My friends and I have been tennis players for many years, and all of us seem to have had some level of back injury while playing, why do these injuries seem so common?

In a recent report by Dines at al, there is a good description of common tennis injuries and why they occur. Tennis has many different movements associated with playing, but frequently there are explosive bursts of energy and there are repeated motions. Over the course of a few months playing this can involve thousands of repeated strokes. This high repletion and high energy can often lead to overuse injuries and many back injuries fall into this category. Specifically, repetitive rotational forces in combination with flexion or extension (very common in tennis, think serving or reaching way in front to get a ball with your back hand) increases the risk for injury to both the discs and joints of the lumbar spine. Usually injuries of this kind are due to tiny forces adding up over a long time. This probably includes forces while playing tennis and in other life activities. As we age this repetitive trauma adds up and can eventually result in pain. Back injuries of this kind are quite common in tennis players because of these factors. Fortunately there are some preventative measures to take, such as working on core strength, flexibility, and body awareness for all movements.

What is an osteoporotic compression fracture?

Osteoporosis is a disease in which bones become weak and become more prone to breaking. Compression fractures due to osteoporosis most often occur in the vertebrae and are caused when too much pressure is placed on a weakened vertebrae and the front of the vertebrae cracks and loses height

I am the director of a fairly large and well-attended senior citizen center. One of the members of our board of directors in a gerontologist specializing in the care of older adults. He suggested we hold a screening clinic to help identify seniors who have scoliosis. We are investigating the idea. What can you tell me about this problem? I need more information before presenting it to the membership at large for a vote.

You may find our pamphlet on adult degenerative scoliosis (Patient Guide to Adult Degenerative Scoliosis) a helpful tool in educating yourself and your seniors. By definition, <iscoliosis is an abnormal or exaggerated> curve of the spine when observed either 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.

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.

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. It is estimated that 35 per cent of older adults have scoliosis. This would represent slightly more than one-third of your group. Early detection and treatment can help prevent disease progression. A medical examination with X-rays is usually the most reliable method of diagnosis.

I’ve been doing some investigation myself on-line looking at results of studies using blood injection therapy for bone healing. So many of the studies seem to suggest it doesn’t always work as well as expected. Why not? I was kind of hoping this could be something that would help me with my very unstable low back.

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets and growth factors. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the treatment of musculoskeletal problems, but gaining popularity.

However, the use of PRP to aid spinal instability by fusing the vertebrae is still under investigation. The goal to create a bony bridge between two vertebrae has had mixed results. Most of the time, the results (measured based on how much bone growth and blood supply are stimulated) are incomplete.

Although they find some new bone growth, complete bridging of bone to form a solid fusion doesn’t occur. Signs of inflammation and some blood vessel formation are observed but not enough to consider this a successful approach to spinal instability.

Previous studies have used other materials such as stem cells, bone morphogenetic protein (BMP), and bone graft to stimulate bone bridging and fusion. But none of the studies so far have shown complete bony bridging needed for spinal fusion (including efforts to use platelet activation and release of growth factors via platelet-rich plasma injection.

Researchers have made some suggestions that might explain why PRP is not completely successful in promoting bone growth or blood supply. For example, no one really knows the ideal amount of platelets (and therefore growth factors) to use. And growth factors don’t last long before they become inactive.

Injecting them into the area is one challenge but they must also be released and activated. It is still unknown just what is the best way to deliver and activate them. Should they be “preactivated” or will they start up on their own once they reach the intended destination? Is there a way to create a “time-release” effect? These are just some of the questions that remain to be answered before platelet-rich plasma can be used routinely to enhance spinal fusion.

I saw on your website the Patient Guide to Platelet-Rich Plasma Treatment of Musculoskeletal Problems. It says, “blood injection therapy has been used for knee osteoarthritis, degenerative cartilage, and spinal fusion.” I’d like to know about the spinal fusion part since that’s something I might end up needing. Could this injection therapy work for me?

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets and growth factors. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

The use of PRP to aid spinal fusion is still under investigation using animal models. For example, a recent study from Italy reported on the use of PRP in experimental spinal fusion. They used rabbits and performed the fusion using a posterolateral approach (injecting the PRP from the back and side of the spine).

The goal was to create a bony bridge between the transverse processes of the vertebrae. The transverse processes are bony knobs that point out to the side, one on the left and one on the right.

The rabbits were divided into three groups. One group received just the PRP (on the right side of the vertebrae) while the second group were injected with PRP combined with uncultured bone marrow (on the left side). Group three (control group) had a sham operation on both sides to simulate the other two groups but without actually injecting anything into the area.

