-time interpretation by an experienced neurophysiologist is the standard of care in many regions in the United States.

If the spinal cord or nerve roots are damaged while drilling into bone, placing hardware in the spine, or decompressing the spine, the SSEP or EMG signal will change. This alerts the technician who can then alert the surgeon. Some monitoring units are equipped with a loudspeaker that allows immediate audio feedback. The surgeon can make a change at that time to avoid damage to nerve tissue.

Intraoperative Monitoring

When pedicle screws are used, the surgeon may use a handheld probe that can give an electrical stimulation to the pedicle screw once it has been placed. If the screw is where it is supposed to be, it will take a certain amount of current to cause a muscle contraction and wave on the monitor. If it is misplaced, it will take less. This is called an evoked EMG.

The surgeon can then re-evaluate the placement of the screw in order to avoid harm to the nerve root or spinal cord.

SSEPs and EMG recordings can be taken several times during the surgery if necessary without causing harm to the patient.

What are possible complications of intraoperative monitoring?

There really are none. The surgery need not be interrupted unnecessarily during surgery when neurophysiological monitoring is used. This is safer for the patient. Because the skin is penetrated with needle electrodes, there is a small risk for infection. This is minimal as the skin is disinfected before the needles are placed. The needles are sterile. They are thrown away after a single use. Mild soreness may be experienced where the needles were inserted.

Intraoperative monitoring is usually not costly. It is well worth it to avoid neurological complications during spinal surgery when possible.

Spondyloarthropathies

A Patient’s Guide to Spondyloarthropathies

Introduction

Spondyloarthropathies

There are many different types of rheumatological diseases that affect the spine. A rheumatological disease is a problem that affects the entire body as a whole – such as the relatively well known rheumatoid arthritis. When a rheumatological disease affects the spine, the resulting conditon is called a spondyloarthropathy. The term is made up of Greek words: “Spondylo” means “vertebra,” “arthro” means “joint” and “pathos” means “disease.”

The most common diseases in the spondyloarthropathies include:

  • Ankylosing Spondylitis (AS)
  • Psoriatic Arthritis (PsA)
  • Reactive Arthritis (ReA)
  • Enteropathic Arthritis (EA)
  • Rheumatoid Arthritis (RA)

This guide will help you understand

  • which parts of the spine are affected
  • what causes these diseases
  • what the most common symptoms are
  • what tests your doctor may recommend
  • what treatment options are available

Anatomy

What parts of the spine are involved?

This group of diseases cause damage by creating inflammation that attacks the connective tissues of the body. In most cases, the cause of these diseases is unknown. There is increasing evidence that the underlying cause may be a combination of genetics and infection. A person born with certain genes may react differently to certain types of infections. Once that person is exposed to certain infections, the body responds by defending itself. The way the body defends itself against infection is through an inflammatory response. This is normal. What is not normal is that long after the infection
is gone, the inflammation continues. This chronic inflammation causes damage to many of the connective tissue structures in the body and leads to the symptoms.

There are several rheumatological diseases that can affect the spine. The rheumatological diseases that affect the spine primarily affect the connective tissues. One of the most common rheumatological diseases is rheumatoid arthritis (RA). RA primarily attacks the synovial joints.

Spondyloarthropathies

Most of the joints in the body are synovial joints – such as the knee, hip and shoulder. A synovial joint is where two bones come together to form a connection that needs to be flexible – the two bones need to move against one another. The ends of the bones are covered with articular cartilage. Articular cartilage is a white, shiny material that is very slippery. It provides shock absorption and allows the bones to glide against one another easily. The synovial joint is completely enclosed by a joint capsule made up of tough connective tissue on the outside and a thin layer of tissue on the inside called the synovial lining. The joint is water tight. Inside the joint there is a small amount of fluid called synovial fluid. Articular cartilage does not have any blood vessels. The synovial fluid brings nutrients to the articular cartilage as it lubricates the joint.

Spondyloarthropathies

In RA, the synovial lining of the joint is affected. The normally thin tissue of the synovial lining becomes inflamed and thickened. This material begins to produce inflammatory chemicals that damage the articular cartilage and bone underneath. The joint is slowly destroyed until bone rubs against bone. There are synovial joints between each vertebra in the spine and between the skull and the first cervical vertebra. It is easy to see why RA affects the spine.