The results were measured based on how much bone growth and blood supply were stimulated.
Although they did find some new bone growth, none of the rabbits had formed a complete bridge of bone across the transverse processes. Signs of inflammation and some blood vessel formation were observed but no significant changes were seen in either of the PRP groups. The control group had significantly fewer changes seen in terms of bone growth or new blood supply compared with the other two (treatment) groups.

Previous studies have used stem cells, bone morphogenetic protein (BMP), and bone graft in rabbit models to stimulate bone bridging and fusion. This is one of the first attempts to use platelet activation and release of growth factors (via platelet-rich plasma injection) in the bone healing process. But none of the studies so far have shown complete bony bridging needed for spinal fusion (including this study).

The authors made some suggestions that might explain why PRP did not work in promoting bone growth or blood supply in their rabbits. For example, no one really knows the ideal amount of platelets (and therefore growth factors) to use.

Growth factors don’t last long before they become inactive. Injecting them into the area is one challenge but they must also be released and activated. It is still unknown just what is the best way to deliver and activate them. Should they be “preactivated” or will they start up on their own once they reach the intended destination? Is there a way to create a “time-release” effect? These are just some of the questions that remain to be answered before platelet-rich plasma can be used routinely to enhance spinal fusion.

Our company is going to move us away from sitting at desks more toward a standing station. This is supposed to help us reduce our work stress and hopefully reduce absenteeism due to back problems. Do other companies have as much problem with lost productivity due to back disability as we do?

There’s no doubt that lost productivity due to back pain is a major problem in the work force. This has been reported in most developed countries around the world. And with fewer younger adults entering certain areas of industry, the drain on productivity is likely to increase.

Many studies have been done reporting on the cost of missed work (absenteeism), sick leave, inactivity (reduced productivity), and worker’s compensation. A recent study from Australia also evaluated the cost (in dollars) of retirement among workers between the ages of 45 and 64 (Baby Boomers). Each worker reported leaving work permanently due to spinal disorders such as disc herniation, scoliosis, mechanical low back or neck pain, and spinal deformities.

The personal cost of lost wages as well as the burden on the government in the form of lost taxes and welfare or unemployment benefits was in the billions. The loss of workers was also reflected in the increased costs associated with government support payments to retirees.

There is a great deal of focus now on what can be done about this problem. Prevention of back problems is the first. Getting injured workers or workers with painful spinal disorders back to work rather than into retirement or on permanent disability is also an important goal.

Moving desk workers away from sitting all day has started to become a popular approach. Research has also shown that exercise is an effective way to prevent (or if necessary: to manage) spinal disorders. In fact, when comparing different forms of exercise (stretching, calisthenics, aerobics, coordination, strength training, relaxation) people generally improve across the board. There are fewer episodes of back pain, less absenteeism at work, and greater productivity.

A more specific approach may be needed for those workers who continue to experience a decreased ability to carry out daily activities due to back pain from spinal disorders. Rather than a global exercise approach, physical therapy to address individual problems may be helpful.

And when conservative (nonoperative) care fails to get the worker back into the labor force, surgery has been shown to benefit many people. Even with the added costs of these treatment measures, they are more cost-effective than not getting anyone back on the job.

Any plan that includes company investment in preventive health measures is money well-spent. Spending money to prevent chronic spine problems that would otherwise force early retirement of workers still capable of staying in the labor force will ultimately pay off. Maintaining the health of the work force and prevention of spinal disorders is important now and into the future.

I am a manager of a large work force in a physical (not virtual) setting. Many of our middle-aged workers (the dependable “lifers” we call them) are dropping out and into early retirement due to back problems. It costs us much more to train someone new than to rehab a good, productive worker. What can we do to stop the “strain drain” (our term for lost productivity due to back pain).

You are not alone in pondering this question. A recent study from Australia seems to have hit the nail on the head. Like you, they noticed that early retirement due to spinal disorders is costing a bundle (in the billions). Lost personal wages leads to lost taxable income and decreased spending. And consequently, there are fewer dollars in the government coffers to support the national budget.

The problem and the impact of the problem are clear. What can be done about this? Everyone agrees we need a Plan. The authors of the study we mentioned suggested a two-step approach. First, prevention of spinal disorders and second, getting injured workers or workers with painful spinal disorders back to work rather than into retirement. These are the keys to keeping the labor force in full work participation.

Research has shown that exercise is one way to prevent (or if necessary: to manage) spinal disorders. In fact, when comparing different forms of exercise (stretching, calisthenics, aerobics, coordination, strength training, relaxation) people generally improve across the board. There are fewer episodes of back pain, less absenteeism at work, and greater productivity.

A more specific approach may be needed for those workers who continue to experience a decreased ability to carry out daily activities due to back pain from spinal disorders. Rather than a global exercise approach, physical therapy to address individual problems may be helpful.

And when conservative (nonoperative) care fails to get the worker back into the labor force, surgery has been shown to benefit many people. Even with the added costs of these treatment measures, they are more cost-effective than not getting anyone back on the job.

The Plan proposed by these researchers also includes government investment in preventive health measures. Spending money to prevent chronic spine problems that would otherwise force early retirement of workers still capable of staying in the labor force will ultimately pay off. More workers on-the-job means more taxable income and government revenue to support government budgets.

The authors concluded that the cost of early retirement because of spinal disorders is very high. Maintaining the health of the work force and prevention of spinal disorders is important now and into the future. In fact, these goals are essential to the personal health of the labor force as well as the economic health of the country. A national plan of action must be put into place soon before the work force dwindles further.

At the local level, employing the skills of a physical therapist to evaluate the work setting and suggest ways to prevent injuries is a good place to start. The therapist can help you set up group exercise programs as well as evaluate individual workers when a specific rehab program is needed. Programs like the Back Care Boot Camp (available through our Medical Multimedia Group) can also be very effective under the supervision of your therapist.

Could you please settle an argument for me and my wife? She says because I am so fat, the metal plates and screws in my low back won’t set off the airport security alarms. I’m not so sure. This will be my first time through. Should I take precautions and carry my X-rays with me?

Anyone with a joint replacement knows to carry a special letter from the doctor when traveling through airport security. Even with the documentation, travelers with implants can expect delays while security measures are applied. But what about metal implants in the spine? Are they deep enough and/or surrounded by enough body mass to avoid detection?

These questions were explored by a group of researchers in a recent study from England. Both handheld metal detectors and arch way metal detectors were put to the test. Researchers used volunteers carrying metal implants commonly put in the spine as well as patients with metal plates, screws, rods, disc replacements, and/or cages already surgically implanted. Implants varied in size and weight, region (neck, thoracic spine, low back region), and location (anterior, posterior).

All electronic metal devices used were standard ones approved for use in European airports. The volunteers carrying implants walked through the arch way detectors with different combinations of implants (weight, size, location). Some implants were taped to the arms or legs. Others were carried in pockets.

Then 40 patients with spinal implants walked through. Of course, everyone removed all the usual items (cell phones, jewelry, watches, belts, shoes, and so on). Each person in the study (volunteers carrying metal implants and patients implanted with metal devices) was also tested using the handheld wand type of metal detector.

Would it surprise you to know that not one person set off the archway detector? Body fat did not affect the results.Density of the metal did not influence the alarm mechanism either. Volunteers carrying metal could carry up to seven and a half ounces (215 grams) in one location before detection.

The handheld detector was able to pick up most (but not all) spinal implants inside the body. The handheld wand was able to detect even a single screw when the wand was held five centimeters (1.25 inches) away from the body. The ones that were NOT detected were in the front (anterior) portion of the neck. Anything implanted posteriorly (from the back) did set off the alarm on the handheld detector.

The authors concluded that modern handheld metal detectors are sensitive enough to detect most (but not all) metal hardware in the spine. Even when set at maximum sensitivity, the handheld devices did not trigger an alarm for disc replacements or anterior plates and cages. It is possible the position of the implant makes a difference but this will have to be tested further to know for sure.

It is also likely that detection rates are low because the implants are made of titanium (and not iron like weapons and guns). It is also possible that the technology for archway detectors (developed in the late 1970s) needs to be updated for today’s modern devices. Different manufacturers and models of archway metal detectors may also make a difference that should be investigated.

Keep in mind that this study was done in Europe and may not reflect the kind of results you may get moving through airport detection devices in the United States. It is always advised to carry printed documentation (not just X-rays) such as a letter from your physician when traveling. Even with these sources of proof, you will need to allow an extra measure of time when traveling. Equipment, personnel, and the way security procedures are carried out vary from airport to airport so it’s best to be fully prepared.

My wife and I are taking our first trip ever to Hawaii to celebrate our 25th wedding anniversary. Two years ago, I was in a car accident that left me with multiple spine fractures. After six surgeries, I have metal plates, rods, and screws up and down my spine. My friends have warned me to get a letter from my doctor in order to get through airport security. The surgeon says the implants I have won’t set off the alarms. What do you think?