Spondyloarthropathies

In some rheumatological diseases, the inflammatory process affects other connective tissue structures. One structure that is commonly affected is where ligaments and tendons attach to the bone. This area is called an enthesis. There are entheses located all over the body – wherever tendons and ligaments need to attach to bone. There are also many entheses in the spine itself, such as where the intervertebral disc attaches to the vertebra. Many of the rheumatological diseases that affect the spine seem to attack these areas of the spine. It is unclear why this occurs.

Related Document: A Patient’s Guide to Lumbar Spine Anatomy

Causes

What causes this problem?

The cause, or causes, of all of these rheumatological diseases is still unknown. There is increasing evidence that the underlying cause in many of these conditions is a combination of a person’s genetic makeup and how that person responds to certain types of infections.

For many years, doctors have been aware that people with these diseases have a higher percentage of a gene called HLA-B27. The HLA-B27 gene plays a role in determining how the cells of the body react against infection. Not everyone with this gene will develop a rheumatological disease, but the vast majority of people with any of the diseases have the gene. Recently, more research has shown that there are a number of variations of the HLA-B27 gene. This further complicates a very complex situation in trying to understand what role genetics plays in the cause of these diseases.

There are also a number of different infections that have been found to be related to the development of the rheumatological diseases. When patients with these diseases are studied, there seems to be certain bacterial infections that are more likely to precede the development of the rheumatological disease. The infection may be over, but the body continues to mount an inflammatory response that instead attacks the connective tissue
structures of the body itself.

The current evidence suggests that people with certain genes are more likely to react to certain types of infections by developing a rheumatological disease.

Related Document: A Patient’s Guide to Rheumatoid Arthritis

Symptoms

What does the condition feel like?

Most of these diseases cause pain and stiffness as the primary symptoms affecting the spine. The pain and stiffness is worse in the morning and improves with activity. The flexibility of the spine decreases as time passes and the disease progresses.

Spondyloarthropathies

In diseases that affect the synovial joints, destruction of the joints can result in instability of the spine and may cause pressure on the spinal nerves or spinal cord. In the diseases that affect the entheses, the spine more commonly develops large bone spurs and may fuse together and become stiff. Instability occurs if the stiff spine is fractured.

Because these diseases are systemic, meaning that they affect the entire body, the symptoms also affect the entire body. The symptoms include pain in areas that are affected, such as the other synovial joints, and the other entheses of the body.

Besides back pain, sacroiliac, hip, and shoulder pain are also common. The exact location of symptoms depends on the type of spondyloarthropathy (SpA) present. Some of the diseases may include a skin rash, such as psoriasis. Several of the spondyloarthropathies affect the eyes, causing uveitis (inflammation of the iris). Inflammation of the urethra (the tube from the bladder to the outside) can cause pain when urinating, called urethritis. Ankylosing Spondylitis (AS) can also affect the gut, aorta, or heart. All of the symptoms mentioned here are called extraskeletal manifestations. This means the symptoms affect some part of the body other than the tendons and bones.

Diagnosis

How do doctors diagnose the problem?

The diagnosis requires a careful history followed by a thorough physical examination. Many patients have someone directly related to them that suffers from the same disease. Your doctor may ask questions about symptoms of recent infections such as diarrhea, burning with urination, difficulty with vision and eye pain.

The laboratory evaluation is very useful in the diagnosis. Tests such as C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) may be ordered to look for signs of infection and chronic inflammation other tests can be done for rheumatoid arthritis and the presence of the HLA-B27 gene. The HLA-B27 gene is not always present in patients with spondyloarthropathy. And it may be present in normal, healthy individuals without spondyloarthropathies.

Analysis of synovial fluid may be needed to rule out septic (infectious) arthritis. Additional tests may be ordered for patients with inflammatory bowel disease (IBD) or when reactive arthritis is suspected.