A recent study from England may have some (but not all) the answers you are looking for.

In this study, handheld metal detectors and arch way metal detectors were put to the test. Researchers used volunteers carrying metal implants commonly put in the spine as well as patients with metal plates, screws, rods, disc replacements, and/or cages already surgically implanted. Implants varied in size and weight, region (neck, thoracic spine, low back region), and location (anterior, posterior).

All electronic metal devices used were standard ones approved for use in European airports. The volunteers carrying implants walked through the arch way detectors with different combinations of implants (weight, size, location). Some implants were taped to the arms or legs. Others were carried in pockets.

Then 40 patients with spinal implants walked through. Of course, everyone removed all the usual items (cell phones, jewelry, watches, belts, shoes, and so on). Each person in the study (volunteers carrying metal implants and patients implanted with metal devices) was also tested using the handheld wand type of metal detector.

Would it surprise you to know that not one person set off the archway detector? The handheld detector was able to pick up most (but not all) spinal implants inside the body. The ones that were NOT detected were in the front (anterior) portion of the neck. Anything implanted posteriorly (from the back) did set off the alarm on the handheld detector.

The handheld wand was able to detect even a single screw when the wand was held five centimeters (1.25 inches) away from the body. Body fat did not affect the results. Density of the metal did not influence the alarm mechanism either. Volunteers carrying metal could carry up to seven and a half ounces (215 grams) in one location before detection.

The authors concluded that modern handheld metal detectors are sensitive enough to detect most (but not all) metal hardware in the spine. Even when set at maximum sensitivity, the handheld devices did not trigger an alarm for disc replacements or anterior plates and cages. It is possible the position of the implant makes a difference but this will have to be tested further to know for sure.

It is also likely that detection rates are low because the implants are made of titanium (and not iron like weapons and guns). It is also possible that the technology for archway detectors (developed in the late 1970s) needs to be updated for today’s modern devices. Different manufacturers and models of archway metal detectors may also make a difference that should be investigated.

It is still advisable to carry proper documentation in order to prevent the possibility of any travel delays. More conclusive studies are needed before patients with spinal metal implants are given the green light to travel via airfare without carrying the necessary paperwork.

I saw in the newspaper that a doctor was sued for “inappropriate use of a bone graft sponge.” I have had a spinal fusion and my surgeon used a BMP sponge. What would be an inappropriate use of something like this?

The safety of bone morphogenetic protein (called BMP) in spinal fusions has been raised and evaluated by the Food and Drug Administration (FDA). BMP is a naturally occurring protein that scientists have discovered can be a replacement for bone grafts. But inappropriate use of this product has resulted in some adverse effects that have only been reported after the fact.

What constitutes “inappropriate” use of BMP? The manufacturers of this product are clear in how it is to be used. Off-label use (in other words, using it for something other than it was meant for) is one inappropriate use. Another is changing the concentration of the BMP. It is usually applied on a collagen sponge. Squeezing the sponge too much or overfilling the sponge are two ways the implant may be used differently than recommended by the manufacturer.

That might not seem like such a terrible offense but the list of adverse effects suffered by patients as a result of using BMP inappropriately is long. Bone resorption, inflammation, leg pain from radiculitis, breathing problems, infection, swelling and fluid collections, too much bone growth or bone growth into the soft tissues, and blood clots are just a few of the complications reported.

Until more is known about the true risks and safety concerns about BMPs, surgeons are advised to be aware of potential problems and discuss them ahead of time with their patients. Using the products according to the manufacturer’s directions may help ensure safe and effective use of BMP. Inappropriate and off-label uses should be avoided until safety issues have been resolved.

Should I go ahead and agree to let the surgeon use the special bone growth sponges available now for my spinal fusion? After reading the list of all the things that can go wrong, I’m not so sure it’s a good idea.

BMP is a naturally occurring protein that scientists have discovered can be a replacement for bone grafts. This is a good way to avoid some of the painful problems that can occur when bone is harvested from some other part of the patient’s body.

But as with most surgical procedures, there is a list of adverse effects suffered by patients as a result of the surgery. Bone resorption, inflammation, leg pain from radiculitis, breathing problems, infection, swelling and fluid collections, too much bone growth or bone growth into the soft tissues, and blood clots are just a few of the complications reported.