Spondyloarthropathies

X-rays can be very useful to show the changes in the spine, joints and pelvis that are common with many of these diseases. X-rays are usually the first test ordered before any of the more specialized tests. In the early stages the x-rays may be negative, but as time passes, the changes may appear and confirm the diagnosis.

Other radiological imaging tests may be useful. A bone scan can show the sites of inflammation before the changes appear on x-rays. A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special x-rays of your back. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem. Other tests such as the computed tomography (CT) scan or magnetic resonance imaging (MRI) scan are then used to look at the area in detail.

Spondyloarthropathies

If there are symptoms suggesting the spinal nerves or spinal cord are in danger, an MRI scan may be recommended to look at the spine more closely. The MRI scan uses magnetic waves to create pictures of the lumbar spine in slices. The MRI scan shows the lumbar spine bones as well as the soft tissue structures such as the discs, joints and nerves. MRI scans are painless and don’t require needles or dye. Specialized MRI techniques are now available that can detect inflammatory changes in the sacroiliac and vertebral joints long before they appear on x-rays.

Treatment

What treatment options are available?

There is no cure for any of these diseases. The goal of treatment is to manage the pain and, when possible, to slow the progression of the damage to the underlying structures.

Remaining as active as possible is critical to maintaining your function. A physical therapy program can teach you how to maximize your function and retain as much flexibility as possible. Learn all you can about what you can do to control your symptoms and remain as healthy as possible.

If you smoke or use tobacco products, long-term outcomes are worse. You should quit as soon as possible. Your doctor can help you with this important step.

Spondyloarthropathies

Medications are the primary tools available for treatment. Non-steroidal anti-inflammatory drugs (NSAIDs) are the main drugs used for treatment of the pain associated with these diseases. These drugs include aspirin, ibuprofen, indomethacin and naprosyn. There are others in the group as well. These drugs reduce the inflammation and control pain. There is no evidence that they stop or slow the progression of the disease.

Cortisone can be used to control flare-ups of pain. Cortisone is a powerful anti-inflammatory medication. When used for short periods of time, the medication is safe and well tolerated. When used continuously over a period of months, the side effects can be significant. Your doctor will probably not want to use cortisone if possible. In some cases, such as with advanced rheumatoid arthritis it may become necessary to use cortisone indefinitely to control the disease.

There are newer medications that have been developed to control rheumatoid arthritis that are sometimes beneficial in the spondyloarthropathies. Some of these medications actually slow the progression of the damage from the disease. These medications are known as disease modifying anti-rheumatic drugs (DMARDs). DMARDs include gold injections, methotrexate, sulfasalazine and azothioprine. These medications may be used primarily to control the symptoms in other parts of the body, but may also improve the spinal disease as well.

Recently, new medications have been available that may prove to be very beneficial for these diseases. One of the chemicals that seems to make the inflammation worse in these diseases is tumor necrosis factor (TNF). Drugs that block the effect of this chemical are called tumor necrosis factor-a inhibitors. TNF-a inhibitors are used to treat a variety of inflammatory diseases. These have recently begun to be used to treat a variety of inflammatory diseases. These drugs have shown promise in helping control the inflammation and symptoms of the spondyloarthropathies as well. TNF-a inhibitors result in dramatic decreases in CRP levels and ESR improvements are also seen on MRIs.

Treatment with TNF-a inhibitors must be kept up over the long-term to stay in control of the disease. If one agent doesn’t work, your doctor may switch you to another. There are some serious side effects with these agents, so they aren’t used with everyone. We don’t know yet if these agents will prevent the bony changes that lead to spinal fusion. More study is needed to determine this.

Surgery is rarely indicated in the treatment of these diseases, except where the damage caused by the disease has caused pressure on the spinal nerves or spinal cord. Total joint replacement may be needed for patients with severe damage to the hip or knee. Some patients elect to have surgery to correct kyphosis (forward curve or humpback of the upper spine) or to correct spine instability from fracture.

Finally, learning as much as you can about how you can take care of yourself is an important part of managing these chronic diseases. Support groups are available online and in many cities where people can come together and help with information and support. There is nothing as valuable as getting advice and guidance from someone who has experience with the disease and can provide tips and pointers for living with the disease on a daily basis. It is always nice to know that you are not alone.