Data is available on both neck and lumbar spinal fusions. Some adverse effects are specific to the location of the fusion. For example, dysphagia (difficulty swallowing) can occur with cervical spine fusions. And retrograde ejaculation has been reported with anterior lumbar spine fusions.

Half of all patients who develop adverse effects from the use of BMP in spinal fusion end up having another (revision) surgery to deal with the problem. Some of the problems encountered are potentially life-threatening, so there is a need to pay close attention to these reports of adverse effects.

But reports of problems and complications after spinal fusion using BMP don’t necessarily mean the BMP was a direct cause of these effects. There are some serious adverse effects from BMP for sure but not all problems can be linked to this device.

More studies are needed to take a closer look at whether these reported events are, in fact, device-related adverse effects. Maybe the patients would have developed these problems as a result of the surgery and they have nothing to do with the use of the BMP. And it would be helpful if researchers could identify risk factors for adverse events associated with the use of BMP in spinal fusion.

Until more is known about the true risks and safety concerns about BMPs, surgeons are advised to be aware of potential problems and discuss them ahead of time with their patients. Using the products according to the manufacturer’s directions may help ensure safe and effective use of BMP. Inappropriate and off-label uses should be avoided until safety issues have been resolved.

I am writing this as a nurse who has just come back from Operation Enduring Freedom where I worked on the battlefield with some amazing surgeons and flight nurses. I think the American people need to know that many, many surgeons, physicians, nurses, and physical therapists are working around the clock to help save the lives of wounded soldiers in this ongoing War on Terror. There isn’t enough said to support these unsung heroes.

We appreciate your reminder of the many people who live and work behind the scenes to aid our servicemembers in the Global War on Terror both in Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan).

In the last 11 years, there have been more than 48,000 casualties among our American servicemen and women. That number doesn’t tell you the severity of injuries. Neither does it highlight the fact that many of our soldiers counted as one casualty, in fact, suffer multiple injuries. Some are minor; others are life-threatening.

The use of improvised explosive devices (IEDs) planted along the roadsides has caused many instances of lost limbs, eyes, and serous wounds. Spinal cord injuries resulting in paralysis have been reported in a significant number of soldiers.

You are right when you say these folks are “unsung heroes.” It is to the credit of the medical personnel on the ground, in the air, and at our hospital bases that the lives of our soldiers are often spared and with injuries minimized. They work in extreme environmental conditions with very few resources while attempting to treat severe, complex war-time injuries. It’s not like anything seen or treated in the civilian world, even among gang-related hospitalizations.

Once our injured servicemembers return home, they may need to continue working toward recovery and function. The number of civilian medical personnel who assist should also be acknowledged and recognized. We join you in suggesting two things: if you know a member of the military or former military personnel, thank them each and every time you can. If you know of any social worker, vocational rehab counselor, physical therapist, nurse, physician or other professional who is helping our returned veterans, give them your thanks as well.

I kind of hate to ask this question but it is really on my mind so here goes. My twin brother just returned from his third tour of duty over in Afghanistan. This time he came back with a blast injury to the spine and some serious damage. They brought him home in a “flying hospital” and tell us he got the best of care. I still can’t help but wonder if all the problems he developed (infections, blood clots, nerve damage) wouldn’t have happened if this type of injury was treated stateside. Is there any way to even compare this or figure it out?

Your concern is very understandable and having some answers might help reassure you. Our military medical personnel are functioning in a very challenging arena. The environment in which they are working (desert conditions with extreme weather patterns) and the complications of evacuation are beyond anything we can fully appreciate.

They do indeed have flying intensive care units (ICUs). Surgeons and nurses treat the soldiers while in the air evacuating from the field of battle to military hospitals. But there are many challenges as you can imagine. They have limited equipment to make a complete diagnosis. The evacuation process is complex and can delay treatment. And there’s really only so much that can be done to treat serious injuries even in a flying ICU.

Even so, every effort is made to provide rapid response to any injury with complete medical care — either at the theater of operations, in the air, or at the nearest hospital setting. Sometimes that is a mobile hospital like the kind featured in the long-time TV series MASH. In other situations, it is a med-evac to a hospital in Europe. Once the wounded soldier is stable, evacuation to the United States takes place.

It may help you to know that a recent study of military spine injuries was published. In that report, they noted that the specific types of complications experienced in our wounded warriors aren’t that different from what happens among civilian patients with similar injuries.

Infections, blood clots, urinary tract infections, cerebrospinal leak after surgery, and pneumonia are typical minor complications. Likewise, more serious problems such as failure of the wound to heal, injury to blood vessels or nerves during surgery, spinal cord injury, injury to the gastrointestinal tract, and even death were the same for U.S. military solders as are reported in civilian studies following surgery for spine injuries.

Protection of our troops is an important goal — whether on the ground, in armored vehicles, during transport following injury, or during and after surgery. Examining the type and number of complications associated with military spine injuries will help with decision-making in the Theater of Battle. The fact that our military medical staff are paying attention to these kinds of problems and studying them closely is very reassuring.

I hope you will post my question anonymously because I don’t want to be seen as crying over spilt milk. But our 20-year-old son was wounded in Iraq while walking alongside an armored vehicle (with other American soldiers inside). Only the soldiers on the ground were wounded. Everyone else inside the vehicles were safe. It doesn’t take a brain surgeon to figure this one out. Why don’t the military doctors put a stop to this? The amount of personal devastation (not to mention expense of care for the taxpayer) is astronomical.

You ask a very important question and make a very good point. This type of scenario has not gone unnoticed by military surgeons and policy makers. In fact, an article was recently published by military surgeons outlining the number, type, and mechanisms of military spine injuries in the Global War on Terror.

Focusing on ways to minimize complications that occur before, during, and after surgery is one way to aid our wounded warriors. As this studied showed, major and minor complications are fairly common. And multiple complications in many soldiers were typical. They especially focused on complications associated with military spine injuries from these blast munitions intended to penetrate armored vehicles but often hitting dismounted troops.

Major complications occurred in nine per cent of the military spine injuries. Minor complications were reported in six per cent of the total. But the most significant finding was the high number (more than 30 per cent) of complications among the dismounted soldiers who had surgery. And 80 per cent of all complications occurred among the dismounted service members. Military personnel in vehicles when injured made up only 20 per cent of those who had complications with treatment.

Understanding the mechanism of injuries is also important when planning wartime strategies. For example, the data from this study showed that soldiers in armored vehicles suffered fewer and less serious injuries compared with those individuals who were unprotected walking on the ground. The idea behind dismounted troops in today’s war theatre is to “win hearts and minds” of the nationals (people living in those countries) whom we are protecting. But this strategy does expose our soldiers to the risk of blasts from exploding bombs.

How will the military use this information? Protection of our troops is an important goal — whether on the ground, in armored vehicles, during transport following injury, or during and after surgery. Examining the type and number of complications associated with military spine injuries will help with decision-making in the Theater of Battle. Given these findings, the placement of troops on the ground in an unprotected fashion will require some additional thought and consideration by military strategists.

My brother came back from Iraq in a wheelchair no longer able to use the lower half of his body. They say he had a “penetrating spinal cord injury.” What is that exactly? Will he ever get the use of his legs back?

There are two basic types of spinal cord injuries most common among U.S. ground troops involved in the War on Terror: blunt and penetrating. As the names suggest, a blunt injury occurs when the soldier is exposed to a blast from a bomb explosion. In Iraq, most bomb explosions come from improvised explosive devices (IEDs) that are hidden along the roadside. For those soldiers inside an armored vehicle, the force of the blast throwing them against the inside of the vehicle can cause a concussive (blunt) spinal injury.

Penetrating injuries are more likely from gunshot wounds or schrapnel to the spine injuring the spinal cord. With penetrating injuries from gunshot, there is a greater chance for significant damage to the spinal cord as the bullet tumbles and spins, picking up speed and force before impact.

These are not typical injuries seen in the civilian sector but rather, specific to military war-time efforts in Iraq and Afghanistan. So information about treatment, effects of treatment, and prognosis are not exactly the same as for civilian spinal cord injuries. A recent study by the military is helping shed some light on what to expect for your brother.

High-energy, penetrating injuries to the spine from gunshot or blunt concussive force result in extensive wounds and multiple injuries. Soldiers are treated quickly on the field of battle but conditions are sparse with few supplies and limited medical personnel. Most seriously injured servicemembers must be evacuated to the nearest medical base that can provide needed services, including surgery.

Surgery to decompress the spine is more common in penetrating injuries of the spinal cord. Current recommendations are to perform surgical decompression only when the servicemember is medically stable and does not have a complete spinal cord injury.

Both blunt and penetrating injuries often cause additional injuries to the head, face, chest, and abdomen. Neurologic recovery is less likely with penetrating spinal cord injuries. Severing of the spinal cord usually results in long-term paralysis.

Rehab programs today combined with inflammation-fighting medications give our spinal cord injured patients a much better chance of some recovery from partial spinal cord injuries. Your brother’s prognosis will depend on the level and severity of injury as well as his attitude and efforts during the recovery process. Your interest, love, and support as a family member will continue to be a valuable tool for him during this time.

I’ve heard that bone substitute products used in spinal fusions can cause cancer. Is that true? I had such a procedure done two years ago and now I’m concerned. It’s not like when they recall cars with faulty parts. This stuff is a permanent feature in my back.

Since 2002 surgeons have had a special tool in their box of techniques for spinal fusion. And that is a substitute for bone graft called bone morphogenetic protein or BMP. Although more expensive, this product has two major advantages over using the patients’ own bone: 1) patients no longer suffer pain and discomfort at the pelvic crest where donor bone was taken from and 2) patients with poor bone growth due to diabetes or tobacco use can have a spinal fusion when necessary.

But as you have heard, there are some serious complications and post-operative problems being reported. So it’s time to take a second look at the safety of this bone substitute product. BMPs were first discovered in 1965 with more than 20 types now being studied. Only one (BMP-2) has been approved for use by the Food and Drug Administration (FDA) in spinal fusion surgeries.

When used as it was approved and intended, BMP stimulates safe and effective bone growth to aid in the fusion process. And that primary use for which it was intended is only anterior lumbar (low back) interbody fusion. Troubles begin when this product is used off-label such as for cervical (neck) fusion, especially anterior (from the front of the spine) procedures and posterior (from the back) lumbar fusion.

Massive soft tissue swelling, extra bone formation, seromas (fluid-filled pockets), and even cancer have been reported as emerging concerns with BMP-use. BMP receptors have been found on some (but not all) types of cancer cells. Since BMP stimulates bone growth, there is concern that it could actually promote the formation of cancer cells or speed up cancer metastases (spread).

The number of patients who have developed cancer after receiving BMP in spinal fusions is small. But the rate of increase compared to fusion patients without BMP is significant. Therefore, until further studies are done, the current recommendation is to only use patient bone graft material for individuals who have had a history of cancer or who have active cancer at the time of the intended spinal fusion.

Some experts suggest that the link between BMP and cancer is only when high-doses of BMP are used — much higher than the dose applied during a spinal fusion. If you have not experienced any problems in the first two years, a little watchful waiting may be advised since problems have been reported up to five years later. Talk with your surgeon about your situation. Ask him or her about your own risk and what to watch out for.

Is there any advantage to using the new BMP bone graft substitute other than personal comfort? It costs at least $5,000 more. I’m inclined to take my chances with donating my own bone graft and saving the money. What do you think?

The product you mentioned (bone morphogenetic protein or BMP) is more expensive, but product has two major advantages over bone taken from the patient: 1) patients no longer suffer pain and discomfort at the pelvic crest where donor bone has been taken from and 2) patients with poor bone growth due to diabetes or tobacco use can have a spinal fusion when necessary.

But there are some new complications and post-operative problems that have been reported that could be quite serious. So surgeons are taking a second look at the safety of this bone substitute product. BMPs were first discovered in 1965 with more than 20 types now being studied. Only one (BMP-2) has been approved for use by the Food and Drug Administration (FDA) in spinal fusion surgeries.

When used as it was approved and intended, BMP stimulates safe and effective bone growth to aid in the fusion process. And that primary use for which it was intended is only anterior lumbar (low back) interbody fusion. Troubles begin when this product is used off-label such as for cervical (neck) fusion, especially anterior (from the front of the spine) procedures and posterior (from the back) lumbar fusion.

Massive soft tissue swelling, extra bone formation, seromas (fluid-filled pockets), and even cancer have been reported as emerging concerns with BMP-use. Surgeons at the University of Pittsburgh suggest BMP should only be used as indicated until further studies expand its use. In other words, it should not be used as an off-label product. They advise surgeons to select patients carefully for spinal fusion. Not everyone is appropriate for the primary surgical procedure. Surgical success is more likely when used for the right patients.

They also note that until perfected through studies, BMP should NOT be used in anterior cervical spine patients and certainly not for anyone who has a past (or current) history of cancer of any kind. Using BMP for the ease and convenience of the surgeon is not considered acceptable when there are added costs, safety concerns, and risks of serious harm to the patient.

I’ve heard that spinal fusion surgery is simple, effective, and low risk. But my mother just had this procedure and then had a stroke two weeks later. Why was she allowed to even have this surgery if there was a risk of a stroke?

If you have ever had surgery of any kind or even known someone else getting ready for surgery, one thing is always discussed preoperatively. And that’s the possible complications. Though most post-op problems are uncommon or even rare, it is still the responsibility of the health care provider to review all possibilities with patients. Infection, blood clots, heart attacks, stroke and even death are all listed for major spine surgery.

It is very unfortunate that your mother suffered a stroke following spinal fusion. Stroke is a rare complication after spinal fusion and not one that can always be predicted. In fact, there may not be a direct link between the surgery and the stroke. In other words, your mother might have had that stroke even if she had not undergone spinal fusion.

Since back pain can limit a person’s activity level, it is possible that spinal fusion could actually lower someone’s risk of stroke. That was one of several conclusions from a recent study from Taiwan. They investigated the risk of stroke following spinal fusion surgery — the very thing you are wondering about!

Taiwan has a unique study situation in that the entire one million population is covered by a government-run health insurance. Everyone has free and unlimited access to health care even if they are traveling or out of their own country and receive treatment overseas.

This type of system makes follow-up easier and more predictable. Even if a patient in a study like this goes somewhere else within the system, the records are still available for follow-up. Therefore, incidence rates calculated tend to be more accurate and estimates of stroke risk more reliable.

Out of one million people, there were 2,249 who had spinal fusion. This group was matched with a very similar group of 2,203 adults who did not have spinal fusion. When we say the groups were “matched” closely, it means they were the same ages, gender (male versus female), education level, income level, and living location (rural versus urban). They were also very similar in terms of general health and the presence of other health problems such as diabetes, high blood pressure, heart or lung disease, and so on.

The rates of stroke during a three-year follow-up were compared. They found no differences between the two groups (those who had spinal fusion surgery and those who did not). In fact, the spinal fusion group had slightly (though not significantly) lower rates of stroke.

The authors suggest some possible reasons for these results. As we already mentioned, stabilizing the spine reduces pain and improves function. Patients who were previously inactive or sedentary because of back pain can increase their activity and exercise after spinal fusion. This effect could reduce the risk of stroke.

Surgeons do screen patients before surgery in order to select those who are more likely to have a positive result. Anyone with significant health problems may not be accepted for surgery. The healthier and more active someone is before surgery, the more likely they will have fewer complications and better results after surgery.

Your mother would not have been approved for spinal fusion surgery if there were any obvious risks of stroke or other potential post-operative problems. This rare but still unfortunate outcome may have had nothing to do with the surgery.

I don’t have a question, just a comment. It seems like one way our country could reduce the cost of health care is to quit sending everyone to a specialist. It seems like everyone is running off to see these highly specialized doctors when their GP could take care of the problem just as well and at a fraction of the cost. That’s the way I see it.

According to some health care policy makers, you are on the right track with your thinking. Just using spine problems as an example, we know that the treatment of back and neck (spine) problems accounts for billions (not just millions, but billions) of dollars every year.

Low back pain alone accounts for 90 billion dollars in diagnosis and treatment. It is estimated that another 20 billion can be chalked up to lost wages and lost productivity. And those figures don’t include similar costs associated with neck pain and problems.

Given that up to 80 per cent of all adults will have back pain at least once (and often more than once) in a lifetime, this problem has grabbed the attention of health care policy makers. It’s their job it is to hold costs down without compromising care or outcomes (results).

When care exceeds recommendations made based on evidence, then health care policy makers get concerned. In a recent report from The Dartmouth Institute for Health Policy and Clinical Practice, it was noted that money spent on spine problems (including both the neck and back) is linked to specialty services that don’t necessarily improve results. Expensive MRIs and other imaging tests, referrals to orthopedic surgeons and neurologists, visits to the emergency department, and unnecessary lab testing make up some of the specialty costs that might be considered unnecessary.

In addition to expanded diagnostic tests thanks to improved technology, more aggressive marketing of medical supplies has driven some costs up. And the rising costs of care associated with these services don’t come with improved results.

On the other hand, dollars spent on spine care provided by general practitioners (GPs), chiropractors, and physical therapists have not gone up. This is contrasted with evidence that these services provide improved outcomes. Future research is needed to determine what is the most cost effective treatment (i.e., least cost and most benefits).

With the continued rise in health care costs, finding ways to improve results of treatment for spine problems (again, at a lower cost) is important to health care policy makers. It may be necessary to limit patient access to specialty care by restricting (rather than expanding) reimbursement. Policies that encourage better reimbursement can be put in place as more research is done to identify effective spine care.